E-cigarettes are significantly less harmful than regular cigarettes. That's the conclusion of a first-of-its kind expert report commissioned by Public Heath England.

The report also says a lot of people don't realize e-cigarettes are better for health than regular combustibles.

But there are a few things this report doesn't say, and these messages have been glossed over in some of the media coverage. The report doesn't say that e-cigarettes are completely safe. (We don't know whether that's the case.) It doesn't say anything about the long-term health impact of vaping. (There are no published studies on years-long e-cigarette use.) And it doesn't say nonsmokers should take up the habit.

So this isn't a glowing endorsement of vaping, full stop. Instead, the report says that when stacked against one of the most harmful substances known to human health (regular cigarettes), e-cigarettes fare better. So the independent researchers behind the paper suggest e-cigarettes should be regulated as a medicine to help smokers quit, alongside other smoking cessation devices like nicotine patches.

England's stance on e-cigarettes is different from America's

As I explained in my assessment of the evidence on e-cigarettes, since the immediate harms of these devices so far appear to be minimal compared with regular cigarettes, many researchers agree that there’s a compelling case for vaping as a harm-reduction tool for heavy smokers.

The question of how to apply this emerging consensus in policy is where things get interesting. With this report, England for the first time advocates "harm reduction" — policies that will reduce the adverse health consequences of cigarettes. This means ensuring the quality of e-cigarettes through regulation and making them more easily available to regular smokers who want to quit.

This view was best articulated by England's chief medical officer, Dame Sally Davies, in the Guardian newspaper last week. While she said that "there continues to be a lack of evidence on the long-term use of e-cigarettes," she also suggested these devices should be used to help smokers quit:

I want to see these products coming to the market as licensed medicines. This would provide assurance on the safety, quality and efficacy to consumers who want to use these products as quitting aids, especially in relation to the flavourings used, which is where we know least about any inhalation risks.

Public Health England's counterpart in the US — the Centers for Disease Control and Prevention — has not taken a harm-reduction stance to date. Instead, the agency seems to be taking more of a zero-risk approach, viewing any harm e-cigarettes may cause as problematic and drawing attention to the rising use of e-cigs among American youth.

On the teenage usage trend, Tom Frieden, the CDC's director, has said, "This is another generation being hooked by the tobacco industry. It makes me angry." Frieden's colleagues, like Brian King of CDC's Office on Smoking and Health, have voiced similar concerns. Here's King in the New Scientist this past spring:

King says the CDC rejects any notion that replacing cigarettes with e-cigarettes is positive, and claims that e-cigarettes are actually prompting youngsters to take up smoking, not just taking the place of cigarettes. "In just one year, the number of kids using hookah doubled, and the number of kids using e-cigarettes appears to have tripled," he says. "These increases are driving an uptick in the total number of our children who are using tobacco products for the first time in a generation."

A harm-reduction approach to vaping reflects the current evidence

It's not surprising that America isn't running down the harm-reduction road. When it comes to policies around sex and recreational drugs, this country hasn't been a harm-reduction exemplar. (As some countries have embraced safe-injection sites for heroin users and other harm-reduction drug policies instead of waging a war on drugs, for example, the US has often lagged or gone in the opposite direction.)

But e-cigarettes aren't going to go away anytime soon, and ignoring the emerging scientific consensus doesn't make for evidence-based policy.



The CDC's Frieden defers questions about policy to the Food and Drug Administration, which is moving toward regulating e-cigarettes like tobacco products (instead of medical devices, as England wants to do).



"I would be in favor of regulating e-cigarettes as medical devices," said Judith Prochaska, a professor at Stanford's prevention research center. "[We need] government regulation of this widely marketed and used product." She added: "At this time, users have no assurance of what is in an e-cigarette and at what level and with what long-term health consequences."

Public Health England estimates these devices are 95 percent safer than cigarettes. But as Prochaska points out, "In the US alone, cigarettes cause 480,000 deaths annually. Does this mean e-cigarettes will cause about 24,000 deaths?"

The truth is, we don't yet know. It's possible long-term e-cig use will cause diseases we aren't even looking for, ones that look much different than the cancers and heart disease brought on by smoking. It's also possible we'll learn these devices lead to no extra deaths but save many more lives.



For now, we know this: the weight of evidence suggests e-cigarettes are the lesser of two evils — even despite the unknowns. Therefore, treating them as equal to standard cigarettes doesn't make sense.