short report Wien Klin Wochenschr (2015) 127:570–576 DOI 10.1007/s00508-015-0800-0
A public health strategy for e-cigarettes Sven Schneider · Katharina Diehl
Received: 12 December 2014 / Accepted: 21 April 2015 / Published online: 27 May 2015 © Springer-Verlag Wien 2015
Abstract The e-cigarette may present a new and significant Public Health problem: Studies published so far do not seem to indicate that e-cigarette use is just a passing trend. If e-cigarette use is less harmless than it is portrayed in many advertisements, Public Health would do well to start a serious discussion about a suitable prevention policy as soon as possible.The aim of this short paper is to discuss a range of measures designed to prevent e-cigarette consumption.Concretely, we suggest to monitor e-cigarette use, the e-cigarette industry and prevention policies, to implement a vapor-free policy, to develop help to quit e-cigarette use, to inform about the health risks of e-cigarette use, to establish regulations on e-cigarette advertising, promotion and sponsorship, and to introduce taxes on e-cigarettes.
eine angemessene Prävention nachdenken.Ziel dieses kurzen Beitragesist es, Maßnahmen zur Prävention des e-Zigarettenkonsums zur Diskussion zu stellen.Konkret schlagen wir vor, ein Monitoring des e-Zigarettenkonsums sowie der e-Zigarettenindustrie und der Präventionspolitik zu implementieren, Schutz von Passivdampf sicherzustellen, den Ausstieg aus dem e-Zigarettenkonsum zu fördern, über potenzielle Gesundheitsrisiken der e-Zigarette zu informieren, Werbebeschränkungen zu erlassen und e-Zigaretten zu besteuern.
Keywords Electronic cigarette · e-cigarette · Electronic nicotine delivery system · Electronic nicotine delivery device · Prevention · Nicotine
Introduction
Zusammenfassung E-Zigaretten stellen möglicherweise ein neues und bedeutendes Public Health-Problem dar. Bisherige Studienlegen nahe, dass die Verbreitung von e-Zigaretten nicht lediglich ein vorübergehender Trend zu sein scheint. Wenn der Konsum von e-Zigaretten weniger harmlos sein sollte als in der Werbung dargestellt, sollte das Öffentliche Gesundheitswesen rechtzeitig über Prof. Dr. S. Schneider, M.A. () · Dr. K. Diehl Mannheim Institute of Public Health, Social and Preventive Medicine (MIPH), Medical Faculty Mannheim, Heidelberg University, Ludolf-Krehl-Str. 7–11, 68167 Mannheim, Germany e-mail: [email protected] Dr. K. Diehl e-mail: [email protected]
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Schlüsselwörter Elektronische Zigarette · E-Zigarette · Electronic nicotine delivery system · Electronic nicotine delivery device · Prävention · Nikotin
It is possible that in a few years we will consider the impact of e-cigarettes (short for: electronic cigarettes) irrelevant to Public Health. But, it is also possible that it represents the development of a new worldwide health risk. We should not ignore the possibility of such a development, and therefore it is definitely worth looking more closely at the e-cigarette use, even at this early stage. E-cigarettes include a wide product range and are offered with nicotine as well as without nicotine (e.g. e-shishas or e-hookahs). Hereafter, we use the common definition of e-cigarettes as ‘any electronic oral device, such as one composed of a heating element and battery or electronic circuit, or both, which provides a vapour of nicotine or any other substances, and the use or inhalation of which simulates smoking. The term shall include any such device, whether manufactured, distributed, marketed, or sold as an e-cigarette, e-cigar, and e-pipe or under any other product, name or descriptor’ [1]. Members of the e-cigarette Working Group of the International Union against tuberculosis and lung dis-
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ease recently expressed their concern that popularity, use, and marketing of e-cigarettes are growing rapidly [2, 3]. E-cigarette use has increased globally in recent years; in some regions three-digit increases in the rate of e-cigarette use have been recorded [4–7]. The European Commission reported in the Eurobarometer 2012 for Austria a prevalence of ever use of 6 % (including a prevalence of regular e-cigarette use of 1 % and of occasionally use of 1 %) [8]. The tobacco industry has also recently begun producing and distributing e-cigarettes on a large scale [9, 10]. Therefore we, as Public Health scientists, consider it imperative to initiate an early discussion on how to deal with these developments. In the first section of the following manuscript, we review the current discussion on e-cigarettes and develop a worst-case scenario of the risk profile of e-cigarettes. In the second section, we suggest measures which could be implemented to deal with such a worst-case scenario. These measures result from lessons learned in tobacco control during the last decades and are in part based on the so-called mpower recommendations which were developed by the WHO for tobacco regulation and which have since been implemented by numerous Public Health actors as preventative measures to stem the global tobacco epidemic [11]. The aim of this paper is to suggest a range of measures designed to prevent e-cigarette consumption, and thus respond to numerous recent calls to initiate early discussion on a topic that may receive increased academic attention in the coming decades [2, 12, 13].
