Experts debate public health consequences of e-cigarettes

How do we reduce health risk in the face of harm that can’t be eradicated completely? That’s the question Lloyd Minor, MD, dean of the School of Medicine, presented to the audience Oct. 26 at a Health Policy Forum on e-cigarettes — a topic about which he said “intelligent and reasonable people can disagree.”

E-cigarettes are a controversial subject in the public-health community. Panelists at the event debated whether the recently developed devices hold promise to help long-time smokers move away from combustible cigarettes, or whether they could abet a renormalization of smoking.

All panelists agreed that those under the age of 21 shouldn’t be using any nicotine delivery devices, and they shared a goal of minimizing general use of harmful health products. They disagreed, however, on what the advent of e-cigarettes means in accomplishing those goals.

Clinical psychologist David Abrams, PhD, executive director of the Schroeder Institute for Tobacco Research and Policy Studies at Johns Hopkins University, described himself as a harm reductionist. He argued that, as an alternative mode of nicotine delivery, e-cigarettes pave the way for saving lives by helping addicted smokers avoid traditional cigarettes.

“I do think the evidence is very solid that they are dramatically less harmful than cigarettes ... because they absolutely have very low, almost undetectable levels or trace amounts of the top eight carcinogens that are found in cigarettes, and they have no carbon monoxide,” he said.

But a lack of extensive research makes Stanford’s Robert Jackler, MD, professor and chair of otolaryngology, and Bonnie Halpern-Felsher, PhD, professor of adolescent medicine, question whether vaping is actually safe. And a prevalence of candy-flavored e-liquids leaves them concerned about the potential for harm to youth.

“Let me point out that you can smoke [combustible cigarettes] for many years before you get chronic destructive lung disease,” said Jackler, the Edward C. and Amy H. Sewall Professor in Otorhinolaryngology, who leads a Stanford research team studying the impact of tobacco advertising, marketing and promotion. “So while I agree ... that they are safer, the presumption that they are safe for teenagers to adopt as opposed to combustible tobacco, we won’t know that for decades.”

In the meantime, he worries that “we’re experimenting with the lungs of teens.”

Teens susceptible to marketing claims

Jackler and Halpern-Felsher also expressed concern about the perception of e-cigarettes in the eyes of young people. They worry that touting e-cigarettes as cessation devices has led to a misconception that e-cigarettes carry no health risks.

“We are now seeing early evidence that those ... who never would have used or intended on using a tobacco product, when you ask them about e-cigarettes they do have an intention. They are more susceptible to it,” said Halpern-Felsher. She explained that when teens see claims about the cessation benefits associated with e-cigarette use, they assume that it’s safe to start using them.

“Kids are seeing tons of advertisements about the benefits, but not about the risks,” she said.

Abrams acknowledged these concerns but countered with an analogy to safe sex: “What we say to kids is that we’d rather you don’t have sex at all, but if you do please use a condom. We don’t go on and on [about the fact] that 2 percent of condoms fail and therefore you shouldn’t use them.”

In the end, the three all agreed that marketing plays a huge role in the popularity and social acceptability of smoking. 

“Brilliant marketing of a lethal product that nobody needed made half the population buy it,” Abrams said, referring to traditional cigarettes.

“And now we're seeing it again with e-cigarettes,”  Halpern-Felsher added.