Commentary on Wagener et al. (2012): E-cigarettes: a vulnerable promise


Wagener, Siegel & Borrelli [1] provide a much-needed counterbalance to the generally negative response to e-cigarettes (EC) by most tobacco control activists. The calls to ban or at least to severely regulate EC, even in the absence of any clear evidence of harm or risk, may seem prudent and protecting public health from one perspective, or misguided and harmful to public health from another.

EC seem to have potential both as a smoking cessation treatment and as a consumer product, paving the way for nicotine delivery systems to compete with conventional cigarettes (CC) on the open market. The former is important, but the latter could have an even larger impact. The aim of this commentary is to expand the arguments of Wagener et al. in this less often-addressed direction.

The treatment potential of EC is clear. They seem more attractive to smokers than the existing nicotine replacement products (NRT), which are rarely used recreationally; they are cheaper; and in experienced users at least they probably provide better nicotine delivery [2]. To be marketed as treatment, EC will need to undergo the usual requirements regarding proof of efficacy and production and content controls. Wagener et al. make such points succinctly and well.

The consideration of EC as a consumer product is even more exciting. If a harmless nicotine delivery device appeared which would be capable of competing with tobacco products in the market-place, the public health benefit would be enormous. I personally do not think that the current versions of EC are as yet up to the task of replacing CC, but they can be seen as a trial run of a hugely promising new development. The first evidence is emerging that perhaps 20% of smokers who try EC become regular users [3]. Our reaction to this first dawn of a credible non-tobacco consumer nicotine product is likely to influence future developments profoundly. If we ban EC or make them jump through hoops and choke them in red tape, the deadly CC will continue to rule unchallenged.

The general approach to EC at the moment seems to be dictated by an a priori suspicion that they are bad. Wagener et al. show that the main objections to EC generated so far are largely spurious. Others can be added to the list. I have heard it argued that if EC are not regulated, some smokers may purchase brands which deliver little nicotine or deliver it inconsistently. No regulation is needed on how much caffeine different brands of teabags must deliver (the drug content is not even marked), or how tasty and consistent in taste a chocolate bar has to be, or how entertaining a film must be. Consumer products which are not very good will leave a few purchasers disappointed, this is true, but such products will not stay on the market for long, and their failure becomes a valuable benchmark for everyone else.

Since Russell's call for harmless alternatives to cigarettes to compete with the tobacco products on the open market [4], smokers who are unable or unwilling to quit have been waiting for a palatable alternative to conventional cigarettes which gives them what they want without killing them. EC are the first sign that such a product can be commercially viable. The public health community should support this development.

Declarations of interest

P.H. has received funding from manufacturers of stop-smoking medications but has no links with any manufacturers of e-cigarettes.