Open questions Current e-cigarette research focuses on the following four points: 1. Do the contents of directly inhaled e-cigarette aerosol have the potential to become addictive and/or do they present other health risks to the consumer? Controversial points include the addictive properties of the nicotine contained in the aerosol of most e-cigarettes and other health risks (such as cardiovascular and neurological risks), poisoning, and the risks posed to unborn children [2, 3, 9, 14–20]. 2. Does second-hand inhalation of e-cigarette aerosol pose health risks? The discussion focuses on the concentration of substances in exhaled e-cigarette aerosol and whether they pose health risks to third parties [2, 3, 21–23]. 3. Do e-cigarettes make it easier and/or more attractive for non-smokers to consequently begin consuming tobacco products? Discussions focus on the gateway hypothesis and the idea that tobacco smoking may be ‘renormalized’ by the similar consumption patterns and product characteristics of tobacco and e-cigarettes [2, 3, 24–26]. 4. Does the use of e-cigarettes make it harder for tobacco smokers to quit? Issues which are discussed include
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the danger of so-called dual use (the simultaneous consumption of tobacco and e-cigarettes) and undermining of consumers’ intention to quit [2, 3, 10, 27]. It is possible that it will take several years before these and many other open questions have been conclusively answered [13]. It is also possible that the investigation of these questions will become more difficult or even impossible as the e-cigarette industry will change and optimize their products and marketing strategies continuously. These changes are likely to affect not only the contents of the fluids used in e-cigarettes, but also technical aspects of the devices themselves, advertising strategies, and target groups. Nevertheless, if the answers to the above-mentioned questions are ‘yes’, e-cigarette use would present a new and significant Public Health problem and adequate prevention measures would need to be implemented.
Elements of a potential Public Health strategy for e-cigarettes First reflections on a Public Health strategy for e-cigarettes should consider both the positive and the negative experiences in tobacco control. Ideally, these experiences are combined with current scientific results on e-cigarettes. Such considerations should be guided by the mpower strategy developed by the WHO: The strategy incorporates six types of measures which were designed to fight the tobacco epidemic [11]. The individual measures of this approach can be modified and used as a starting point for the prevention of e-cigarette use. However, such an adaption requires careful consideration of several differences between e-cigarettes and tobacco cigarettes. The Table 1 illustrates how the adaption of the strategy could be conceptualized.
Monitor e-cigarette use, the e-cigarette industry and prevention policies When a potential new health risk factor is in the process of emerging, it is especially important to establish a valid international and national monitoring system early on. This is not only necessary to monitor the distribution, development, and determinants of consumption, but also to evaluate the long-term effectiveness of the five types of measures detailed below [28]. Such a monitoring system would need to assess the prevalence and incidence of use, the age at which consumers begin using e-cigarettes as well as additional quantitative and qualitative use indicators at an early stage. Additionally, this type of system should make the analysis of subgroups (based on age, gender, ethnic background, social status, etc.) and the identification of determinants for the initiation, continuation, and cessation of e-cigarette use possible. Moreover, this type of monitoring should also assess the activities of the e-cigarette industry, includ-
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Table 1 Core elements of a Public Health strategy for ecigarettes Core elements
Components
Monitor e-cigarette use, the ecigarette industry, and prevention policies
Studies on prevalence and incidence, taking longitudinal trends and subgroups into consideration Studies on determinants which influence initiation and cessation of e-cigarette use Studies on e-cigarettes as a gateway to tobacco smoking Studies on dual or alternating use of e-cigarettes and tobacco cigarettes Studies on the other core elements of the prevention strategy
Implement a vapour-free policy
Studies quantifying the risks posed by passive vapour Protection from second-hand e-cigarette aerosol similar to second-hand tobacco smoke Implementation of programs to raise public awareness on the risks posed by e-cigarette vapour
Develop and offer help to quit ecigarette use
Development and provision of tailored support to those wishing to quit Provision of quit lines Development of guidelines Education and training of Public Health actors to help users quit
Inform about product details and warn about the consequences of e-cigarette use
Interventions to improve health literacy and risk awareness
Establish regulations on ecigarette marketing and trade
Regulations on e-cigarettes similar to tobacco cigarettes including flavouring, youth access, advertising, promotion and sponsorship
Introduce taxes on e-cigarettes
Health economics studies on health-related costs and possible taxation scenarios
Development and implementation of standardized content declarations and health warnings on packaging
Development and introduction of e-cigarette tax
ing aspects such as product design, marketing, sales, and lobbying [29], as well as health policy measures on situational and behavioural levels [6, 30]. In our opinion, the first and most important step towards this type of comprehensive motoring system is to develop and establish an objective, valid and reliable set of indicators. So far empirical researchers have only rudimentarily begun this process. Evidence of this can be seen in the fact that—up to now—no consensus has been reached as to whether the use of e-cigarettes should be referred to as ‘smoking’, ‘vaping’ or something different [31]. The establishment of a standard definition of e-cigarette use that guarantees differentiation between tobacco and e-cigarette use is necessary to avoid survey participants referring to both types of consumption as ‘smoking’, which can lead to the overestimation of the prevalence of tobacco consumption and to incomplete information about the prevalence of e-cigarette use in epidemiological studies. It is also necessary to differentiate between the use of liquids which contain nicotine and those which do not. For the purposes of prevention, we believe that it is
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important to assess the use of these two types of e-cigarettes separately and to evaluate to what extent users switch from one type to the other. The dynamic development of incidence rates coupled with relatively low prevalence rates makes developing an adequate monitoring system all the more difficult. Studies involving large case numbers with short intervals between surveys and follow-ups are essential for establishing a valid monitoring system at this early stage.
Implement an aerosol-free policy If it is shown that the aerosol exhaled by e-cigarette users contains critical levels of harmful substances (nicotine, carcinogens, allergens, irritants, etc. [3, 14]), then measures similar to those developed to protect non-users from ‘environmental tobacco smoke’ will need to be taken to protect third parties from passive aerosol inhalation [2]. This is especially important for vulnerable groups such as unborn babies, children, and adolescents, as well as elderly and ill individuals, in particular patients with bronchial asthma or ischaemic heart disease [14, 30]. These measures should conform to the recommendations made by the WHO regarding ‘smoke-free environments’ [11]. The WHO considers the ‘complete prohibition of smoking at least in all indoor environments as the only intervention that effectively protects people from the harm of second-hand smoke’ [11]. Adapting this recommendation to cover e-cigarettes should include regulation of their use in public, the workplace, and private areas [3]. Children are especially at risk of exposure to e-cigarette aerosol in cars and small residences. Changing existing national legislation on tobacco smoke protection to additionally cover e-cigarette aerosol should be relatively simple, fast, and inexpensive. Such legislative changes would ideally be accompanied by media campaigns to raise awareness on the risks associated with second-hand exposure to e-cigarette aerosol. This argument is based on one made by Al-hamdani [10], who asserts that expanding the ‘smoke-free policy’ to include e-cigarettes is likely to prevent the ‘renormalization’ of smoking.
