The Future of E-Cigarettes in the World of Public Health

The popularity of e-cigarettes continues to grow with every passing year. Words like “vape” are now part of our everyday vernacular, and it’s becoming increasingly more common to see people vaping instead of smoking. Approximately 2.5 million American smokers regularly vape e-cigarettes. This might sound like a high number, but it actually amounts to fewer than 6 percent of all smokers.

The e-cigarette industry is approaching a pivotal point in its growth and development. Early technologies have given way to newer generations of products that can increasingly satisfy the needs of adult smokers looking for alternatives.

Meanwhile, regulatory oversight is being put in place in Europe and the U.S. As e-cigarette technologies mature and enter the mainstream, it’s important to educate consumers and physicians on the realities of e-cigarettes so they’re assigned a proper place in the market and an appropriate role in the world of public health.

Smoking vs. Vaping 

There’s no question that smoking traditional cigarettes is unhealthy. Their main health issue directly relates to the manner in which the nicotine is consumed: combustion. Cigarette smoke generated via combustion contains more than 7,000 chemicals known to cause a litany of health problems for both smokers and those around them. One recent study reported that 75 percent of cigarette smoke was made up of carbon monoxide and other combustion byproducts — certainly not the makings for clean breathing air.

E-cigarettes are designed to avoid combustion and the generation of smoke. Nothing is burned; instead, liquid nicotine is heated by a small battery to produce a vapor that the user inhales. The aerosol is mainly comprised of vegetable glycerin and/or propylene glycol, nicotine, flavoring, and water.

While it’s important to recognize that e-cigarette vapor isn’t completely free of harmful or potentially harmful constituents (known as HPHCs), these chemicals are typically reduced by 90 to 99 percent relative to a cigarette.

New generations of e-vapor products are reaching the market each year, and it’s likely that increasingly cleaner products will be produced in the future, as long as regulation doesn’t overly restrict innovation. For instance, many newer devices include sophisticated temperature controls to help minimize the generation of unwanted HPHCs.

While most studies that assess the health implications of e-cigarettes are ongoing, one recent study did conclude that e-cigarettes “represent a historical opportunity to save millions of lives and significantly reduce the burden of smoking-related diseases worldwide.” Another one compared urine samples from e-cigarette smokers to tobacco smokers and found a significantly lower biomarker toxicity profile in those who vaporize.

The technology to emit vapor, rather than smoke, presents the potential for harm reduction when switching from consuming smoke to consuming e-vapor. There is a need for a Cochrane Review of the latest evidence to conclusively establish this potential. Given the speed of innovation in the field, this type of review should be updated yearly.

Here’s what I would predict such a review would find:

• Strong evidence that the chemical composition of e-vapor is preferable to smoke.
• Evidence that biomarkers of health demonstrate harm reversal associated with switching from consuming smoke to e-vapor.
• Initial evidence that long-term use of electronic cigarettes may result in harm reversal, although a full picture will require data spanning decades.

We now have eight years of post-market data from e-cigarettes, and so far, the accumulated data is consistent with e-vapor being safer than cigarettes when used responsibly by adult smokers.

Placing E-Cigs in the Public Health Picture: Second-Line Use and Harm Reduction

Doctors generally encourage smokers to quit by using pharmaceutical nicotine replacement products (NRTs), which meet the FDA standard of being considered “safe.” Unfortunately, these NRT products have limited efficacy. A Cochrane Review concluded that NRTs “might be expected to increase the rate by 2 to 3 percent” in smokers trying to quit on their own; intense behavioral therapy can also increase this success rate somewhat.

The reality we face as a society is that in spite of decades of concerted tobacco control initiatives and the efforts of the pharmaceutical industry, cigarettes are likely not going away soon. In fact, the number of global users has been increasing, not decreasing.

E-vapor products offer the most realistic opportunity to displace cigarette use in smokers who have not been able to quit with traditional methods. In fact, their appropriate use could mirror two concepts that are central to medicine: second-line use and harm reduction.

Many cancer treatment medicines, for instance, typically enter the market by proving that they have efficacy in a second-line setting — meaning they can be used if a patient has failed to respond to established medicines. Because of the great unmet need for better products in this area, cancer treatment medicines can often enter the market on an accelerated basis before all the evidence is in.

This is similar to the “expedited pre-market review” proposed by the FDA for tobacco products that present a more favorable toxicity and risk profile, such as e-cigarettes. After entering the market, post-market surveillance can continue to provide the FDA with an oversight mechanism.

Harm reduction strategies are also commonly used in patients engaging in potentially risky behaviors or with undesirable addictions, where a less harmful product can replace or mitigate a more harmful one. The medical community embraces products like HPV vaccines, condoms, prophylactic use of HIV drugs, methadone, and abuse-resistant opioids.

Similarly, I predict that e-vapor products will ultimately be understood by the public health community as having a role when used responsibly as second-line harm reduction products for adult smokers. However, some questions still need to be addressed:

• Can e-cigs actually help people switch? Many former smokers have testified in letters to the FDA that e-cigarettes were effective in helping them to stop using cigarettes. Anecdotal evidence, while strongly suggestive, is not sufficient to stand firmly in the court of public health. More formalized information about the use of e-cigs as a cigarette displacement tool is needed before they can be publicized as such. Supportive scientific evidence, however, is beginning to accumulate.

• What is the long-term health outlook? It will take many years of research before we can uncover whether switching to e-cigarettes actually does reduce the rates of deadly diseases like lung cancer, COPD, and emphysema. While the early returns are promising, many more clinical studies are needed to properly assess the potential long-term health impact of switching to e-cigarettes.

• Can e-cigs become even safer? In order for e-cigarettes to be identified as a safer nicotine source, manufacturers must continually strive to improve the quality of their ingredients. Right now, there are still a handful of concerning chemicals present in certain brands of liquid nicotine. Manufacturers need to find ways to phase these ingredients out as technology improves and additional chemical research is conducted.

• Will e-cigs be regulated fairly? In 2014, the FDA proposed new requirements for previously unregulated tobacco products like e-cigarettes. While moderate levels of regulation are necessary and helpful, there can be some major consequences of over-regulation. For example, overly taxing e-cigarettes could discourage people from attempting to switch to safer alternatives and may even have the unintended consequence of driving users back to smoking. Consumers deserve reasonable regulations to ensure that all e-vapor products meet quality standards and that the potential public health benefits aren’t overshadowed by regulations.

• How will e-cigs be advertised? Moving forward, e-vapor products need to walk a fine line. They should be sufficiently attractive to truly be used by adult smokers, but they should also not be marketed in a way that targets youth. Paradoxically, proposed FDA regulations restrict e-vapor product manufacturers from comparing their vapor chemistry with the smoke chemistry of cigarettes in consumer communications, leaving e-cigarette brands reliant on traditional advertising strategies to attract smokers. However, this advertising shouldn’t overshadow the fact that nicotine is addictive and inappropriate for youth.

The e-vapor industry and the public health establishment can (and should) work together to bring an end to cigarettes and smoking. With more research, innovation, and responsible marketing, e-vapor may soon play an important role in the public health world.

*The author is employed by PAX Labs, Inc. The opinions expressed herein belong to the author and do not necessarily reflect the views of PAX Labs, Inc.