Electronic cigarettes as a harm reduction strategy for tobacco control: A step forward or a repeat of past mistakes?

Zachary Cahna,* and Michael SiegelbDepartment of Political Science, University of California at Berkeley, UC Berkeley Department of Political Science, 210 Barrows Hall #1950, Berkeley, CA 94720-1950, USA.

Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118, USA.*Corresponding author.

Abstract

The issue of harm reduction has long been controversial in the public health practice of tobacco control. Health advocates have been reluctant to endorse a harm reduction approach out of fear that tobacco companies cannot be trusted to produce and market products that will reduce the risks associated with tobacco use. Recently, companies independent of the tobacco industry introduced electronic cigarettes, devices that deliver vaporized nicotine without combusting tobacco. We review the existing evidence on the safety and efficacy of electronic cigarettes. We then revisit the tobacco harm reduction debate, with a focus on these novel products. We conclude that electronic cigarettes show tremendous promise in the fight against tobacco-related morbidity and mortality. By dramatically expanding the potential for harm reduction strategies to achieve substantial health gains, they may fundamentally alter the tobacco harm reduction debate.

Journal of Public Health Policy advance online publication, 9 December 2010; doi:10.1057/jphp.2010.41

Keywords: electronic cigarette; harm reduction; nicotine regulation; tobacco control

Introduction

Harm reduction is a framework for public health policy that focuses on reducing the harmful consequences of recreational drug use without necessarily reducing or eliminating the use itself.1 Whereas harm reduction policies have been widely adopted for illicit drug use (for example, needle exchange programs2) and alcohol use (for example, designated driver programs3), they have not found wide support in tobacco control. Many within the tobacco control community have embraced nicotine replacement therapy (NRT) and other pharmaceutical products, but these products are designed as cessation strategies rather than recreational alternatives. Recently, however, a new product that does not fit neatly into any previous category has entered the nicotine market: the electronic cigarette. Electronic cigarettes do not contain tobacco, but they are recreational nicotine devices and the user closely mimics the act of smoking. Thus, they are neither tobacco products nor cessation devices. The novel potential of electronic cigarettes warrants revisiting the harm reduction debate as it applies to these products. In this article, we first explain what electronic cigarettes are and why they are difficult to categorize. Second, we examine the available evidence concerning the safety and efficacy of electronic cigarettes. Then, we review the most common arguments made against harm reduction in the tobacco control literature, followed by an analysis of each of these arguments in light of the recent emergence of electronic cigarettes. Finally, we identify conclusions from this analysis and their implications for the public health practice of tobacco control.

What are Electronic Cigarettes and why are They Novel? Electronic cigarettes are hand-held devices that deliver nicotine to the user through the battery-powered vaporization of a nicotine/ propylene-glycol solution.

The act of ‘smoking’ an electronic cigarette is called ‘vaping’ and it mimics smoking; but, there is nocombustion and the user inhales vapor, not smoke. Although thenicotine is derived from tobacco, electronic cigarettes contain notobacco. Theoretically, we would expect vaping to be less harmfulthan smoking as it delivers nicotine without the thousands ofknown and unknown toxicants in tobacco smoke.

Moreover, aproduct that mimics the act of smoking, in addition to deliveringnicotine, can address both pharmacologic and behavioral componentsof cigarette addiction. Electronic cigarettes are not manufacturedor distributed by the tobacco industry or by thepharmaceutical industry. Hundreds of small distributors marketthem over the internet and in shopping mall kiosks. They havebeen on themarket in theUnited States for more than 3 years and havebecome increasingly popular.

Review of Evidence Regarding the Safety of Electronic Cigarettes

As B5300 of the estimated 10 000–100 000 chemicals in cigarettesmoke have ever been identified,4 we already have more comprehensive  knowledge of the chemical constituents of electronic cigarettes than tobacco ones.

We were able to identify 16 studies5–17 that have characterized, quite extensively, the components contained in electronic cigarette liquid and vapor using gas chromatography mass spectrometry (GC-MS) (Table 1). These studies demonstrate that the primary components of electronic cigarette cartridges are propylene glycol (PG), glycerin, and nicotine. Of the other chemicals identified, the FDA has focused on potential health hazards associated with two: tobacco-specific nitrosamines (TSNAs) and diethylene glycol (DEG).5

TSNAs have been detected in two studies at trace levels.5,6The maximum level of total TSNAs reported was 8.2 ng/g.6 This compares with a similar level of 8.0ng in a nicotine patch, and it is orders of magnitude lower than TSNA levels in regular cigarettes.18 Evidence shows that electronic cigarettes contain only 0.07–0.2 per cent of the TSNAs present in cigarettes, a 500-fold to 1400-fold reduction in concentration. The presence of DEG in one of the 18 cartridges studied by the US Food and Drug Administration (FDA) is worrisome, yet none of the other 15 studies found any DEG. The use of a non-pharmaceutical grade of PG may explain this contamination.

Other than TSNAs and DEG, few, if any, chemicals at levels detected in electronic cigarettes raise serious health concerns. Although the existing research does not warrant a conclusion that electronic cigarettes are safe in absolute terms and further clinical studies are needed to comprehensively assess the safety of electronic cigarettes, a preponderance of the available evidence shows them to be much safer than tobacco cigarettes and comparable in toxicity to conventional nicotine replacement products.

Review of Evidence about the Effectiveness of Electronic Cigarettes in Smoking Cessation.

No studies have measured directly the effectiveness of electronic cigarettes in helping smokers cease smoking. Two published studies have examined the effectiveness of the product by measuring their effect on cravings and other short-term indicators.

We summarize them briefly in Table 3.19,20 Bullenet al19 demonstrated that electronic cigarettes deliver nicotine effectively, more rapidly than a nicotine inhaler. In this study, electronic cigarette use significantly reduced craving, a similar effect to what was observed with a nicotine inhaler. Nicotine delivery and reduction in cigarette craving was much less than with a regular cigarette.

Eissenberg20 found that 10 puffs on one brand of electronic cigarettes delivered a small amount of nicotine, again far less than a tobacco cigarette, whereas another brand delivered little to none. The first brand was able to significantly reduce cigarette craving.

Taken together, this evidence suggests that electronic cigarettes are capable of reducing cigarette craving, but that the effect is not due exclusively to nicotine. Bullen et al observe that ‘the reduction in desire to smoke in the first 10 minutes of [electronic cigarette] use appears to be independent of nicotine absorption’ (p. 100).19 Thesizable craving reduction achieved by the ‘placebo’ – a nicotine-free electronic cigarette – demonstrates the ability of physical stimuli to suppress cravings independently.19 Many studies have established the ability of denicotinized cigarettes to provide craving relief.21, 22

Barrett21 found that denicotinized cigarettes reduce cravings more than a nicotinized inhaler, supporting Buchhalter et al’s22 conclusion that although some withdrawal symptoms can be treated effectively with NRT, others, such as intense cravings, respond better to smoking-related stimuli.

Although more research is needed before we will know how effective electronic cigarettes are at achieving smoking abstinence, there is now sufficient evidence to conclude that these products are at least capable of suppressing the urge to smoke. There is also reason to believe that they offer an advantage over traditional nicotine delivery devices ‘[t]o the extent that non-nicotine, smoking related stimuli alone can suppress tobacco abstinence symptoms indefinitely’ (p. 556).22