If you want a truly frustrating job in public health, try getting people to stop smoking. Even when researchers combine counseling and encouragement with nicotine patches and gum, few smokers quit.
Recently, though, experimenters in Italy had more success by doing less. A team led by Riccardo Polosa of the University of Catania recruited 40 hard-core smokers — ones who had turned down a free spot in a smoking-cessation program — and simply gave them a gadget already available in stores for $50. This electronic cigarette, or e-cigarette, contains a small reservoir of liquid nicotine solution that is vaporized to form an aerosol mist.
The user “vapes,” or puffs on the vapor, to get a hit of the addictive nicotine (and the familiar sensation of bringing a cigarette to one’s mouth) without the noxious substances found in cigarette smoke.
After six months, more than half the subjects in Dr. Polosa’s experiment had cut their regular cigarette consumption by at least 50 percent. Nearly a quarter had stopped altogether. Though this was just a small pilot study, the results fit with other encouraging evidence and bolster hopes that these e-cigarettes could be the most effective tool yet for reducing the global death toll from smoking.
But there’s a powerful group working against this innovation — and it’s not Big Tobacco. It’s a coalition of government officials and antismoking groups who have been warning about the dangers of e-cigarettes and trying to ban their sale.
The controversy is part of a long-running philosophical debate about public health policy, but with an odd role reversal. In the past, conservatives have leaned toward “abstinence only” policies for dealing with problems like teenage pregnancy and heroin addiction, while liberals have been open to “harm reduction” strategies like encouraging birth control and dispensing methadone.
When it comes to nicotine, though, the abstinence forces tend to be more liberal, including Democratic officials at the state and national level who have been trying to stop the sale of e-cigarettes and ban their use in smoke-free places. They’ve argued that smokers who want an alternative source of nicotine should use only thoroughly tested products like Nicorette gum and prescription patches — and use them only briefly, as a way to get off nicotine altogether.
The Food and Drug Administration tried to stop the sale of e-cigarettes by treating them as a “drug delivery device” that could not be marketed until its safety and efficacy could be demonstrated in clinical trials. The agency was backed by the American Cancer Society, the American Heart Association, Action on Smoking and Health, and the Center for Tobacco-Free Kids.
The prohibitionists lost that battle last year, when the F.D.A. was overruled in court, but they’ve continued the fight by publicizing the supposed perils of e-cigarettes. They argue that the devices, like smokeless tobacco, reduce the incentive for people to quit nicotine and could also be a “gateway” for young people and nonsmokers to become nicotine addicts. And they cite an F.D.A. warning that several chemicals in the vapor of e-cigarettes may be “harmful” and “toxic.” But the agency has never presented evidence that the trace amounts actually cause any harm, and it has neglected to mention that similar traces of these chemicals have been found in other F.D.A.-approved products, including nicotine patches and gum. The agency’s methodology and warnings have been lambasted in scientific journals by Dr. Polosa and other researchers, including Brad Rodu, a professor of medicine at the University of Louisville in Kentucky.
Writing in Harm Reduction Journal this year, Dr. Rodu concludes that the F.D.A.’s results “are highly unlikely to have any possible significance to users” because it detected chemicals at “about one million times lower concentrations than are conceivably related to human health.” His conclusion is shared by Michael Siegel, a professor at the Boston University School of Public Health.
“It boggles my mind why there is a bias against e-cigarettes among antismoking groups,” Dr. Siegel said. He added that it made no sense to fret about hypothetical risks from minuscule levels of several chemicals in e-cigarettes when the alternative is known to be deadly: cigarettes containing thousands of chemicals, including dozens of carcinogens and hundreds of toxins.
Both sides in the debate agree that e-cigarettes should be studied more thoroughly and subjected to tighter regulation, including quality-control standards and a ban on sales to minors. But the harm-reduction side, which includes the American Association of Public Health Physicians and the American Council on Science and Health, sees no reason to prevent adults from using e-cigarettes. In Britain, the Royal College of Physicians has denounced “irrational and immoral” regulations inhibiting the introduction of safer nicotine-delivery devices.
“Nicotine itself is not especially hazardous,” the British medical society concluded in 2007. “If nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved.”
The number of Americans trying e-cigarettes quadrupled from 2009 to 2010, according to the Centers for Disease Control. Its survey last year found that 1.2 percent of adults, or close to three million people, reported using them in the previous month.
“E-cigarettes could replace much or most of cigarette consumption in the U.S. in the next decade,” said William T. Godshall, the executive director of Smokefree Pennsylvania. His group has previously campaigned for higher cigarette taxes, smoke-free public places and graphic warnings on cigarette packs, but he now finds himself at odds with many of his former allies over the question of e-cigarettes.
“There is no evidence that e-cigarettes have ever harmed anyone, or that youths or nonsmokers have begun using the products,” Mr. Godshall said. On a scale of harm from 1 to 100, where nicotine gums and lozenges are 1 and cigarettes are 100, he estimated that e-cigarettes are no higher than 2.
If millions of people switch from smoking to vaping, it would be a challenge to conventional wisdom about the antismoking movement. The decline in smoking is commonly attributed to paternalistic and prohibitionist social policies, and it’s ritually invoked as a justification for crackdowns on other products — trans fats, salt, soft drinks, Quarter Pounders.
But the sharpest decline in smoking rates in the United States occurred in the decades before 1990, when public health experts concentrated on simply educating people about the risks. The decline has been slower the past two decades despite increasingly elaborate smoking-cessation programs and increasingly coercive tactics: punitive taxes; limits on marketing and advertising; smoking bans in offices, restaurants and just about every other kind of public space.
Some 50 million Americans continue to smoke, and it’s not because they’re too stupid to realize it’s dangerous. They go on smoking in part because of a fact that the prohibitionists are loath to recognize: Nicotine is a drug with benefits. It has been linked by researchers (and smokers) to reduced anxiety and stress, lower weight, faster reaction time and improved concentration.
“It’s time to be honest with the 50 million Americans, and hundreds of millions around the world, who use tobacco,” Dr. Rodu writes. “The benefits they get from tobacco are very real, not imaginary or just the periodic elimination of withdrawal.
“It’s time to abandon the myth that tobacco is devoid of benefits, and to focus on how we can help smokers continue to derive those benefits with a safer delivery system.”
As a former addict myself — I smoked long ago, and was hooked on Nicorette gum for a few years — I can appreciate why the prohibitionists fear nicotine’s appeal. I agree that abstinence is the best policy. Yet it’s obviously not working for lots of people. No one knows exactly what long-term benefits they’d gain from e-cigarettes, but we can say one thing with confidence: Every time they light up a tobacco cigarette, they’d be better off vaping.