Develop and offer help to quit e-cigarette use If the misgivings regarding the harmfulness of e-cigarettes outlined above are fully or partly confirmed, measures to help users quit will become a central part of the comprehensive Public Health strategy. It is still unclear whether regular use of e-cigarettes currently on the market leads to addiction [14]. If it is shown that the nicotine contained in e-cigarettes has the potential to cause physical and/or psychological addiction, it will become imperative to develop cessation support measures similar to those already in place to help tobacco smokers quit. Previous studies revealed that most e-cigarette users tend to be ‘dual users’—they continue to smoke tobacco
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as well as using e-cigarettes: Numerous researchers have expressed their concern that the use of e-cigarettes does not lead to the reduction or cessation of tobacco consumption (so-called harm reduction [2, 17]). On the contrary, it is possible that e-cigarette use makes quitting tobacco even more difficult [17]. If this is the case, those wanting to quit would have to quit smoking both tobacco and e-cigarettes at the same time. This means that even if further research does not show that e-cigarette use is addictive, encouraging users to quit is still desirable to prevent ‘dual-use’ which delays quitting, maintains tobacco addiction, and ‘renormalizes’ tobacco smoking. This argument applies equally to the use of both e-cigarette liquids which contain nicotine and those which do not. Material encouraging users to quit can be provided in written form, via telephone and the internet or in other tailored ways. The information and support offered by national ‘quit-lines’ could be broadened to include e-cigarette users as soon as a suitable treatment protocol has been developed and established [32]. This also means that the topics of e-cigarette consumption and cessation should be included in medical education curricula. In addition, the incorporation of information on e-cigarette consumption in medical education and training programs, national healthcare guidelines should be adapted to consider the possible use of e-cigarettes by patients trying to quit tobacco smoking (relevant when prescribing NRT, adjusting treatment strategies, etc.) and include recommendations on how to assist those wishing to quit e-cigarette use [30, 32].
Inform about product details and warn about the consequences of e-cigarette use New findings regarding concrete health risks should be made public quickly and consequently, especially when they are becoming popular rapidly: This is particularly true for e-cigarette use. We suggest that it would make sense to consider a public engagement strategy aimed at particular target groups. First of all, Public Health experts need information to be able to effectively engage in prevention measures. Secondly, when informing the public, the target group of current and potential future consumers should be adequately differentiated into (a) e-cigarette users and non-users, (b) those who use liquids which contain nicotine and those who chose nicotine-free products, (c) tobacco smokers and non-tobacco smokers and further categories such as children, adolescents, adults, pregnant women, parents, etc. In addition to health risks, the economic consequences of e-cigarette use (e.g. cumulative procurement costs) should be mentioned when communicating with different target groups. Moreover, the general public and e-cigarette users in particular should be informed about the risk of e-cigarette consumption contributing to the ‘renormalization’ of tobacco smoking, which could, in turn, lead to more children and adolescents taking up tobacco smoking [2]. Ingredients should be declared on every container of
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e-liquids. Moreover, every e-cigarette device should have childproof seals and also display information on how to handle liquids and to dispose wastes safely (e.g. to avoid swallowing or skin absorption) [3, 30, 33]. The inclusions of warnings on e-cigarette packaging (such as those decided upon in the revised EU Tobacco Products Directive) are only the first step. Measures designed to inform the public about e-cigarettes need to be flexible enough to incorporate new research findings swiftly. This is especially important in order to be able to balance against the positive portrayal of the new products by the developing e-cigarette industry [34]. These public education measures should be implemented for all e-cigarettes, regardless of whether they contain nicotine or not.
Establish regulations on e-cigarette marketing and trade We consider establishing regulations for e-cigarette advertising, promotion and sponsorship to be one of the most important first steps [35]. E-cigarettes are an example of an innovative product and the introduction of such new products to the market is usually accompanied by aggressive marketing campaigns [27]. Regardless of the type of new product being introduced, these marketing campaigns aim to attract new customers and occupy new market segments. Some of the current e-cigarette marketing campaigns are aimed at young adults and non-tobacco smokers [9, 35, 36]. Concerns have been expressed that this type of marketing will undermine the WHO Framework Convention on Tobacco Control (FCTC) [2, 9, 35, 36]. We believe that, ideally, nations should agree to a total ban on the marketing of e-cigarettes. At least, we consider the immediate prohibition of the sale of e-cigarettes to minors to be imperative [2, 3]. At the moment, the sale of e-cigarettes to minors is legal in many countries [12, 17]. In Austria, the ‘Bundesgremium der Tabaktrafikanten’ has banned the sale of all e-cigarettes (including e-shishas) solely to persons less than 16 years of age [37]. We also believe that advertising aimed at minors and marketing falsely claiming that e-cigarettes are ‘healthy’ should be banned immediately [27, 35, 38]. An example of an organization which has implemented such regulatory measures is the Advertising Standards Authority in the United Kingdom; it has taken action against advertising aimed at children and commercials which claimed e-cigarette to be ‘completely harmless’[31]. Measures such as the banning of the distribution of free sample products at public events (e.g. concerts, music festivals) and the prohibition of corporate sponsorship (such as the renaming of a British football field as ‘Cigg-e stadium’) should also be taken into consideration [2, 31]. These sorts of measures could be implemented in parallel to the prevention policies discussed in the first group of measures outlined above [39]. This intervention field is made all the more relevant due to the fact that
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e-cigarettes are increasingly being produced and sold by the tobacco industry [9, 10]. The Austrian National Council has recently decided that from 2015 e-cigarettes come under the tobacco monopoly and therefore only tobacconists (‘Tabaktrafiken’) are allowed to sell them [40]. Thus the same points of sale will be used for both tobacco and e-cigarettes. In other words: The tobacco industry and tobacconists profit from the success of e-cigarette sales [10]. This means that the tobacco industry’s market position and power is likely to grow, if (as first studies suggest) it is shown that e-cigarettes do not help tobacco smokers to quit, but rather lead to ‘dual use’ of both products [2, 17, 41].
