E-cigarettes: striking the right balance
Authors: K Michael Cummings, David Hammond
Journal: The Lancet Public Health (2020)

Natalie Walker and colleagues'1Walker N Parag V Wong SF et al.Use of e-cigarettes and smoked tobacco in youth aged 14–15 years in New Zealand: findings from repeated cross-sectional studies (2014–19). Lancet Public Health; online Jan 22.https://doi.org/10.1016/S2468-2667(19)30241-5Google Scholar Article provides evidence on New Zealand's new regulatory framework for e-cigarettes, which permitted the sale and marketing of nicotine-containing electronic cigarettes (e-cigarettes) in March, 2018. Before this date, the sale of e-cigarettes was illegal, although as the authors acknowledge, the law was not aggressively enforced. The data analysed by Walker and colleagues1Walker N Parag V Wong SF et al.Use of e-cigarettes and smoked tobacco in youth aged 14–15 years in New Zealand: findings from repeated cross-sectional studies (2014–19). Lancet Public Health; online Jan 22.https://doi.org/10.1016/S2468-2667(19)30241-5Google Scholar are from annual cross-sectional Year-10 student surveys, which were circulated to nearly half of New Zealand students aged 14–15 years. The findings indicate a decrease in ever having used a cigarette and daily use of cigarettes among Year-10 students, between 2014 and 2019, while ever having used an e-cigarette and daily use of e-cigarettes increased.1Walker N Parag V Wong SF et al.Use of e-cigarettes and smoked tobacco in youth aged 14–15 years in New Zealand: findings from repeated cross-sectional studies (2014–19). Lancet Public Health; online Jan 22.https://doi.org/10.1016/S2468-2667(19)30241-5Google Scholar The provocative question posed by Walker and colleagues1Walker N Parag V Wong SF et al.Use of e-cigarettes and smoked tobacco in youth aged 14–15 years in New Zealand: findings from repeated cross-sectional studies (2014–19). Lancet Public Health; online Jan 22.https://doi.org/10.1016/S2468-2667(19)30241-5Google Scholar is whether nicotine vaping is displacing cigarettes as the preferred form of nicotine consumption among New Zealand adolescents and, if so, to what effect? The idea that cigarette smoking could be replaced by a less harmful tobacco product is not new. Several decades ago, adolescents in northern Sweden largely replaced smoking with a new type of oral tobacco called snus.2Ramström ML Foulds J Role of snus in initiation and cessation of tobacco smoking in Sweden.Tob Control. 2006; 15: 210-214Crossref PubMed Scopus (170) Google Scholar Over a generation, the development of smoking-associated diseases in Sweden declined at a much faster pace than they did in other countries in Europe, as snus displaced cigarettes as the preferred form of tobacco consumption.3Rodu B Cole P The burden of mortality from smoking: comparing Sweden with other countries in the European Union.Eur J Epidemiol. 2004; 19: 129-131Crossref PubMed Scopus (37) Google Scholar However, evidence of smoking displacement in the New Zealand data remain unclear. Smoking prevalence over the past 30 days changed very little between 2014 and 2019 (from 6·0% to 5·9%), while e-cigarette use more than tripled (from 3·5% to 12·0%). Notably, smoking prevalence among New Zealand youth has been declining for more than 20 years, including the years before the introduction of e-cigarettes. Therefore, whether e-cigarette use among New Zealand youth will eventually displace cigarettes remains unclear, but might be clarified when these teenagers transition into adulthood and smoking patterns are established. Even though most adolescents who reported using e-cigarettes were current smokers, regular e-cigarette use doubled between 2018 and 2019 among adolescents who had never smoked.1Walker N Parag V Wong SF et al.Use of e-cigarettes and smoked tobacco in youth aged 14–15 years in New Zealand: findings from repeated cross-sectional studies (2014–19). Lancet Public Health; online Jan 22.https://doi.org/10.1016/S2468-2667(19)30241-5Google Scholar Removing the restrictions on the marketing and sale of e-cigarettes in New Zealand was associated with overall increase in the use of e-cigarettes by both smokers and non-smokers. Use of nicotine in any form, but especially aerosolize nicotine inhaled into the airways, is a concern for non-smokers of any age because it could lead to nicotine addiction with unknown long-term health consequences.4National Academies of Sciences, Engineering, and MedicinePublic health consequences of e-cigarettes. The National Academies Press, Washington, DC2018Google Scholar, 5McNeill A Brose LS Calder R et al.Evidence review of e-cigarettes and heated tobacco products: a report commissioned by Public Health England. Stationery Office, London2018Google Scholar However, an addicted smoker who is struggling to stop smoking cigarettes might find a nicotine-containing e-cigarette an acceptable replacement for continued smoking.4National Academies of Sciences, Engineering, and MedicinePublic health consequences of e-cigarettes. The National Academies Press, Washington, DC2018Google Scholar, 5McNeill A Brose LS Calder R et al.Evidence review of e-cigarettes and heated tobacco products: a report commissioned by Public Health England. Stationery Office, London2018Google Scholar Randomised trials have shown that some nicotine-containing e-cigarettes are equally as effective or more effective for smoking cessation than are nicotine patches.6Hartmann-Boyce J McRobbie H Bullen C Begh R Stead LF Hajek P Electronic cigarettes for smoking cessation.Cochrane Database Syst Rev. 2016; 9: CD010216PubMed Google Scholar, 7Walker N Paraj V Verbiest M Laking G Laugesen M Bullen C Nicotine patches used in combination with e-cigarettes (with and without nicotine) for smoking cessation: a pragmatic, randomised trial.Lancet Respir Med. 2020; 8: 54-64Summary Full Text Full Text PDF PubMed Scopus (96) Google Scholar, 8Hajek P Phillips-Waller A Przulj D et al.A randomized trial of e-cigarettes versus nicotine-replacement therapy.N Engl J Med. 2019; 380: 629-637Crossref PubMed Scopus (799) Google Scholar Although substitution of e-cigarettes has considerable potential in reducing smoking among adults who are already addicted to nicotine, in the context of youth, the question is how to maintain a reduction in smoking without substitution to other nicotine products. Public health authorities are concerned about the apparent surge in e-cigarette use by adolescents who have never smoked, but calls for a complete prohibition on the sale of nicotine-containing e-cigarettes is an overreach and could be counterproductive to public health.9Fairchild A Healton C Curran J Abrams D Bayer R Evidence, alarm, and the debate over e-cigarettes: prohibitionist measures threaten public health.Science. 