Neil McKeganey | 27 August 2014
Have health professionals started a new moral panic over e-cigarettes? Neil McKeganey thinks they have.
There are few things more powerful than the narrative of fear. The concern that something may be harming us in ways that we might have been unaware, and that action should be taken to limit its occurrence, is a foundational tablet of interventionist public policy. The narrative of fear can be equally strong when it comes to new items that emerge in our social world and about which we know relatively little.
E-cigarettes are a good example of the narrative of fear in action. There are a whole host of things we do not know about e-cigarettes. We don’t know much about the impact of their long-term use (hardly surprising given that their use has only become widespread in recent years), we don’t know a great deal about why people are attracted to them, why they might try them, persist with them, or reject them. We don’t know whether e-cigarettes appeal because they look like cigarettes or because they smell and taste nothing like cigarettes. We don’t know whether e-cigarettes are a way of reducing smoking or increasing nicotine intake. I saw an advert recently for e-cigarettes that said “vaping” a single e-cigarette is the equivalent of smoking 40 cigarettes. I don’t know if that advert is targeted at the person who wants to stop smoking or the person who wants to increase their nicotine intake. You could say it is deliberately ambiguous to appeal to both.
There is so much that we don’t yet know about e-cigarettes, but what seems beyond doubt is the fact that they are substantially less harmful than smoking combusted tobacco. What we also know is that e-cigarettes are being consumed by an increasing number of people. Within the United States it has been estimated that 2% of smokers had used an e-cigarette in 2010 with that figure rising to 30% by 2012. Within the UK, a survey undertaken by Action on Smoking and Health found that the level of e-cigarette use among smokers had increased from around 3% in 2010 to 13% in 2013. With that rate of growth there is a very real possibility that over the next ten years e-cigarettes might overtake combustible tobacco. If that were to happen the tobacco industry could find itself facing a stark choice – either get into e-cigarettes big time (which they are beginning to do now) or face the inevitable disappearance of their primary market.
On the basis that e-cigarettes are safer than smoking combusted tobacco you might have thought that they would have been given at least a cautious welcome by those concerned for the health of the public. But in that you would be very wrong. In a recent interview in the New Scientist magazine, the Chief Medical Officer for England, Dame Sally Davies, identified e-cigarettes as one of the major threats to public health. Similarly, the Welsh government looks set to ban e-cigarettes in enclosed public spaces. In shops, airplanes, offices and restaurants across the world e-cigarettes have been the subject of informal but non-negotiable restrictions often on the basis of little more than the inconvenient fact that to the untrained eye they may be barely distinguishable from smoked cigarettes. These reactions are about as far from offering e-cigarettes a cautious welcome as it is possible to get- short of an outright ban.
The narrative of fear around e-cigarettes is not so much that they might be harmful in themselves but that they might result in smoking being re-normalised. There are two possible ways in which this ‘re-normalising effect’ might be happening. First, if people using e-cigarettes are inclined to move onto smoked tobacco. Within that scenario e-cigarettes would be acting like a gateway drug to combustible tobacco.
But is there evidence that such a gateway effect is even occurring or is this largely a theoretical anxiety? A recent survey of 19,414 e-cigarette users found that 99.5% of those surveyed were already smoking tobacco when they started to use e-cigarettes, and that most of those who were using e-cigarettes were doing so as a way of reducing or quitting smoking. Similarly, recent research from University College London found that e-cigarettes had a stronger effect in quitting smoking than over the counter nicotine replacement patches. On the basis of those results, e-cigarettes look less like a gateway into smoking than a possible road out of smoking.
The second way in which e-cigarettes might be ‘re-normalising’ smoking is through young people being encouraged to take up smoking as a result of seeing increasing numbers of other people doing something that outwardly looks like smoking, even if it is not actual smoking. This is a much more nebulous effect and much harder to prove one way or another. To date there have been no studies that have actually shown that this effect is even occurring. However for the narrative of fear to take hold you don’t actually need evidence. What you need instead is a plausible story that some untoward effect might be happening and in the very plausibility of the alarm you are raising, you have a reason for interventionist control. You could even say that the narrative of fear thrives best in the absence of evidence since there are few things more fearful than the threat you can’t assess, and there are few things that gets public health practitioners more exercised than a perceived threat to the public health.
Persuade people that something might be harmful, or that it might lead to something that is even more harmful, and you are one step away from accepting the case for regulated control. Once you have accepted the narrative of fear, only the dangerously cavalier would reject the proposed controls. But when the thing you are limiting access to (e-cigarettes) is less harmful than the thing you are saying it re-normalises (smoking), you face a bit of a dilemma in answering the question of why you are not banning the more harmful thing in the first place. If smoking is so dangerous that you are fretting about the thing that might re-normalize it, why don’t you just ban smoking? To do that of course would be to jeopardise the billions in tax revenue that tobacco generates for governments across the world. Far better, you might say, to tackle the thing that may be re-normalising smoking and which is not generating you much in the way of tax revenue anyway.
However it is not only the public health practitioners that are getting into lather over e-cigarettes. In a move that is virtually unheard of in addictions research, the leading journal Addiction recently ran an editorial calling for greater oversight of research around e-cigarettes, conceding that in some cases the claims being made around e-cigarettes cannot be trusted.
“Current research and commentaries on electronic cigarettes”, they point out, “vary widely in quality, accuracy and objectivity”. The authors of this editorial go on to note that what is needed now is more rigour and oversight “to ensure that interpretation of evidence is guided by data, not emotions, and that strong statements based on weak evidence are avoided.” E-cigarettes, they say “may offer a way out of the smoking epidemic or a way of perpetuating it; robustly designed, implemented and accurately reported scientific evidence will be the best tool we have to help us predict and shape which of these realities transpires”. In nearly thirty years of drugs research I cannot recall an editorial, in such a prestigious journal, calling into question the very integrity of the scientists carrying the research and conceding the need for greater oversight of their work.
However the fears around e-cigarettes have to do with more than the content of the vapour lifting languidly from the electronically illuminated cigarette tips or the impact of e-cigarettes on individual’s behaviour. In a word it has to do with the involvement of the tobacco industry. The tobacco industry is now closely involved in the production and sale of e-cigarettes, buying up e-cigarette companies with increasing frequency and clearly preparing itself for the possibility of a mass flight from tobacco.
According to The Lancet, the involvement of the tobacco industry in the e-cigarette equation has delivered public health practitioners with an unexpected “moral quandary”. Increasingly public health practitioners are facing the dilemma of whether to embrace e-cigarettes as a result of their evident public health benefit or reject them as a way of avoiding “colluding” with what The Lancet describes as “one of the industries most devastating to health”.
It would be a tragedy of epic proportions if the negative views of the tobacco industry were to impede individual’s access to what may turn out to be the single most influential means of reducing tobacco related harm. Those whose antipathy towards the tobacco industry leads them to a negative view of e-cigarettes may feel that they are remaining true to the tobacco control mantra, but in doing so they may find themselves promoting the very harm they have dedicated themselves to reducing. It is too early to say whether the tide will turn in favour or against e-cigarettes but what is certain is that there will be much more soul searching to come before the place of e-cigarettes in tobacco control and tobacco related harm reduction is finally determined.
Neil McKeganey is Director of the Centre for Drug Misuse Research, Glasgow.
This article was originally published in Druglink August/September 2014. See http://www.drugscope.org.uk/publications for more details.