Our Guest Blogger today is Dr. Cheryl Healton, Dean of Global Public Health at NYU and the Director of the Global Institute of Public Health. She weighs in on the proposed legislation to extend the NYC Smoke-Free Air Act to include e-cigarettes:
The New York City Council will vote tomorrow whether to extend the NYC Smoke-Free Air Act (SFAA) to e-cigarettes. This decision is a key turning point for tobacco control policy and will have potentially broad national and even global implications. How e-cigarettes will influence youth entry to tobacco use and the efforts of people to quit smoking and to stay quit remain unknown, but the net impact could be dire.
Who is the e-cigarette industry?
Increasingly the e-cigarette industry is owned by the tobacco industry, an industry that would not be permitted to exist were it invented tomorrow because it would violate the consumer protection laws of all states and virtually every country in the world. For this reason, a healthy degree of skepticism about the industry’s ultimate goal in buying up e-cigarette manufacturers and creating more “efficient” e-cigarettes should prevail as policy makers establish regulations governing them. It is quite possible that the net effect of e-cigarettes will be to induce greater youth initiation of smoking and reduce the adult cessation rate, but the jury is still out. Both youth and adult smoking rates are at their lowest levels in decades, so much is a stake for the health of the public. There is also much at stake for the tobacco industry as it seeks to apply its considerable marketing acumen and seemingly endless resources to maximize profit by increasing the number who start smoking by enticing youth worldwide to smoke and by trying to retain current smokers.
Who might be hurt by e-cigarettes?
The tobacco products the industry has historically manufactured and promoted as “reduced harm” are not benign products created to meet the broad range of consumer preferences in the United States, rather they are deadly products that when used as directed kill over 400,000 Americans each year and are predicted by the World Health Organization to kill a billion people worldwide this century, 10 fold more than they killed in the 20th century. To put the scope of the current tobacco-related epidemic in perspective, in a few years, global lung cancer deaths will surpass AIDS deaths as the steady march of tobacco industry marketing continues to engulf the world’s poorest nations. Whatever role e-cigarettes may come to play with regard to the tobacco epidemic in rich countries will play out worldwide in the decades to come.
Nicotine addiction is in and of itself a gateway to tobacco product use because once addicted many will broaden the products they use and included among these will be the most dangerous products like cigars, cigarettes and hookah. Most tobacco-related deaths are the culmination of substantial suffering and societal cost from heart disease, emphysema or various cancers and are the direct result of nicotine addiction. Moreover, nicotine addiction is considered by many scientists as the most intractable of all addictions as measured by the percent of ever users who become addicted and the percent who remain addicted until death. Half of lifelong smokers lose their lives to tobacco addiction and among these people nearly half die before retirement age.
E-cigarettes are a complex product and their availability and the regulatory framework for governing them may have different implications and considerations for youth non-smokers compared to adult smokers. E-cigarette policy could produce sharply differing results by population sub-group. Data demonstrate that a significant swath of adolescents already are using e-cigarettes. Time will soon tell whether e-cigarettes function as one more point of entry to cigarette, cigar and hookah consumption among those using e-cigarettes initially. One thing is clear however, since cessation efforts have thus far not worked with teens, e-cigarettes will likely not do anything good for kids and may well entice many to start smoking in view of the broad array of sweet, candy flavors and slick e-cigarette marketing already blanketing the internet, mall kiosks, TV and radio, which have to date eluded regulation.
Whether e-cigarettes will offer an incremental boost to cessation rates nationally also remains to be seen. While one well-designed but small study found modest cessation effectiveness in a clinical trial, the effectiveness was no better than the nicotine patch. Another analysis of over 5000 smokers in 4 countries including the US, found no association with e-cigarettes use and stopping smoking but did find that users vaped where they otherwise could not smoke. Time will tell whether e-cigarettes help people quit and we should remain open to the possibility that e- cigarettes may indeed improve cessation rates for some sub-groups. We should also remain open to another highly plausible effect of e-cigarettes-that they will function in the same manner “light” cigarettes did when they were introduced in the 70’s, promoted by the tobacco industry as a step smokers could take to feel safer without actually quitting smoking. As many subsequent studies showed, in fact they were not safer and millions who would have quit had they not been introduced failed to do so costing innumerable lives.
Do we really want everyone vaping where they once could smoke?
The proposed extension of the SFAA to e-cigarettes, which will be voted on tomorrow, also will reduce the “walking billboard” effect of thousands of New Yorkers once again lighting up in bars, subways, parks, office buildings and restaurants throughout the city. But banning e-cigarettes in some locations solely for this reason is un-American in a country that prides itself on maximizing the freedom of its adult citizens to choose to engage in a range of risky and frisky behaviors. It should be noted, however, that while we in general embrace this ethos, when it comes to public drinking we often do not. We do not embrace wandering down the street drinking a cocktail, hopping into the elevator rum and coke in hand or whipping out a flask of whiskey on a plane.
Do we know enough to allow vaping in public spaces?
So what are the real risks of public vaping? Is it as its promoters would like us to believe a benign, reduced harm practice that is at worst a passing fancy? Or is it a potentially toxic practice that places those in its immediate vicinity at risk. The answer is we do not completely know yet, although already studies have shown elevated nicotine levels among those exposed to secondhand vaping, and this in and of itself is ominous. Not definitively measured as yet among second hand vapers are the myriad other toxic substances which are contained in e-cigarettes. Under these circumstances, the prudent course is to extend the SFAA to encompass e-cigarettes until, if ever, sufficient evidence exists demonstrating their safety.
The only conceivable downside of not extending the SFAA to e-cigarette use is the loss of any incremental harm reduction for smokers associated with being permitted to smoke e-cigarettes in locations where smoking is now banned. It is highly unlikely that such a benefit, if it in fact exists, would outweigh the harms to youth, to non-smokers exposed to vaping nicotine laden vapors and potentially other toxins, and to recovering smokers who now stay quit in part because smoking has become less ubiquitous than it was 50 years ago when the Surgeon General released the first report on Smoking and Health.
Sadly e-cigarettes may lead to four negative outcomes: the initiation of more youth to nicotine dependence and subsequent conventional smoking; the use of e-cigarettes by current cigarette smokers who would otherwise have quit but instead use both conventional cigarettes and e-cigarettes in combination and therefore delay quitting or never quit and; the relapse to smoking by those who have already quit, first to smoking “benign” e-cigarettes and then to conventional cigarettes; and the exposure of people to e-cigarettes’ emissions unknown risks.
Who loses, if anyone, by extending the SFAA to e-cigarette use?
Virtually no one loses. Vapers can still smoke everywhere current smokers now do. Let’s do what NYC has become known for and enact a policy that saves lives, not costs them.