2019; 366: 1318-1320Crossref PubMed Scopus (26) Google Scholar The recent outbreak of electronic cigarette vaping associated lung injury (EVALI) in the USA suggests caution: EVALI is primarily attributable to vitamin E acetate in cannabis oils distributed through illicit channels.10Blount BC Karwowski MP Shields PG et al.Vitamin E acetate in bronchoalveolar-lavage fluid associated with EVALI.N Engl J Med. 2019; (published online December 20.)DOI:10.1056/NEJMoa1916433Crossref PubMed Scopus (372) Google Scholar Prohibiting the sale of nicotine- containing e-cigarettes might have the effect of driving some consumers back to smoking or to acquisition of unregulated products through illicit channels.9Fairchild A Healton C Curran J Abrams D Bayer R Evidence, alarm, and the debate over e-cigarettes: prohibitionist measures threaten public health.Science. 2019; 366: 1318-1320Crossref PubMed Scopus (26) Google Scholar However, the unfettered marketing of e-cigarettes containing nicotine is not a reasonable option, as non-smokers should not be enticed to use these products.9Fairchild A Healton C Curran J Abrams D Bayer R Evidence, alarm, and the debate over e-cigarettes: prohibitionist measures threaten public health.Science. 2019; 366: 1318-1320Crossref PubMed Scopus (26) Google Scholar Thus, the question for government regulators is how to strike the right balance between making potentially lower risk nicotine products intended for smokers accessible, while discouraging use by non-smokers, especially youth.9Fairchild A Healton C Curran J Abrams D Bayer R Evidence, alarm, and the debate over e-cigarettes: prohibitionist measures threaten public health.Science. 2019; 366: 1318-1320Crossref PubMed Scopus (26) Google Scholar Public health authorities in England have embraced nicotine e-cigarettes as a harm reduction alternative to cigarettes and have seen the prevalence of adult smoking decline at an accelerated pace as e-cigarette use has escalated, without stimulating an epidemic of e-cigarette use by adolescents.5McNeill A Brose LS Calder R et al.Evidence review of e-cigarettes and heated tobacco products: a report commissioned by Public Health England. Stationery Office, London2018Google Scholar, 11Beard E West R Michie S Brown J Association of prevalence of electronic cigarette use with smoking cessation and cigarette consumption in England: a time-series analysis between 2007 and 2017.Addiction. 2019; (published online October 16.)DOI:10.1111/add.14851Crossref Scopus (60) Google Scholar In England, the Medicines and Healthcare Products Regulatory Agency has created a notification system that requires assurance by manufacturers of the safety and quality of any nicotine-containing e-cigarettes sold, alongside regulations on e-cigarette marketing.5McNeill A Brose LS Calder R et al.Evidence review of e-cigarettes and heated tobacco products: a report commissioned by Public Health England. Stationery Office, London2018Google Scholar Additionally, the nicotine concentration of e-liquids sold in England is capped at less than half of the concentration permitted in some products sold in the USA and Canada, where youth vaping prevalence has increased. In response to the surge in adolescent e-cigarette use, some jurisdictions have adopted rules to increase the legal age for purchasing tobacco products, restricted the sale of tobacco products to adult-only retail establishments, and prohibited the use of so-called kid friendly e-liquid flavors. Evaluating the effect of such regulations on the use of e-cigarettes and cigarettes by both adolescents and adults would be helpful to guide the adoption of future policies. Continued surveillance of e-cigarette and smoking in all age groups is warranted. Health authorities need to recognise the continuum of risk associated with all nicotine products, so that regulations are proportionate to the harm the products cause—ie, more stringent for the highest risk products (cigarettes) than those that are less harmful (nicotine medications, oral tobacco, e-cigarettes).9Fairchild A Healton C Curran J Abrams D Bayer R Evidence, alarm, and the debate over e-cigarettes: prohibitionist measures threaten public health.Science. 2019; 366: 1318-1320Crossref PubMed Scopus (26) Google Scholar KMC and DH have served as paid expert witnesses in legal challenges against tobacco companies. KMC receives funding from the US National Cancer Institute. DH is supported by a Canadian Institutes of Health Research (CIHR)-Public Health Agency of Canada (PHAC) Applied Public Health Research Chair Use of e-cigarettes and smoked tobacco in youth aged 14–15 years in New Zealand: findings from repeated cross-sectional studies (2014–19)The overall decline in smoking over the past 6 years in New Zealand youth suggests that e-cigarettes might be displacing smoking. Ongoing monitoring will be important to determine whether the liberalisation of e-cigarette availability and marketing in New Zealand has any effect on long-term patterns of daily e-cigarette and cigarette use. Full-Text PDF Open Access