Balancing consideration of the risks and benefits of e-cigarettes

Junaid Ali Khan

As in the rest of the world, Pakistan remains divided or opposed to the use of tobacco harm reduction as one of the solutions to reducing the prevalence of combustible smoking. If one goes by various estimates, the number of tobacco users in the country ranges from 25 to 30 million.

Most of them are cigarette smokers. Compared to them, the users of e-cigarettes or heat-not-burn devices are miniscule – a few thousands. With only 100-odd vaping shops in Pakistan, most of the vapers are from the middle class and rich families, mainly because of the higher prices. 

Tobacco control activists remain opposed to the use of e-cigarettes as a quitting tool for adult smokers, as they claim it is another ploy for gateway to smoking.  From time to time, they call for ban on vaping, which is legally allowed in Pakistan.

There is a clear division on those who oppose tobacco harm reduction and those who back it in Pakistan – an “us versus them” situation. Interestingly both the parties want to reduce or end the use combustible smoking, especially among the youth.

Perhaps the time has come to take an objective view of the tobacco harm reduction and then decide how it can be part of the tobacco control efforts in Pakistan.

An article coauthored by K. E. Warner and contributors – Balancing Consideration of the Risks and Benefits of E-Cigarettes – gives us a comprehensive overview of the opponents and supporters of e-cigarettes. The paper was first presented at E-Cigarette Summit: Science, Regulation & Public Health, USA Virtual Summit, on 25 May 2021.

Admitting that the issue of e-cigarettes is controversial, it says, “Opponents focus on e-cigarettes’ risks for young people, while supporters emphasize the potential for e-cigarettes to assist smokers in quitting smoking.”

Published by the American Journal of Public Health, the article reviews the health risks of e-cigarette use, the likelihood that vaping increases smoking cessation, concerns about youth vaping, and the need to balance valid concerns about risks to youths with the potential benefits of increasing adult smoking cessation.

This is perhaps first effort where the use of e-cigarettes has been seen from the lens of opponents and supporters. The article has tried to look into the health risks of vaping, the likelihood that vaping increases smoking cessation, the principal concerns about youth vaping, and balancing concerns about risks to youths with potential benefits for adult smokers.

Talking about the fatalities in the US by “e-cigarette or vaping use-associated lung injury” or EVALI, it says “media coverage was extensive. Several states and cities promptly banned retail and online sale of flavored e-cigarettes.”

However, in early 2020, research attributed the illness to vitamin E acetate, an adulterant in illicit tetrahydrocannabinol (THC) vaping devices shown to produce pulmonary injury in animals. The article says, “Once the potential harm of vitamin E acetate was publicized and adulterated THC removed from the market, the incidence of new cases fell precipitously.”

But the damage has been done. “After the outbreak, two thirds of respondents to a poll related the lung disease deaths to use of ‘e-cigarettes such as JUUL.’ Only 28% related the deaths to use of “marijuana or THC ecigarettes.”

The paper concludes that the combustible cigarettes are more harmful and dangerous than e-cigarettes. “The number of chemicals in cigarette smoke, greater than 7000, exceeds that of e-cigarette aerosol by 2 orders of magnitude.” Additionally tests of lung and vascular function indicate improvement in cigarette smokers who switch to e-cigarettes. And exclusive users of e-cigarettes (most being former smokers) report fewer respiratory symptoms than do cigarette smokers and dual users.

Although the evidence is not definitive, a growing body of evidence indicates that vaping can foster smoking cessation, it said.

On the all-important issue of vaping as a ploy to attract youth to smoking, there are chiefly three concerns. The first is that vaping can cause nicotine addiction among young people who never would have tried smoking. Secondly, vaping by never-smoking youths may cause some to try smoking, risking “renormalizing” smoking among young people. Thirdly, Nicotine can harm developing brains, and vaping nicotine may have other adverse health effects.

Saying that vaping likely addicts some young people to nicotine, it however, says the evidence does not suggest it is addicting very large numbers.” Quoting a study, the article maintains, “Data . . . do not provide support for claims of a new epidemic of nicotine addiction stemming from use of e-cigarettes.” Another study reported that the e-cigarette–driven increase in nicotine product use among high-school students is not associated with an increase in population-level dependence.  It called for concerted efforts to reduce youth vaping.

However, it concluded that large majority of nontobacco product–using young people do not vape and, thus, have no nicotine exposure. Among those who vape, most do so infrequently; many are short-term experimenters. And the most dangerous form of youth exposure to nicotine, cigarette smoking, has declined at an unprecedented rate during the era of youth vaping. Use of other tobacco products has declined as well.

The authors of the article said they are alive to the legitimate concerns about youth vaping. “Our goal is to put those concerns in perspective. We agree with former Surgeon General C. Everett Koop who, in 1998, urged that “[A]s we take every action to save our children from the ravages of tobacco, we should demonstrate that our commitment to those who are already addicted . . . will never expire.” The latter appears at risk today.”

It concluded that it is high time the public health community seriously thinks about vaping’s potential to help adult smokers. “While evidence suggests that vaping is currently increasing smoking cessation, the impact could be much larger if the public health community paid serious attention to vaping’s potential to help adult smokers, smokers received accurate information about the relative risks of vaping and smoking, and policies were designed with the potential effects on smokers in mind. That is not happening.”

This call for seriously studying the potential of e-cigarettes is also not happening in Pakistan. Therefore it is not surprising that the use of e-cigarettes in the country is an individual decision, with no involvement of public health experts. Anecdotal evidence suggests some have successfully used e-cigarettes to give up combustible smoking and then also quit vaping.

Instead of rejecting, the government of Pakistan and the tobacco control activists should look at and review the potential of tobacco harm reduction.

If Pakistan is to meet its target of reducing the target of smoking prevalence by 10% by 2025, it has to provide accessible and affordable cessation services, and ensure that THR is part of tobacco control initiatives.