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Public Health Math: Does “less bad” = “good”? A look at the increasing popularity of e-cigarettes

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The field of public health is premised on epidemiological number games. While eradicating disease may be the paragon of the field, in practice, public health leaders apply a more rational lens focused on achieving the best health outcomes for the majority.  Tackling the health issues associated with tobacco products presents a ripe example of this realist approach to public health.  While incontrovertibly, the health consequences associated with tobacco use have an easy fix – stop using the product – even the most ardent anti-tobacco voices would likely admit, at least in the near term, that this is a highly improbable solution. The equation then becomes, to reduce the incidence of tobacco-related disease, does the “less-bad” alternative = a “good” option?

The recent popularity of e-cigarettes illustrates this tension. E-cigarettes are touted by the tobacco industry as the “safe” alternative to conventional nicotine delivery systems like the combustible cigarette.  E-cigarettes create a vapor from a nicotine solution that is delivered in an aerosol form. Proponents laud the product because the toxic carcinogens generated by conventional cigarettes are eliminated and there is no risk of second-hand smoke. However, the fundamental goal of an e-cigarette is to deliver a highly addictive and indisputably dangerous chemical –nicotine- to the user. Though studies about the health consequences of e-cigarette use remain vague and inconclusive, we can reasonably presume consequences are nonetheless real.

Recently, the Centers for Disease Control (CDC) released a study reporting on the alarmingly high increase in use of e-cigarettes among middle and high school students. Between 2011-2012, the use of e-cigarettes among high school students doubled, from 4.7-10%. While the study did not assign a reason for this dramatic increase, a few likely culprits can be inferred.            

First, few states have restricted the sale of e-cigarettes to minors, making them readily available. Second, e-cigarettes are significantly cheaper than conventional cigarettes. Third, e-cigarettes are relatively new and anti-smoking campaigns have yet to adequately address their inherent risks. Fourth, the Food and Drug Administration does not (yet) have the authority to regulate e-cigarettes, therefore the restrictions on sales, smoking laws, and bans on advertising do not apply.  Accordingly, a consumer may reasonably conclude that this lack of regulation means that e-cigarettes are inherently safer. Lastly, this product is still new (first released in 2007), unconventional and exciting.

Despite the fact that the science on the health risks of e-cigarettes is not yet conclusive, many in the industry, including some at FDA, have at least drawn the conclusion that because the e-cigarette is presumptively “less bad” than a conventional cigarette, it is a “good” alternative. When it comes to youth smoking, advocates argue that teens are going to smoke anyway, so why not encourage them to smoke the safer option? If public health professionals are champions of the greatest health outcome for the majority, should advocacy center on the least bad alternative, even when that alternative is fraught with health risks itself?

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