E-cigarettes: Harm reduction or ‘gateway’ to new smokers?

Smoking is an issue that has been at the heart of public health concerns for decades, with many efforts to restrict tobacco sales, tax cigarettes and sometimes hard-hitting campaigns to get people to quit smoking. But if the tobacco control community has long agreed on the harms of smoking, the place of reducing, rather than eliminating, harm has been hotly contested. Products containing nicotine have varying associated health risk. Nicotine replacement products like patches and gum fall on the safer end of the scale; cigarettes, which deliver nicotine through inhaled smoke particles, are on the deadly end. While there is increasing agreement that electronic cigarettes fall toward the lower end of the risk scale, the role they should play in harm reduction efforts has been the subject of considerable debate.

In a new perspective article in the New England Journal of Medicine, Amy Fairchild, PhD, associate dean of academic affairs and professor in the Department of Health Policy and Management at the Texas A&M School of Public Health—together with Ju Sung Lee, a doctoral student at Texas A&M; Ronald Bayer, PhD, from Columbia University; and James Curran, MD, dean of the Rollins School of Public Health at Emory University—underscore the importance of recognizing not just a continuum of risk when it comes to products that deliver nicotine, but a continuum of harm reduction strategies. In 2017, the U.S. Food and Drug Administration (FDA) announced a new plan on tobacco and nicotine regulation, pushing the date for setting rules on electronic cigarettes to August 2022 to give researchers and policymakers time to fully consider the role e-cigarettes might play.

In their paper, Fairchild and colleagues find that harm reduction proposals fall across a continuum between tactics that, while allowing for the sale and use of e-cigarettes, place strict limits on availability and policies that give smokers easier access to electronic cigarettes as an alternative to smoking. More restrictive policies include limiting access only to current smokers and limiting the sale of electronic cigarettes to pharmacies. Such restrictions prioritize preventing young people and non-smokers from using electronic cigarettes. On the opposite end of the spectrum are policies recognizing that some people using nicotine will not stop, and thus the goal should be to minimize health risks for current smokers. Many proposals—age restrictions, taxation and public awareness campaigns about the risks of electronic cigarettes—occupy the middle ground. One of the keys for taxing electronic cigarettes is to find a taxation level that is high enough to put them out of the reach of young people but low enough that, for smokers, they are still less costly than combustible products.

Policies regarding electronic cigarettes will continue to evolve with further research, and the decisions of organizations like the FDA will play a crucial role in the future. Fairchild and her colleagues state that many of these policies hold uncertainties, which can make it difficult to decide which path to take; however, given the nature of the health risks involved with smoking, policymakers will need to act even in the face of uncertainty. The key will be determining how much policies reduce harm and whether they find the right balance of restriction.

Regardless of how restrictive the approach policymakers take regarding electronic cigarettes, there will be a need for ongoing monitoring of health and safety, both for harm reduction and as a consumer protection issue.

“Policymakers will need to be willing to change their approaches to ensure that they actually reduce population harm,” Fairchild said. “This not only means that a harm reduction measure might need to be rolled back if it hurts more people than it helps, but it also means that just because a tactic is by definition called harm reduction, that it actually works to reduce harm. An overly restrictive approach to harm reduction that leaves potentially disruptive products hard to obtain and use may be harm reduction in name only.”