Introduce taxes on e-cigarettes The political discussion on the topic of e-cigarette taxation is ongoing [24]. The variety of types of e-cigarette products, hardware, and variations of liquids available make developing a comprehensive taxation system challenging. At this early stage, we believe that a taxation system based on the nicotine content of the individual products would be most practical. In addition to establishing the unit to be taxed, other open questions include the tax rate, the adjustment criteria, and how the tax should be levied. Abrams [24] suggests levying the tax proportional to the costs posed by specific products to the health care economy. Accordingly, tobacco cigarettes would be taxed at a higher rate than e-cigarettes [24]. Additionally, it will be important to discuss how to appropriately tax nicotine-free e-cigarettes based on their possible side-effects (health risks, renormalization of smoking, gateway to tobacco smoking, etc.) To our knowledge, there has so far been no discussion about the issue of e-cigarette related smuggling activities, which can be expected to develop as soon as taxes are imposed. In comparison to the tobacco industry, liquid containing nicotine, or even pure nicotine, would be much easier to smuggle, dilute, and process. This is just one example of how much easier it is for producers, consumers, and illegal dealers to manipulate (and potentially increase the potency/harmfulness of ) e-cigarette liquid than it is for them to alter the contents of tobacco cigarettes.
The next steps to be taken towards a prevention strategy There are obvious parallels between the development of the global tobacco epidemic and the increasing popularity of e-cigarettes. Therefore, Public Health actors can refer to the experience gathered in the fight against tobacco when developing an e-cigarette prevention strategy [42]. Hence, we have suggested six core elements as a first step towards a comprehensive prevention program—based on the current state of the discussion and the mpower measures developed by the WHO to stem
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the global tobacco-epidemic. The second step should be the development of a more detailed prevention strategy. During this process, the following aspects should be carefully considered: 1. The potential of e-cigarettes to assist tobacco smokers to quit is still unclear [3, 14]. E-cigarettes may provide tobacco smokers with a means to help them quit, or to at least reduce the level of harm they are doing to their bodies. This is especially true for tobacco smokers who wish to quit, but who have not been able to do so with the help of other cessation aids (e.g. nicotine replacement products). 2. The level of conflicts of interest among e-cigarette researchers is still unclear: The few hundred studies published so far show that information on conflicts of interest are either completely absent, or often mention sponsorship by the e-cigarette industry. It needs to be established whether this has led to a publication bias. 3. The risks and the benefits associated with nicotinefree e-cigarettes are yet to be established. Nicotinefree e-cigarettes, often marketed as e-shishas or e-hookahs, contain nicotine-free liquids and appealing aromas such as chocolate, vanilla, and fruits. It is known from tobacco control research that especially those additives appeal to adolescents [3, 43, 44]. For this reason, such additives are banned in traditional cigarettes by the EU tobacco product directive, but not in e-cigarettes. Not surprisingly, among the users of such flavoured nicotine-free e-cigarettes are many adolescents [45]. In Austria, these types of e-cigarettes are still allowed being sold to 16- and 17-year-old adolescents [37]. The development of a comprehensive prevention strategy should take these types of nicotine-free e-cigarettes into consideration. The points discussed above focus on e-cigarettes with liquids containing nicotine. However, as we have pointed out in the text, some of the prevention strategies discussed are also relevant for nicotine-free e-cigarettes.
Discussion The e-cigarette—a new global health risk factor? This is one of the many unanswered questions about e-cigarettes. The issues mentioned in the introduction, as well as many more health-related questions which were beyond the scope of this paper, are still unanswered. However, the studies published so far do not seem to indicate that e-cigarette use is just a passing trend (for an overview see [2]). Thus, if it is established in the future that e-cigarette use is less ‘harmless’ than it is portrayed in many advertisements [35], we would do well to start a serious discussion about a suitable Public Health policy as soon as possible. Nicotine is an addictive chemical [2, 14, 29]. The development of the e-cigarette has provided the nicotine industry with a revolutionary new product with which this
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addictive substance can be provided to a broader range of consumers. It can be expected that the product will be further ‘improved’ and ‘optimized’ in the future. From a strictly economic perspective, ‘optimization’ means that the nicotine transfer process will be enhanced by means of technical and chemical improvements, thus also increasing the addiction potential of the liquids so that the consumers use e-cigarettes as often and as long as possible [10]. These changes can involve the contents of the aerosol (e.g. manipulating the pH-values, the amount of nicotine, and the size of the droplets), as well as the ‘optimization’ of the inhalation process [46]. We are certain that this ‘optimization process’ will proceed much more swiftly and easily than it was the case with the classic tobacco cigarette with its organic ingredients. From our perspective ‘Big tobacco may repeat history’[10]— this time with the e-cigarette instead of tobacco. Acknowledgements The authors wish to thank Laura Beckmann for her assistance in preparing this manuscript. Conflict of interest Both authors, Sv. S. and K. D., declare that there are no actual or potential conflicts of interest in relation to this article.
