E-Cigarettes, Harm Reduction, and Tobacco Control

The 34th Surgeon General’s Report on Smoking and Health, published early in 2020, prominently noted that prevalence of cigarette smoking among US adults has declined from nearly 43% 1964, to a low 14% 2018. This represents the smallest percentage adult smokers United States since just after World War I, century ago, resulted saving millions lives debilitating illnesses.1US Department Health Human ServicesSmoking Cessation: A General. U.S. Services, Centers for Disease Control Prevention, National Center Chronic Prevention Promotion, Office Atlanta, GA2020Google Scholar These findings should be cause celebration what is, without doubt, one greatest public health achievements past century. Driven by collaborative efforts clinicians, scientists, experts, political policy advocates, advocacy organizations, magnitude progress long-term trends declining made demise seem almost inevitable. In fact, 2014 suggested we might entering era “the tobacco endgame,” period exceedingly little-to-no uptake youth young adults.2US ServicesThe Consequences Smoking—50 Years Progress: GA2014Google Progress, however, may danger stalling. Instead continued collaboration, tobacco-control community finds itself bogged down an extended conflict, often quite vitriolic, pitting former allies against each other, splitting into factions, seeing same data interpreted differently, putting future ending use combusted at risk.3Fairchild A.L. Bayer R. Lee J.S. e-cigarette debate: counts as evidence?.Am J Public Health. 2019; 109: 1000-1006Crossref PubMed Scopus (33) Google Scholar, 4Pisinger C. Dagli E. Filippidis F.T. et al.ERS harm reduction.Eur Respir J. 54: 1902009Crossref (18) 5Britton George Bauld L. al.A rational approach e-cigarettes: challenging ERS 2020; 55: 2000166Crossref (3) 6Harvard T.H. Chan School dilemma: perspective. 2019.https://theforum.sph.harvard.edu/events/the-e-cigarette-dilemma/Date accessed: August 25, 2020Google 7Glynn T.J. E-cigarettes control.CA Cancer Clin. 2014; 64: 164-168Crossref (30) 8Cummings K.M. Hammond D. E-cigarettes: striking right balance.Lancet 5: e180-e181Abstract Full Text PDF (6) 9Fairchild A. Healton Curran Abrams Evidence, alarm, debate over e-cigarettes.Science. 366: 1318-1320Crossref (17) 10Baker T.B. Fiore M.C. What do not know about e-cigarettes is lot.JAMA Netw Open. 3: e204850Crossref immediate precipitating factor this conflict been introduction 2007.11Nguyen Aamodt G. Electronic cigarettes past, present future: history e-cigarettes.https://www.dentalcare.com/en-us/professional-education/ce-courses/ce451/the-history-of-e-cigarettesDate (The term article refers generically multiple electronic nicotine-delivery devices deliver inhaled aerosol heating liquid, usually containing nicotine.) But are really only representative larger concept fueling debate, known “harm reduction,” generally considered risky behavior prioritizes minimizing damage behavior, rather than eliminating itself.12Marlatt G.A. Harm Reduction: Pragmatic Strategies Managing High-Risk Behaviors. Guilford Publications, New York, NY2002Google 13Inciardi J.A. Harrison L.D. reduction: International Perspectives. Sage Publishing, Newbury Park, CA2000Google 14Ho A.F. Move Hippocrates: reduction new paradigm care. 2017.https://www.statnews.com/2017/05/30/harm-reduction-health-care/Date 15Fairchild Colgrove renormalization smoking? "endgame.".N Engl Med. 370: 293-295Crossref (221) 16Vinchurkar S. Jain N. Jhamtani Gupta Tobacco underpinning issues, challenges, scope innovation.Int Res Innov. 8: 7-21Google long pillar practice; examples include methadone needle exchanges, more daunting task intravenous drug use; condoms during sexual activity, relying abstinence; or helmets seatbelts, forgoing bicycles cars. community, somewhat committed practitioners with side arguing path scourge abstinence all forms nicotine (with possible exception Food Drug Administration [FDA]-approved nicotine-replacement therapy [NRT]), whereas other argues it eliminated because they responsible overwhelming portion nonsensical dismiss less harmful alternatives demanding absolute safety.17Chapman best worst case scenarios health.BMJ. 349: g5512Crossref (40) 18Warner K.E. How think-not feel-about reduction.Nicotine Tob Res. 21: 1299-1309Crossref (39) 19Abrams D.B. Promise peril can disruptive technology make obsolete?.JAMA. 311: 135-136Crossref (142) part, split occurred versions “reduced harm” products (eg, filtered 1950s low-tar 1960s 1970s) proved no harmful,20US Using Smokeless Tobacco: Advisory Committee General: NIH Publication No. 86-2874. Service, Bethesda, MD1986Google exacerbating distrust any ”harm