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E-cigarettes have considerable potential to provide an alternative to combusted tobacco use for people who are unable to completely give up tobacco or failed with medicinal nicotine, and thus promise a far safer way of delivering nicotine. However, it is possible they could increase harm if they delay cessation in people who use them just to manage situations where they cannot smoke or who perceive that they are reducing harm by smoking fewer cigarettes. Some commentators have expressed concerns about the potential for e-cigarettes to become a gateway product for non-smokers into long-term nicotine dependence or to take up cigarette smoking, and the possibility involvement of the tobacco industry might undermine tobacco control efforts; however, there is limited evidence to date to support these concerns.

Harm reduction is a viable concept in some areas of substance misuse. Just how viable a harm reduction approach is in tobacco control, particularly in regard to the extent to which it succeeds in delivering overall population health gain, is a key question that has been highlighted by the advent of e-cigarettes. E-cigarettes may serve as a substitute dependency (Zeller & Hatsukami, 2009), which is the very nature of tobacco harm reduction, so long as the dependence is of lower overall harm. In this case, using such a product to deliver the substance (in this case, nicotine delivery by e-cigarettes) instead of a known very harmful one (nicotine in tobacco smoke) would seem preferable from a public health perspective.

Surveys show that many people report using e-cigarettes to reduce harm or risks to their health by substituting e-cigarettes for some or all of the tobacco cigarettes they usually smoke (Etter & Bullen, 2011; Foulds & Veldheer, 2011; Kralikova et al., 2012).

Polosa et al. (2011) reported on an uncontrolled prospective study of 40 smokers not willing to quit, provided with e-cigarettes to use for up to 12 weeks, and followed over 6 months. One third of the participants who attended the six month follow up visit had cut down the number of cigarettes smoked by 50%. In a (n=300) three-arm trial of nicotine versus non-nicotine e-cigarettes, among smokers unwilling to quit, the same researchers found cigarette consumption declined by 50% in around 10% of participants over one year (Capponetto et al., 2013).

Bullen et al. (2013) also found a substantial decline in tobacco use over six months among participants in a cessation trial who didn’t quit, and this was more so in e-cigarettes users than those randomized to patches.

One concern is that the availability of safer products (such as e-cigarettes) may discourage people from quitting tobacco altogether. There is limited evidence for this concern. Indeed, in England, people who used e-cigarettes in situations where they couldn’t smoke were more motivated to quit and to have tried to stop in the recent past than those who did not (Dockrell et al., 2013).

Another concern is that new products may be ‘gateways’ to tobacco use; the worry is that experimentation with e-cigarettes may lead to long term use and dependence, and encourage the transition by some to tobacco smoking. Adolescents typically enjoy taking risks and experimenting; they may view e-cigarettes in the same way they view tobacco cigarettes, as a symbol of rebellion, sophistication and novelty, and functionally (Grana, 2013). However, to date, there is no evidence this concern is valid. Surveys have shown increasing yet very low levels of experimentation with e-cigarettes among young people but no studies have demonstrated this leads to tobacco smoking. Surveys and focus groups conducted in South Korea (Cho et al., 2011), the US (Choi et al., 2012; Choi et al., 2013; Pepper et al., 2013), and Poland (Goniewicz et al., 2012) have found that while many young people are aware of e-cigarettes, only a very small proportion (3% of adolescents who were never smokers in the Polish survey) were willing to try, or had tried, them.

In the US, there is evidence of increasing experimentation with e-cigarettes but mostly in people who were smokers. Analysis of findings from National Youth Tobacco Surveys in 2011 and 2012 on self-reported e-cigarette use (defined as ever use, even a single trial) found among all students in grades 6-12, e-cigarette ever-use increased from 3.3% to 6.8% (p<0.05); current e-cigarette use increased from 1.1% to 2.1% (p<0.05), and current use of both e-cigarettes and conventional cigarettes increased from 0.8% to 1.6% (p<0.05) (Corey et al., 2013). In the UK, a survey of over 12,000 adults and 2,178 children in February and March 2013 found no non-smokers regularly used e-cigarettes, despite awareness being very high (two thirds of 11-18 year olds were aware) (ASH, 2014).

Finally, some commentators have suggested that current tobacco control efforts might be undermined by the wide acceptance of such new products, in particular that the tobacco industry may use the perception of a ‘safer’ product to its advantage, as has occurred in the past with so-called  ‘light’ or ‘mild’ cigarettes (Cobb et al., 2010).

Action on Smoking and Health. Use of e-cigarettes in Great Britain among adults and young people. April 2014.

Bullen C, Howe C, Laugesen M, McRobbie H, Parag V, Williman J, Walker N. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet. 2013 Nov 16;382(9905):1629-37.

Caponnetto P, Campagna D, Cibella F, Morjaria JB, Caruso M, Russo C, Polosa R. EffiCiency and Safety of an eLectronic cigAreTte (ECLAT) as tobacco cigarettes substitute: a prospective 12-month randomized control design study. PLoS One. 2013 Jun 24;8(6):e66317.

Cho JH, Shin E, Moon SS. Electronic-cigarette smoking experience among adolescents. J Adolesc Health. 2011 Nov;49(5):542-6.

Choi K, Fabian L, Mottey N, Corbett A, Forster J. Young adults' favorable perceptions of snus, dissolvable tobacco products, and electronic cigarettes: findings from a focus group study. Am J Public Health. 2012 Nov;102(11):2088-93.

Choi K, Forster J. Characteristics associated with awareness, perceptions, and use of electronic nicotine delivery systems among young US Midwestern adults. Am J Public Health. 2013 Mar;103(3):556-61.

Cobb NK, Byron MJ, Abrams DB, Shields PG. Novel nicotine delivery systems and public health: the rise of the "e-cigarette". Am J Public Health. 2010 Dec;100(12):2340-2.

Etter JF, Bullen C. Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy. Addiction. 2011 Nov;106(11):2017-28.

Foulds J, Veldheer S. Commentary on Etter & Bullen (2011): could E-cigs become the ultimate nicotine maintenance device? Addiction. 2011 Nov;106(11):2029-30.

Goniewicz ML, Zielinska-Danch W. Electronic cigarette use among teenagers and young adults in Poland. Pediatrics. 2012 Oct;130(4):e879-85.

Grana RA. Electronic cigarettes: a new nicotine gateway? J Adolesc Health. 2013 Feb;52(2):135-6.

Kralikova E, Kubatova S, Truneckova K, Kmetova A, Hajek P. The electronic cigarette: what proportion of smokers have tried it and how many use it regularly? Addiction. 2012 Aug;107(8):1528-9.

Pepper JK, Reiter PL, McRee AL, Cameron LD, Gilkey MB, Brewer NT. Adolescent males' awareness of and willingness to try electronic cigarettes. J Adolesc Health. 2013 Feb;52(2):144-50.

Polosa R, Caponnetto P, Morjaria JB, Papale G, Campagna D, Russo C. Effect of an electronic nicotine delivery device (e-Cigarette) on smoking reduction and cessation: a prospective 6-month pilot study. BMC Public Health. 2011 Oct 11;11:786.

Zeller M, Hatsukami D; Strategic Dialogue on Tobacco Harm Reduction Group. The Strategic Dialogue on Tobacco Harm Reduction: a vision and blueprint for action in the US. Tob Control. 2009 Aug;18(4):324-32. logo
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