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A public health strategy for e-cigarettes Sven Schneider · Katharina Diehl
Received: 12 December 2014 / Accepted: 21 April 2015 / Published online: 27 May 2015 © Springer-Verlag Wien 2015
Abstract The e-cigarette may present a new and significant Public Health problem: Studies published so far do not seem to indicate that e-cigarette use is just a passing trend. If e-cigarette use is less harmless than it is portrayed in many advertisements, Public Health would do well to start a serious discussion about a suitable prevention policy as soon as possible.The aim of this short paper is to discuss a range of measures designed to prevent e-cigarette consumption.Concretely, we suggest to monitor e-cigarette use, the e-cigarette industry and prevention policies, to implement a vapor-free policy, to develop help to quit e-cigarette use, to inform about the health risks of e-cigarette use, to establish regulations on e-cigarette advertising, promotion and sponsorship, and to introduce taxes on e-cigarettes.
eine angemessene Prävention nachdenken.Ziel dieses kurzen Beitragesist es, Maßnahmen zur Prävention des e-Zigarettenkonsums zur Diskussion zu stellen.Konkret schlagen wir vor, ein Monitoring des e-Zigarettenkonsums sowie der e-Zigarettenindustrie und der Präventionspolitik zu implementieren, Schutz von Passivdampf sicherzustellen, den Ausstieg aus dem e-Zigarettenkonsum zu fördern, über potenzielle Gesundheitsrisiken der e-Zigarette zu informieren, Werbebeschränkungen zu erlassen und e-Zigaretten zu besteuern.
Keywords Electronic cigarette · e-cigarette · Electronic nicotine delivery system · Electronic nicotine delivery device · Prevention · Nicotine
Introduction
Zusammenfassung E-Zigaretten stellen möglicherweise ein neues und bedeutendes Public Health-Problem dar. Bisherige Studienlegen nahe, dass die Verbreitung von e-Zigaretten nicht lediglich ein vorübergehender Trend zu sein scheint. Wenn der Konsum von e-Zigaretten weniger harmlos sein sollte als in der Werbung dargestellt, sollte das Öffentliche Gesundheitswesen rechtzeitig über Prof. Dr. S. Schneider, M.A. () · Dr. K. Diehl Mannheim Institute of Public Health, Social and Preventive Medicine (MIPH), Medical Faculty Mannheim, Heidelberg University, Ludolf-Krehl-Str. 7–11, 68167 Mannheim, Germany e-mail: [email protected] Dr. K. Diehl e-mail: [email protected]
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Schlüsselwörter Elektronische Zigarette · E-Zigarette · Electronic nicotine delivery system · Electronic nicotine delivery device · Prävention · Nikotin
It is possible that in a few years we will consider the impact of e-cigarettes (short for: electronic cigarettes) irrelevant to Public Health. But, it is also possible that it represents the development of a new worldwide health risk. We should not ignore the possibility of such a development, and therefore it is definitely worth looking more closely at the e-cigarette use, even at this early stage. E-cigarettes include a wide product range and are offered with nicotine as well as without nicotine (e.g. e-shishas or e-hookahs). Hereafter, we use the common definition of e-cigarettes as ‘any electronic oral device, such as one composed of a heating element and battery or electronic circuit, or both, which provides a vapour of nicotine or any other substances, and the use or inhalation of which simulates smoking. The term shall include any such device, whether manufactured, distributed, marketed, or sold as an e-cigarette, e-cigar, and e-pipe or under any other product, name or descriptor’ [1]. Members of the e-cigarette Working Group of the International Union against tuberculosis and lung dis-
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ease recently expressed their concern that popularity, use, and marketing of e-cigarettes are growing rapidly [2, 3]. E-cigarette use has increased globally in recent years; in some regions three-digit increases in the rate of e-cigarette use have been recorded [4–7]. The European Commission reported in the Eurobarometer 2012 for Austria a prevalence of ever use of 6 % (including a prevalence of regular e-cigarette use of 1 % and of occasionally use of 1 %) [8]. The tobacco industry has also recently begun producing and distributing e-cigarettes on a large scale [9, 10]. Therefore we, as Public Health scientists, consider it imperative to initiate an early discussion on how to deal with these developments. In the first section of the following manuscript, we review the current discussion on e-cigarettes and develop a worst-case scenario of the risk profile of e-cigarettes. In the second section, we suggest measures which could be implemented to deal with such a worst-case scenario. These measures result from lessons learned in tobacco control during the last decades and are in part based on the so-called mpower recommendations which were developed by the WHO for tobacco regulation and which have since been implemented by numerous Public Health actors as preventative measures to stem the global tobacco epidemic [11]. The aim of this paper is to suggest a range of measures designed to prevent e-cigarette consumption, and thus respond to numerous recent calls to initiate early discussion on a topic that may receive increased academic attention in the coming decades [2, 12, 13].