reduction” products, whether promoted industry independent companies. Whether newest generation smokeless tobacco, documented reductions harm, least short term, will create opportunity bridge current divide between these 2 positions depend largely willingness individuals organizations involved issue accept some form means reducing toll death disease use. Further complicating differing views its role elimination Nicotine constituent smoke causes positive reinforcement dependence smoking; withdrawal periods drives relapse first few weeks attempt quit.21Gottlieb Zeller M. nicotine-focused framework health.N 2017; 377: 1111-1114Crossref (140) Scholar,22Prochaska J.J. Benowitz N.L. Current advances research treatment recovery: addiction.Sci Adv. eaay9763Crossref replacement therapies (NRTs) patch gum were approved FDA introduced late 1980s. Three decades on, although there doubt efficacy safety NRT,23Hartmann-Boyce Chepkin S.C. Ye W. Bullen Lancaster T. versus control cessation.Cochrane Database Syst Rev. 2018; CD000146PubMed under-used care providers concerns perpetuate addiction24Foulds Hughes Hyland al.Barriers FDA-approved cessation medications: implications action. 2009.https://www.attud.org/pdf/barriers-smoking-cess-meds.pdfDate October 26, misplaced itself.25Steinberg M.B. Bover Manderski M.T. Wackowski O.A. Singh B. Strasser A.A. Delnevo C.D. risk misperception physicians. Gen Intern 2020. [Epub ahead print].https://doi.org/10.1007/s11606-020-06172-8Google For most providers, therapeutic target complete If achieved, even face NRT (because dependence), eliminated. Similar arguments being now e-cigarettes. When became widely available approximately decade welcomed useful addition existing range tools who wanted quit. Others argued unknown entity, both terms effectiveness, put aside until scientific evidence available. science, date, including thousands e-cigarette–focused papers major government-sponsored reviews Kingdom,26Eaton Kwan Stratton K. Academies Sciences Engineering Medicine, Medicine Division, Board Population Practice, E-Cigarettes. Press, Washington, DC2018Google Scholar,27McNeill Brose L.S. Calder Robson Evidence review ecigarettes heated England, London, UK2018Google suggests are, general, helping quit products.28Hartmann-Boyce McRobbie H. Lindson al.Electronic 10: CD010216PubMed Importantly, contrast NRT, effects remain unknown, owing their relatively recent introduction.10Baker Meanwhile, conceptual address sides issue. proposed wide array viewed along “continuum risk,” acknowledging equally harmful, ranging lowest end continuum, through highest end.21Gottlieb concept, Report, accepted, principle, virtually harm-reduction those reject products. Caught middle ongoing clinician wants help patients stop but barraged conflicting interpretations selective bolster other’s argument. Many clinicians employ precautionary principle advise tobacco-smoking medications, attempts Others, looking evidence, have failed using medications consider quitting tools. Responsible clinical practice cannot continue vein, unable engage informed decision making patient continuing exposed known, serious harms smoking. Clinicians need clear guidance trusted sources confidence recommend. 50+-year eliminate States, participants effort remarkably united. There was common enemy—the industry—and steadily accumulating guide efforts. Although previous disagreements, such 1998 Master Settlement Agreement state attorneys general industry, unity become significantly frayed, aware disunity: e-cigarettes, proximally, reduction, distally. So, Vladimir Lenin asked his influential pamphlet turn nineteenth century, “What Be Done? Burning Questions Our Movement,”29Lenin VI. Is To Movement Lenin’s Selected Works. Vol 1; 1902.Google movement must ask done?” get impasse toward endgame. Moving forward require compromise flexibility part involved, while maintaining strict adherence producing following good science sound medical principles. More specifically, suggestions break impasse:•Refocus cigarette. As noted, very identifying vast majority deaths recommended focus tobacco- All field should, before undertaking effort, primary goal reduce question answered affirmatively, action reconsidered. would renewed field’s priorities: prioritizing actions likely result gains population level, if issues non-NRT use.•Continue policies effective. Despite controversies, support implement evidence-based interventions helped achieve rate prevalence: smoke-free environments, high taxation dangerous widespread availability services, focused media campaigns, production unbiased, high-quality science.30World OrganizationWHO Global Epidemic. Organization, Geneva, Switzerland2019Google 31Centers PreventionBest Practices Comprehensive Programs. 