All Commentary
Wednesday, May 15, 2019

E-Cigarettes: The Cold Hard Facts

India should reverse it's ban on e-cigarettes because they are substantially safer than regular cigarettes and capable of preventing millions of avoidable deaths if smokers switch to them.

Image Credit: U.S. Air Force photo/Staff Sgt. Evelyn Chavez

According to the WHO, more than one million Indians die every year of tobacco-related causes, amounting to 9.5 percent of all deaths in India. As of 2016-17, 19 percent of all male adults and 10 percent of all adults in India are smokers. Furthermore, 38 percent of adults and 22 percent of youth (aged 12-15) are exposed to secondhand smoke at home. Smoking damages nearly every organ in the body, especially the heart and lungs. As part of its tobacco control efforts, the Indian government has decided to ban e-cigarettes. However, e-cigarettes are proven to be substantially safer than regular cigarettes and are capable of preventing millions of avoidable deaths if a large proportion of smokers are able to switch to them.

India should reverse it’s ban on e-cigarettes because they are substantially safer than regular cigarettes and capable of preventing millions of avoidable deaths if smokers switch to them.

In August 2018, the Indian Ministry of Health issued a non-binding advisory to all states asking them to ban Electronic Nicotine Delivery Systems (ENDS), including e-cigarettes, “in [the] larger public health interest and in order to prevent the initiation of ENDS by non-smokers and youth with special attention to vulnerable groups.” As of today, e-cigarettes are banned in 12 Indian states. More recently, in February 2019, the Central Drug Regulator directed all drug controllers in states and union territories to ban ENDS in their jurisdictions. However, the Delhi High Court stayed the ban till May 17, 2019.

Smoking and its related public health concerns are a rather hot-button issue. It becomes vital in such a case to set emotions aside and look at cold, hard facts. In this piece, I defend e-cigarettes against three major claims used to justify bans on their use.

Are They Safe? 

The first is that e-cigarettes are not safe and that their use can lead to cardiovascular disease, tumors, and long-term brain development problems, among other health problems. It is true that e-cigarettes are not completely safe. The important question, however, is whether they are safer than existing alternatives, i.e. regular combustible cigarettes.

Research shows that e-cigarettes are safer than regular cigarettes by an order of magnitude. According to Nutt et al. (2014), cigarettes are more than 10 times as harmful to the user as e-cigarettes. Even the most pessimistic estimate of the relative safety of e-cigarettes pegs it at 2x.

The reason e-cigarettes are so much safer is that unlike cigarettes, e-cigarettes deliver nicotine by vaporizing a liquid, and they don’t burn any tobacco. Burning of tobacco, as in regular cigarettes, leads to a lethal mix of carbon monoxide and 70 known cancer-causing chemicals, which, when inhaled, have detrimental health effects. As British psychiatrist and scientist Michael Russell so eloquently put it, “People smoke for nicotine but they die from the tar.”

Source: Figure 1, Abrams et al. (2018)

Do They Work? 

Second, e-cigarette skeptics say they don’t help in quitting smoking and are likely to increase addiction. There is evidence from two randomized control trials that e-cigarettes do help smokers to quit, with one study showing they are twice as effective as nicotine patches. E-cigarettes can be an effective tool for enabling smoking cessation precisely because they appeal to smokers. McRobbie et al. (2012) state:

One of the limitations of current treatments is that none adequately address the ritual and sensory aspects that smokers miss when they stop smoking (e.g. holding a cigarette in their hands, taking a puff, etc.) and the enjoyment people derive from smoking.

E-cigarettes are a great way to overcome this limitation. While the evidence here could definitely be strengthened, as long as e-cigarettes are not worse than regular cigarettes in terms of nicotine addiction, the massive reduction in harm to the health of smokers still makes them a public health benefit.

Are They a Gateway Drug for Youth?

The third concern is that e-cigarettes are attractive to youth and are a “gateway drug” to regular smoking for those who wouldn’t have smoked at all had there been no e-cigarettes. But there simply isn’t any concrete causal evidence that shows that adolescents who are exposed to e-cigarettes are more likely to become smokers in the near future. Referring to data from the United States, Warner (2018) writes that

… the implicit notion that a gateway effect will increase smoking by young people and renormalize smoking is inconsistent with findings from population-level surveys that cigarette smoking, and other tobacco product use, declined significantly precisely during the years in which e-cigarette use became popular.

While this is a genuine concern for a vulnerable section of the population, instead of an outright ban, the more pragmatic way to address it is to put strong restrictions on e-cigarette manufacturers preventing them from selling and advertising to persons below the age of 18.

There are more than 100 million smokers in India who face dreadful risks to their lives and health. The risks of e-cigarettes relative to regular cigarettes are vastly exaggerated. Even after taking into account possible risks, e-cigarettes have tremendous potential for harm reduction and are a net public health benefit to the country. Like the UK, US, Norway, Canada, and New Zealand, the Indian government should use them as a complement to other evidence-based smoking prevention and cessation interventions.