Open questions Current e-cigarette research focuses on the following four points: 1. Do the contents of directly inhaled e-cigarette aerosol have the potential to become addictive and/or do they present other health risks to the consumer? Controversial points include the addictive properties of the nicotine contained in the aerosol of most e-cigarettes and other health risks (such as cardiovascular and neurological risks), poisoning, and the risks posed to unborn children [2, 3, 9, 14–20]. 2. Does second-hand inhalation of e-cigarette aerosol pose health risks? The discussion focuses on the concentration of substances in exhaled e-cigarette aerosol and whether they pose health risks to third parties [2, 3, 21–23]. 3. Do e-cigarettes make it easier and/or more attractive for non-smokers to consequently begin consuming tobacco products? Discussions focus on the gateway hypothesis and the idea that tobacco smoking may be ‘renormalized’ by the similar consumption patterns and product characteristics of tobacco and e-cigarettes [2, 3, 24–26]. 4. Does the use of e-cigarettes make it harder for tobacco smokers to quit? Issues which are discussed include
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the danger of so-called dual use (the simultaneous consumption of tobacco and e-cigarettes) and undermining of consumers’ intention to quit [2, 3, 10, 27]. It is possible that it will take several years before these and many other open questions have been conclusively answered [13]. It is also possible that the investigation of these questions will become more difficult or even impossible as the e-cigarette industry will change and optimize their products and marketing strategies continuously. These changes are likely to affect not only the contents of the fluids used in e-cigarettes, but also technical aspects of the devices themselves, advertising strategies, and target groups. Nevertheless, if the answers to the above-mentioned questions are ‘yes’, e-cigarette use would present a new and significant Public Health problem and adequate prevention measures would need to be implemented.
Elements of a potential Public Health strategy for e-cigarettes First reflections on a Public Health strategy for e-cigarettes should consider both the positive and the negative experiences in tobacco control. Ideally, these experiences are combined with current scientific results on e-cigarettes. Such considerations should be guided by the mpower strategy developed by the WHO: The strategy incorporates six types of measures which were designed to fight the tobacco epidemic [11]. The individual measures of this approach can be modified and used as a starting point for the prevention of e-cigarette use. However, such an adaption requires careful consideration of several differences between e-cigarettes and tobacco cigarettes. The Table 1 illustrates how the adaption of the strategy could be conceptualized.
Monitor e-cigarette use, the e-cigarette industry and prevention policies When a potential new health risk factor is in the process of emerging, it is especially important to establish a valid international and national monitoring system early on. This is not only necessary to monitor the distribution, development, and determinants of consumption, but also to evaluate the long-term effectiveness of the five types of measures detailed below [28]. Such a monitoring system would need to assess the prevalence and incidence of use, the age at which consumers begin using e-cigarettes as well as additional quantitative and qualitative use indicators at an early stage. Additionally, this type of system should make the analysis of subgroups (based on age, gender, ethnic background, social status, etc.) and the identification of determinants for the initiation, continuation, and cessation of e-cigarette use possible. Moreover, this type of monitoring should also assess the activities of the e-cigarette industry, includ-
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Table 1 Core elements of a Public Health strategy for ecigarettes Core elements
Components
Monitor e-cigarette use, the ecigarette industry, and prevention policies
Studies on prevalence and incidence, taking longitudinal trends and subgroups into consideration Studies on determinants which influence initiation and cessation of e-cigarette use Studies on e-cigarettes as a gateway to tobacco smoking Studies on dual or alternating use of e-cigarettes and tobacco cigarettes Studies on the other core elements of the prevention strategy
Implement a vapour-free policy
Studies quantifying the risks posed by passive vapour Protection from second-hand e-cigarette aerosol similar to second-hand tobacco smoke Implementation of programs to raise public awareness on the risks posed by e-cigarette vapour
Develop and offer help to quit ecigarette use
Development and provision of tailored support to those wishing to quit Provision of quit lines Development of guidelines Education and training of Public Health actors to help users quit
Inform about product details and warn about the consequences of e-cigarette use
Interventions to improve health literacy and risk awareness
Establish regulations on ecigarette marketing and trade
Regulations on e-cigarettes similar to tobacco cigarettes including flavouring, youth access, advertising, promotion and sponsorship
Introduce taxes on e-cigarettes
Health economics studies on health-related costs and possible taxation scenarios
Development and implementation of standardized content declarations and health warnings on packaging
Development and introduction of e-cigarette tax
ing aspects such as product design, marketing, sales, and lobbying [29], as well as health policy measures on situational and behavioural levels [6, 30]. In our opinion, the first and most important step towards this type of comprehensive motoring system is to develop and establish an objective, valid and reliable set of indicators. So far empirical researchers have only rudimentarily begun this process. Evidence of this can be seen in the fact that—up to now—no consensus has been reached as to whether the use of e-cigarettes should be referred to as ‘smoking’, ‘vaping’ or something different [31]. The establishment of a standard definition of e-cigarette use that guarantees differentiation between tobacco and e-cigarette use is necessary to avoid survey participants referring to both types of consumption as ‘smoking’, which can lead to the overestimation of the prevalence of tobacco consumption and to incomplete information about the prevalence of e-cigarette use in epidemiological studies. It is also necessary to differentiate between the use of liquids which contain nicotine and those which do not. For the purposes of prevention, we believe that it is
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important to assess the use of these two types of e-cigarettes separately and to evaluate to what extent users switch from one type to the other. The dynamic development of incidence rates coupled with relatively low prevalence rates makes developing an adequate monitoring system all the more difficult. Studies involving large case numbers with short intervals between surveys and follow-ups are essential for establishing a valid monitoring system at this early stage.
Implement an aerosol-free policy If it is shown that the aerosol exhaled by e-cigarette users contains critical levels of harmful substances (nicotine, carcinogens, allergens, irritants, etc. [3, 14]), then measures similar to those developed to protect non-users from ‘environmental tobacco smoke’ will need to be taken to protect third parties from passive aerosol inhalation [2]. This is especially important for vulnerable groups such as unborn babies, children, and adolescents, as well as elderly and ill individuals, in particular patients with bronchial asthma or ischaemic heart disease [14, 30]. These measures should conform to the recommendations made by the WHO regarding ‘smoke-free environments’ [11]. The WHO considers the ‘complete prohibition of smoking at least in all indoor environments as the only intervention that effectively protects people from the harm of second-hand smoke’ [11]. Adapting this recommendation to cover e-cigarettes should include regulation of their use in public, the workplace, and private areas [3]. Children are especially at risk of exposure to e-cigarette aerosol in cars and small residences. Changing existing national legislation on tobacco smoke protection to additionally cover e-cigarette aerosol should be relatively simple, fast, and inexpensive. Such legislative changes would ideally be accompanied by media campaigns to raise awareness on the risks associated with second-hand exposure to e-cigarette aerosol. This argument is based on one made by Al-hamdani [10], who asserts that expanding the ‘smoke-free policy’ to include e-cigarettes is likely to prevent the ‘renormalization’ of smoking.
