E-cigarettes—new product, old tricks

December 2018
The Lancet

Tobacco smoking cessation represents one of the most successful public health initiatives in the world, with smoking prevalence at its lowest during the past decade according to recent WHO estimates. However, since the introduction of e-cigarettes in 2003, marketed as a less harmful alternative to tobacco, what should have simply been an effective tool for tobacco smoking cessation is turning into a new mainstream addiction, with tobacco companies being one of the main beneficiaries and regulators entering the debate with naive tolerance. Recent months have seen a substantial increase in public promotion of e-cigarettes, taking advantage of the scarcity of evidence regarding the safety and long-term effects of these products.

On Oct 3, 2018, Philip Morris International, via prominent branding on Ferrari’s Formula 1 racing cars, launched Mission Winnow, a project in which they boldly claim to want to build “a better world for women and men who smoke, using our scientific and engineering expertise to deliver it”. The promotion of this undertaking as a major corporate responsibility exercise is not only deceptive, but also worrying because it demonstrates the extent to which the tobacco industry aims to shape the scientific evidence to support their commercial strategy of e-cigarettes as harmless smoking. The same week, on Oct 7, 2018, The New York Times reported about a cocktail party in Geneva, Switzerland, that coincidentally occurred at the same time and place as the biannual negotiations of the WHO’s tobacco treaty, which were focused on deciding whether to recommend the introduction of stricter regulations for nicotine-delivery devices. In this evening event, cumbersomely named Nicotine Is Not Your Enemy Soirée and sponsored by an organisation partly funded by the tobacco industry—the Consumer Choice Center—the lack of evidence regarding the long-term safety of e-cigarettes was used to persuade guests, who were enjoying an open bar, free tapas, and e-cigarette samples, to believe that e-cigarettes are harmless. This effort by tobacco industry representatives to surreptitiously influence WHO negotiations is yet another desperate attempt to influence the global public health agenda, and although it shouldn’t come as a surprise given the tobacco industry’s past activities, it is nevertheless deplorable.

Although the doors of the WHO are closed to e-cigarettes lobbying parties, those of the global market are wide open, and subliminal advertising are part of the industry’s marketing strategy to promote e-cigarettes as the new smoking alternative. At the end of October, 2018, Philip Morris International was accused of cynical advertising in the UK after the launch of a series of anti-smoking advertisements while still promoting smoking in other countries. Altria and JUUL Labs Inc also announced that they will stop selling some flavoured vaping products in the USA—to pre-empt the US Food and Drug Administration crackdown—amid concerns of increased underage use of flavoured e-cigarettes. This concerted marketing strategy suggests an intensive effort by the tobacco industry to normalise alternative nicotine products despite unforeseen future health effects.

The orchestrated effort and huge investment of the tobacco industry to promote e-cigarettes and alternative nicotine products deserves an equally bold response from policy makers. In August 2018, an Editorial in The Lancet covering the UK’s House of Commons Science and Technology Committee report on e-cigarettes concluded that “it is naive and premature of the Committee to confuse an absence of evidence with an absence of harm”. Indeed, although e-cigarettes are unlikely to replicate the link between nicotine addiction and lung cancer caused by tobacco smoking, the absence of long-term evidence about the safety of vaping calls for a more precautionary attitude from policy makers.

The agenda set out by the tobacco industry is disappointingly familiar. After a century of global inaction against the tobacco epidemic, the 2003 WHO Framework Convention on Tobacco Control provided effective evidence-based recommendations to inform policy and keep countries accountable to global tobacco control targets. Instead of passively waiting for history to repeat itself, non-governmental organisations and governments alike should come together with a united vision to monitor and counter disinformation on e-cigarettes. Although the long-term effects of e-cigarettes are still unknown, we are aware of their potential to create generations of nicotine addicts, which should be enough to trigger stricter regulations on these products. A new, broader set of measures in the WHO Framework Convention on Tobacco Control is clearly warranted.

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