Cutting through

How can consumers cut through the conflicting knot of news and commentary on e-cigarettes and vaping? Web searches find a tangle of pro, con or undecided views, with examples of encouraging and discouraging pieces even within The Huffington Post. The broad class of non-burning, usually nicotine-delivering vaping devices (e-cigarettes) has been clear to some in its value to reduce harm for smokers or equally clear to others in its dangers for public health. Conflicting health information on e-cigs is part of a common problem consumers face in wondering which of any health reports to believe and act upon.

I continue to think that there are ample good reasons to treat e-cigs as a class of products that are much less dangerous to health than are cigarettes and that smokers should be encouraged to use them instead of cigarettes as soon as possible. Cigarettes are by far the most dangerous nicotine delivery system, with smokers dying on average 10 years earlier than never smokers.

Cutting in

E-cigs have thrived with consumers as generally unregulated products that have significantly cut into cigarette sales with an estimated 2 billion dollars in sales in 2013. This is predicted to rise to 17 billion dollars in 2017 and to surpass cigarette sales by 2021. It remains to be seen the extent to which e-cigarettes succeed by replacing cigarettes or by joining cigarettes in the marketplace. Whatever e-cigarette regulation the Food and Drug Administration (FDA) may put in place could change the future for this product. The large market for e-cigs should make the FDA wary of any regulatory steps it might take that could promote a significant black market in e-cigarettes. The FDA is prevented by its rules from making any changes in cigarettes that would create a contraband market in cigarettes, just as it is prevented from banning cigarettes. Similar protections should be considered for the much safer product, e-cigs, especially since they have become so popular.

Cutting down

One manufacturer of popular e-cigs has noted that many of their customers are still using tobacco cigarettes alongside e-cigs. For the public's health, we should be concerned about how many cigarette smokers are just using e-cigs to cut down their smoking rather than to eliminate their smoking. (It is possible that misplaced fears about the dangers of e-cigarettes, compared to cigarettes, support continued smoking.) One might assume that any drop in cigarettes smoked caused by e-cigarette use leads to a reduction in disease risks, but unfortunately this may not be true, especially with smaller reductions in cigarettes used. The toxins that smokers get from each cigarette depend on the details of how each cigarette is puffed, and it is not easy or common for smokers to be monitoring how many or how large are the puffs they take. Consider that a cigarette can be smoked in a standard fashion to deliver 15 mg. of tar, yet the same cigarette with more and larger puffing can yield 70 mg. of tar. The number of cigarettes smoked per day is a very crude measure of what a smoker gets from a day of smoking. One study of smokers who were housed in a laboratory for a few days with controlled access to cigarettes and with precise measures of nicotine and other exposures found examples of smokers who dropped from around 40 cigarettes per day to 15 cigarettes and had very small drops in nicotine intake. Remarkably, one of the participants even increased daily nicotine exposure when reducing from just over 40 to 15 cigarettes per day. Smoking a cigarette is not like taking a pill with a fixed dose of drug: What is gotten from a cigarette depends on how it is smoked, and there is a tendency to compensate for declines in nicotine intake by over-smoking each cigarette. This is known as "compensatory smoking." Insofar as e-cigs (or other nicotine-containing products) are a source of significant doses of nicotine, the pressures for compensatory smoking should decrease. One good test of the satisfactions from an e-cigarette would be the ability to fully substitute for cigarettes.

Cutting out

Of course, smokers will do whatever smokers will do with their choices about continuing or reducing smoking. And the FDA can be seen to help smokers in exercising their choices to continue smoking through its protective regulation of traditional, deadly cigarettes. The FDA has succeeded in banning cigarette flavors other than menthol and in outlawing misleading labels (e.g., light, mild), but the main cigarette products on the market before the regulation started are still available. The FDA can also be criticized for the barriers it raises to the active comparative promotion of less-dangerous products (e.g., smokeless tobacco or nicotine replacement products) as much less dangerous than cigarettes. Depending on current or emerging laws at federal, state or local levels, vapors may have an even more challenging future in the United States. At the same time, given the current, large market for vaping, certain measures may be hard to enforce, especially if adjacent jurisdictions take very different approaches to control.

Smokers should be mindful of the risks of only cutting down their smoking, compared to the clear advantages of cutting out smoking completely. So, I try to offer one clear message to cut through the confusion of information on e-cigarettes: The clearest way to reduce smoking risks with vaping is to stop smoking. If needed, trying different vaping products can help smokers identify which are most helpful in getting them to end smoking.