Develop and offer help to quit e-cigarette use If the misgivings regarding the harmfulness of e-cigarettes outlined above are fully or partly confirmed, measures to help users quit will become a central part of the comprehensive Public Health strategy. It is still unclear whether regular use of e-cigarettes currently on the market leads to addiction [14]. If it is shown that the nicotine contained in e-cigarettes has the potential to cause physical and/or psychological addiction, it will become imperative to develop cessation support measures similar to those already in place to help tobacco smokers quit. Previous studies revealed that most e-cigarette users tend to be ‘dual users’—they continue to smoke tobacco
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as well as using e-cigarettes: Numerous researchers have expressed their concern that the use of e-cigarettes does not lead to the reduction or cessation of tobacco consumption (so-called harm reduction [2, 17]). On the contrary, it is possible that e-cigarette use makes quitting tobacco even more difficult [17]. If this is the case, those wanting to quit would have to quit smoking both tobacco and e-cigarettes at the same time. This means that even if further research does not show that e-cigarette use is addictive, encouraging users to quit is still desirable to prevent ‘dual-use’ which delays quitting, maintains tobacco addiction, and ‘renormalizes’ tobacco smoking. This argument applies equally to the use of both e-cigarette liquids which contain nicotine and those which do not. Material encouraging users to quit can be provided in written form, via telephone and the internet or in other tailored ways. The information and support offered by national ‘quit-lines’ could be broadened to include e-cigarette users as soon as a suitable treatment protocol has been developed and established [32]. This also means that the topics of e-cigarette consumption and cessation should be included in medical education curricula. In addition, the incorporation of information on e-cigarette consumption in medical education and training programs, national healthcare guidelines should be adapted to consider the possible use of e-cigarettes by patients trying to quit tobacco smoking (relevant when prescribing NRT, adjusting treatment strategies, etc.) and include recommendations on how to assist those wishing to quit e-cigarette use [30, 32].
Inform about product details and warn about the consequences of e-cigarette use New findings regarding concrete health risks should be made public quickly and consequently, especially when they are becoming popular rapidly: This is particularly true for e-cigarette use. We suggest that it would make sense to consider a public engagement strategy aimed at particular target groups. First of all, Public Health experts need information to be able to effectively engage in prevention measures. Secondly, when informing the public, the target group of current and potential future consumers should be adequately differentiated into (a) e-cigarette users and non-users, (b) those who use liquids which contain nicotine and those who chose nicotine-free products, (c) tobacco smokers and non-tobacco smokers and further categories such as children, adolescents, adults, pregnant women, parents, etc. In addition to health risks, the economic consequences of e-cigarette use (e.g. cumulative procurement costs) should be mentioned when communicating with different target groups. Moreover, the general public and e-cigarette users in particular should be informed about the risk of e-cigarette consumption contributing to the ‘renormalization’ of tobacco smoking, which could, in turn, lead to more children and adolescents taking up tobacco smoking [2]. Ingredients should be declared on every container of
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e-liquids. Moreover, every e-cigarette device should have childproof seals and also display information on how to handle liquids and to dispose wastes safely (e.g. to avoid swallowing or skin absorption) [3, 30, 33]. The inclusions of warnings on e-cigarette packaging (such as those decided upon in the revised EU Tobacco Products Directive) are only the first step. Measures designed to inform the public about e-cigarettes need to be flexible enough to incorporate new research findings swiftly. This is especially important in order to be able to balance against the positive portrayal of the new products by the developing e-cigarette industry [34]. These public education measures should be implemented for all e-cigarettes, regardless of whether they contain nicotine or not.
Establish regulations on e-cigarette marketing and trade We consider establishing regulations for e-cigarette advertising, promotion and sponsorship to be one of the most important first steps [35]. E-cigarettes are an example of an innovative product and the introduction of such new products to the market is usually accompanied by aggressive marketing campaigns [27]. Regardless of the type of new product being introduced, these marketing campaigns aim to attract new customers and occupy new market segments. Some of the current e-cigarette marketing campaigns are aimed at young adults and non-tobacco smokers [9, 35, 36]. Concerns have been expressed that this type of marketing will undermine the WHO Framework Convention on Tobacco Control (FCTC) [2, 9, 35, 36]. We believe that, ideally, nations should agree to a total ban on the marketing of e-cigarettes. At least, we consider the immediate prohibition of the sale of e-cigarettes to minors to be imperative [2, 3]. At the moment, the sale of e-cigarettes to minors is legal in many countries [12, 17]. In Austria, the ‘Bundesgremium der Tabaktrafikanten’ has banned the sale of all e-cigarettes (including e-shishas) solely to persons less than 16 years of age [37]. We also believe that advertising aimed at minors and marketing falsely claiming that e-cigarettes are ‘healthy’ should be banned immediately [27, 35, 38]. An example of an organization which has implemented such regulatory measures is the Advertising Standards Authority in the United Kingdom; it has taken action against advertising aimed at children and commercials which claimed e-cigarette to be ‘completely harmless’[31]. Measures such as the banning of the distribution of free sample products at public events (e.g. concerts, music festivals) and the prohibition of corporate sponsorship (such as the renaming of a British football field as ‘Cigg-e stadium’) should also be taken into consideration [2, 31]. These sorts of measures could be implemented in parallel to the prevention policies discussed in the first group of measures outlined above [39]. This intervention field is made all the more relevant due to the fact that
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e-cigarettes are increasingly being produced and sold by the tobacco industry [9, 10]. The Austrian National Council has recently decided that from 2015 e-cigarettes come under the tobacco monopoly and therefore only tobacconists (‘Tabaktrafiken’) are allowed to sell them [40]. Thus the same points of sale will be used for both tobacco and e-cigarettes. In other words: The tobacco industry and tobacconists profit from the success of e-cigarette sales [10]. This means that the tobacco industry’s market position and power is likely to grow, if (as first studies suggest) it is shown that e-cigarettes do not help tobacco smokers to quit, but rather lead to ‘dual use’ of both products [2, 17, 41].