32Ghebreyesus T.A. Progress beating epidemic.Lancet. 394: 548-549Abstract (10) Scholar•Build upon FDA’s risk” concept. Recognize that, thing wholly safe product, cigarettes, made—in tandem science—on determining which pose lower risks helpful tobacco. addition, adopting continuum-of-risk model,20US divisive communication across calmed—although eliminated—as productive able discuss potentially quit, proves unhelpful given smoker.•Promote surrounding nicotine. It well nicotine, addictive certainly harmless, (recall Michael Russell’s dictum “smokers die tar”).33Russell M.A. Low-tar medium-nicotine cigarettes: safer smoking.BMJ. 1976; 1: 1430-1433Crossref (131) Yet, substantial public, health, believe matter how delivered amount, cancer diseases.34National InstituteBeliefs adults, 2018.https://hints.cancer.gov/docs/Briefs/HINTS_Brief_37.pdfDate belief stunts needs rectified promoting large body behind NRT.•Support youth. Perhaps single volatile rates youths 5% prevalence, 30% concern many rapid lead erosion success.35Cullen K.A. Gentzke A.S. Sawdey M.D. al.e-cigarette 2019.JAMA. 322: 2095-2103Crossref (287) 36Zeller Youth Administration's multifaceted approach.Am 110: 772-773Crossref (4) 37Glantz S.A. Bareham D.W. use, smoking, risks, implications.Annu Rev 39: 215-235Crossref (222) 38Kozlowski L.T. Minors, moral psychology, nicotine.J Polit Policy Law. 42: 1099-1112Crossref (11) 39Miller quandary dissuading initiation.Am 788-789Crossref (2) 40Warner Will 5.6 million American eventually anatomy commonly accepted measure. Control. 2020.https://doi.org/10.1136/tobaccocontrol-2020-055672Google Alternatively, others diverted e-cigarettes.41Levy D.T. Warner Cummings al.Examining relationship vaping initiation adults: reality check.Tob 28: 629-635Crossref (78) Yet point outbreak product use-associated lung injury (EVALI)12Marlatt reason (although traditional caused EVALI but, instead, contaminated off-market cannabis products).42Gordon Fine Cornering suspects vaping-associated EVALI.N 382: 755-756Crossref answer central issue, communities FDA, Institutes voluntary legislative bodies protect—and extend—the successes delicate balance, Commissioner Scott Gottlieb vividly described,43US & AdministrationStatement Gottlieb, M.D., steps epidemic 2018.https://www.fda.gov/news-events/press-announcements/statement-fda-commissioner-scott-gottlieb-md-new-steps-address-epidemic-youth-e-cigarette-useDate better access potential “on-ramp” youth, keeping “off-ramp” open wish tobacco.•Support reasonable regulation FDA. has, perhaps, further They find correct balance lower-risk users, while, time, discouraging nonsmokers, Examples regulatory environments achieved exist: example, Kingdom, where remains low.44Medicines Healthcare Products Regulatory AgencyE-cigarettes: regulations consumer 2020.https://www.gov.uk/guidance/e-cigarettes-regulations-for-consumer-productsDate complexities constraining approvals process (especially regarding modified-risk [MRTP] pre-market application [PMTA] processes), channels convey perspectives—and data—to regulate take full advantage opportunities solid decisions e-cigarettes.•Promote rigorous new, development promotion. public–private partnerships environment supports acceptably effective devices, standardized well-monitored manufacturing processes, licensing legally allowed marketed, oversight marketing messages restrict targeting youth.•Remember clinician. see every day navigate discourage aid adverse consequences, encourage tried smoking-cessation success. situation, simply answers based expert opinion divergent. deal first-hand principles them advising practical ways up that.•Be flexible, naïve, assessing roles industries play accelerating decline show promise stop, consumers interest, move category, (including companies, vape shops, etc.) also expand. business strategy, as—with 1 billion globally, proportion whom want stop—there significant profitable market case, tobacco-control, tobacco-regulatory reconsider justified opposing enter uneasy peace them—and newer industry—for ready leaders stated “smoke-free” resources used promote noncombusted (and presumably harmful) declaration empty rhetoric, perhaps provides opening negotiate eventual manufacture, distribution, sale discussion raises questions, crucial “Can broached, partially?” naïve think Commentary, could accomplished. nothing, status quo, irresponsible and, damaging health. Consider minutes took points 25 Americans 300 people worldwide died complications arising unacceptable us, stands presented here. We not—and cannot—continue shameful visited community; too stake. can—and must—do