Vapers’ experience and several scientific research suggest e-cigarettes are helping people stop smoking, delivering public health benefits. Yet governments still fear vaping, particularly for the youngster, and contribute to increasing restrictions. On the other side, the vapers community reacted by forming self-help groups and providing alternative cessation support to smokers. Is it possible a compromise between the two parties?
Dr. Roberto A. Sussman is a full-time senior researcher and lecturer in physics at the National University of Mexico. He is the founder and Director of Pro-Vapeo Mexico, an association representing Mexican consumers of noncombustible nicotine products, and is a member of INNCO. He is actively advocating for an appropriate regulation of Tobacco Harm Reduction products in Mexico. He directs and supervises the effort to spread scientific information on these products and advising consumers about them.
Mr. Sussman, in recent years the market of e-cigarettes- with more effective and less expensive devices- has evolved better for vapers. Do you agree?
Yes, I agree. The e-cigarette is a device that substitutes tobacco cigarettes, and thus mimics the ritual of smoking. Their acceptance by smokers is the key to measure their success. The first generation models, the “cigar-likes”, mimicked the shape of cigarettes (10 cm thin metallic cylinders), but their aerosol and nicotine delivery was very inefficient and thus were not very successful. As the technology evolved into more power and better nicotine delivery the second generation models looked like thicker ciga-likes that incorporated replaceable tanks, thus allowing the users to place e-liquids with different flavors and even control power, flow, and temperature.
The third-generation models incorporated more power, larger tanks, more user control of the devices, and better nicotine delivery (same peak intensity but slower time to reach it). However, they became quite distinct from conventional cigarettes, not only in shape but also in the ritual around their usage. The latest models become disposable, and it does not require maintenance, while previous generations required to change resistance and cleaning the tank. In their shape and ritual, they look more like some techno-version of tobacco pipes than tobacco cigarettes. This displeases many smokers.
First and second-generation models are no longer manufactured, while third-generation models have diversified, they can also be low-powered, compact-sized, and with a much simpler usage and maintenance (the so-called “starter kit”).
The fourth-generation model, the pods, emerged in the market 4-5 years ago as a cigar-alike shape but with more power and nicotine delivery comparable with cigarettes using nicotine salts, with some of the pods also allowing replaceable tanks. In terms of prices and practical concerns, pods are less expensive, require much less maintenance, produce a limited aerosol. Typically, those used to large tank models prefer to keep using them, but pods are becoming attractive to smokers willing to migrate into vaping.
Do you believe bias from governments and misinformation on the risks of vaping in the peer-reviewed literature deny the consumers a safer alternative to traditional cigarettes?.
Yes. The effect of misinformation, whether from governments or peer-reviewed sources, can be very disruptive to smokers and even for those who have begun replacing cigarettes with safer alternative products.
The ill-effects of misinformation on these products do not only affect smokers or vapers but also non-users, such as friends or relatives (parents, spouses, siblings). Since smoking abstinence is difficult and traditional pharmaceutic options (patches, gums, varenicline, bupropion) do not reproduce the smoking ritual, the consequence of denying or placing obstacles to alternative products is keeping smokers with traditional cigarettes.
Unfortunately, public health officials, physicians, media, and scientific sources who disseminate misinformation on alternative nicotine products might have reliability on other health issues, so people tend to extrapolate this credibility to all health issues and believe misinformation on e-cigarettes. It is difficult to convince the public that, for example, the medical establishment and the Karolinska Institute in Sweden spread misinformation on snus when they have academic credentials and high credibility on other health issues. Same story for academics spreading misinformation on e-cigarettes in the USA, Australia, and Europe. Paradoxically, the damage of misinformation is limited in countries where public health institutions have low credibility.
Misinformation has managed only to reduce the appeal of alternative smoke-free products, not to extinguish consumption. Most users notice an improvement in their well-being and enjoy using them, often in dual usage with cigarettes, regardless of the misinformation. The adverse effect is on reducing the uptake by smokers who have not used them. If these smokers believe that there is no health improvement, no decrease of the stigma, no chance of indoor usage, then they are effectively dissuaded to switch to a new product that requires a learning curve to learn how to use and a change of ritual.
What is the best practice governments should follow to balance public health and the right of choice for vapers?
First and foremost to regulate these products, following a risk proportional approach and making them fully accessible to adult smokers. Governments must recognize that the regulation of these products cannot be equated to that of combustible tobacco products, as they represent a much lower risk for the user and third parties because of their lack of combustion. Acknowledging the difference in risks, based on science, would minimize the most harmful and insidious misinformation and paved the way to a regulation that would benefit either public health and the right of choice and personal autonomy of smokers and vapers. Governments should also communicate those differences, either by official reports or by allowing communication by controlled commercial advertising.
Governments should invite all stakeholders, including the industries, to participate in the regulation debate. There must be scrutiny over the tobacco industry and industries manufacturing these products and non-industry associations advocating for them. Governments often dismiss exerting scrutiny also on those who oppose them or deny their relative safety, such as medical societies, health technocracies within the governments, or tobacco control academics. These stakeholders might have a conflict of interest with the pharmaceutical industry or with private philanthropies (Bloomberg Philanthropies).
Underage consumption must be prohibited, with information campaigns and preventive measures implemented to enforce it. The protection of minors must be balanced, allowing and facilitating usage for adult smokers. Claims of excess usage by minors must be scrutinized, in terms of available demographic data that records and distinguishes between intermittent exploratory usage from frequent usage and examine the cross-reference with cigarette usage. Usage by nonsmokers must be advised against using information campaigns, but cannot be forbidden. Governments should also facilitate the acceptance of these devices as part of the tools in stop smoking services.