Introduce taxes on e-cigarettes The political discussion on the topic of e-cigarette taxation is ongoing [24]. The variety of types of e-cigarette products, hardware, and variations of liquids available make developing a comprehensive taxation system challenging. At this early stage, we believe that a taxation system based on the nicotine content of the individual products would be most practical. In addition to establishing the unit to be taxed, other open questions include the tax rate, the adjustment criteria, and how the tax should be levied. Abrams [24] suggests levying the tax proportional to the costs posed by specific products to the health care economy. Accordingly, tobacco cigarettes would be taxed at a higher rate than e-cigarettes [24]. Additionally, it will be important to discuss how to appropriately tax nicotine-free e-cigarettes based on their possible side-effects (health risks, renormalization of smoking, gateway to tobacco smoking, etc.) To our knowledge, there has so far been no discussion about the issue of e-cigarette related smuggling activities, which can be expected to develop as soon as taxes are imposed. In comparison to the tobacco industry, liquid containing nicotine, or even pure nicotine, would be much easier to smuggle, dilute, and process. This is just one example of how much easier it is for producers, consumers, and illegal dealers to manipulate (and potentially increase the potency/harmfulness of ) e-cigarette liquid than it is for them to alter the contents of tobacco cigarettes.
The next steps to be taken towards a prevention strategy There are obvious parallels between the development of the global tobacco epidemic and the increasing popularity of e-cigarettes. Therefore, Public Health actors can refer to the experience gathered in the fight against tobacco when developing an e-cigarette prevention strategy [42]. Hence, we have suggested six core elements as a first step towards a comprehensive prevention program—based on the current state of the discussion and the mpower measures developed by the WHO to stem
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the global tobacco-epidemic. The second step should be the development of a more detailed prevention strategy. During this process, the following aspects should be carefully considered: 1. The potential of e-cigarettes to assist tobacco smokers to quit is still unclear [3, 14]. E-cigarettes may provide tobacco smokers with a means to help them quit, or to at least reduce the level of harm they are doing to their bodies. This is especially true for tobacco smokers who wish to quit, but who have not been able to do so with the help of other cessation aids (e.g. nicotine replacement products). 2. The level of conflicts of interest among e-cigarette researchers is still unclear: The few hundred studies published so far show that information on conflicts of interest are either completely absent, or often mention sponsorship by the e-cigarette industry. It needs to be established whether this has led to a publication bias. 3. The risks and the benefits associated with nicotinefree e-cigarettes are yet to be established. Nicotinefree e-cigarettes, often marketed as e-shishas or e-hookahs, contain nicotine-free liquids and appealing aromas such as chocolate, vanilla, and fruits. It is known from tobacco control research that especially those additives appeal to adolescents [3, 43, 44]. For this reason, such additives are banned in traditional cigarettes by the EU tobacco product directive, but not in e-cigarettes. Not surprisingly, among the users of such flavoured nicotine-free e-cigarettes are many adolescents [45]. In Austria, these types of e-cigarettes are still allowed being sold to 16- and 17-year-old adolescents [37]. The development of a comprehensive prevention strategy should take these types of nicotine-free e-cigarettes into consideration. The points discussed above focus on e-cigarettes with liquids containing nicotine. However, as we have pointed out in the text, some of the prevention strategies discussed are also relevant for nicotine-free e-cigarettes.
Discussion The e-cigarette—a new global health risk factor? This is one of the many unanswered questions about e-cigarettes. The issues mentioned in the introduction, as well as many more health-related questions which were beyond the scope of this paper, are still unanswered. However, the studies published so far do not seem to indicate that e-cigarette use is just a passing trend (for an overview see [2]). Thus, if it is established in the future that e-cigarette use is less ‘harmless’ than it is portrayed in many advertisements [35], we would do well to start a serious discussion about a suitable Public Health policy as soon as possible. Nicotine is an addictive chemical [2, 14, 29]. The development of the e-cigarette has provided the nicotine industry with a revolutionary new product with which this
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addictive substance can be provided to a broader range of consumers. It can be expected that the product will be further ‘improved’ and ‘optimized’ in the future. From a strictly economic perspective, ‘optimization’ means that the nicotine transfer process will be enhanced by means of technical and chemical improvements, thus also increasing the addiction potential of the liquids so that the consumers use e-cigarettes as often and as long as possible [10]. These changes can involve the contents of the aerosol (e.g. manipulating the pH-values, the amount of nicotine, and the size of the droplets), as well as the ‘optimization’ of the inhalation process [46]. We are certain that this ‘optimization process’ will proceed much more swiftly and easily than it was the case with the classic tobacco cigarette with its organic ingredients. From our perspective ‘Big tobacco may repeat history’[10]— this time with the e-cigarette instead of tobacco. Acknowledgements The authors wish to thank Laura Beckmann for her assistance in preparing this manuscript. Conflict of interest Both authors, Sv. S. and K. D., declare that there are no actual or potential conflicts of interest in relation to this article.
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