Recent news reports have touted that e-cigarettes are “95% safer than cigarettes” after Public Health England used the statistic in an announcement that the harm-reduction potential of e-cigarettes should be promoted. That statistic, the source of which is problematic, is now being used and misrepresented by many sources. The fact remains that stringent regulation of all tobacco products is the safest path forward for public health.

E-cigarettes are not 95% safer than cigarettes.

The source of that statistic is an article published in European Addiction Research in April 2014. The article was written after a meeting was convened in England to quantify the relative harm of various tobacco products. The twelve attendees decided that, on a scale of 0 to 100, 100 being the most harmful, cigarettes are a 100 and e-cigarettes are a 5. Their conclusion: e-cigarettes are 95% safer than cigarettes.

The article was flawed in several ways. The study reviewed each product in a vacuum without determining the risk for a person who uses multiple types of tobacco products, which is one of the most important factors in examining population health. The authors have only assigned a theoretical value to each product, not a practical one. A more practical assignment of risk would be nearly impossible. There are too many variables, which include the ever-changing variety of e-cigarettes and their ingredients, currently unregulated, which can have significant effects on health outcomes.

Even the authors recognized that we don’t know enough about the long-term health effects to make conclusions about relative risk. “A limitation of this study is the lack of hard evidence for the harms of most products on most of the criteria.” The authors also noted that, even if we did know more about the harms of e-cigarettes, comparing them to cigarettes would still be comparing two very different types of products on the same scale. That scale is warped because cigarettes are so dangerous. As Stan Glantz has said, anything is less harmful when compared to a cigarette, even inhaling from a car’s tailpipe. Is an e-cigarette safer than a cigarette? Possibly yes, but so are many other things that aren’t safe.

Personal bias and conflict of interest also played a role in this study. “Another weakness might be the kind of sample of experts. There was no formal criterion for the recruitment of the experts although care was taken to have raters from many different disciplines.” Possibly most damning: at least one of the twelve meeting attendees has financial ties to the tobacco industry.

E-cigarettes should not be promoted as a harm-reduction product.

Public Health England used the article to suggest that the harm-reduction potential of e-cigarettes should be promoted (a suggestion for which they are now under fire), but there are important differences in the regulatory structure of the U.S. and the U.K., notably the U.K.’s prohibition on e-cigarette marketing that appeals to youth.

Given the lack of restrictions on e-cigarettes in the U.S., the level of advertising and marketing, and the fact that almost all cigarette smokers are aware of e-cigarettes, the more prudent course of action is regulation, not promotion. Remember that even if e-cigarettes are considered safer than cigarettes, safer is not the same as safe. There is no question that e-cigarettes present some risks to individual users and there are significant potential risks for public health.

We know almost nothing about the health effects of e-cigarettes. Long-term epidemiological research is required to make conclusions about the risk of disease. While e-cigarette aerosols contain lower concentrations of some of the harmful constituents found in cigarette smoke, recent studies have found that some e-cigarettes create higher levels of some carcinogens, and that some of the flavoring agents, while safe to consume in food, are not safe to inhale.

There is also a growing body of evidence showing that youth and young adults are experimenting with e-cigarettes at alarming rates. We are also beginning to see evidence that that the use of e-cigarettes is associated with a greater likelihood of using combustible tobacco products, including a study finding that kids who used e-cigarettes were 8.3 times more likely to smoke cigarettes after one year. The youth appeal of e-cigarettes, the ubiquity of their marketing, the addictiveness of nicotine, and the availability of combustible products make for a potential upturn in smoking rates that must be avoided at all costs.

It is possible to regulate tobacco products in a way that minimizes the risk of youth initiation, switching to more dangerous products, and dual and poly-use among adults, all the while still allowing for the possibility that e-cigarettes could eventually represent an interim step towards a tobacco-free world. What we can do is to ensure that it is difficult for youth to acquire e-cigarettes, attempt to minimize the renormalization of smoking, and help adult users quit with proven cessation methods.

The FDA should:

  • Immediately begin regulating e-cigarettes and their components, parts, and accessories by finalizing the deeming regulation
  • Prohibit the sale of all tobacco products to anyone under 18
  • Enforce a timely premarket review of new products
  • Eliminate all advertising that reaches youth and young adults
  • Eliminate the use of flavors other than tobacco
  • Establish accurate, effective warning labels about the harmful effects of nicotine
  • Restrict certain sales practices, such as self-service displays and sales over the internet
  • Establish a requirement that all liquid nicotine be sold in child-resistant packaging
  • Establish product standards and manufacturing controls
  • Fund studies to allow for a better understanding of the health effects of e-cigarettes

In addition, state and local governments can:

  • Raise the minimum purchase age of tobacco products over 18
  • Prohibit the sale of flavored tobacco products
  • Establish a taxation scheme and eliminate price discounting to discourage youth sales
  • Establish licensing requirements for all tobacco retailers, including vape shops
  • Prohibit the sale of liquid nicotine that is not packaged in child-resistant containers
  • Prohibit the use of tobacco products, including e-cigarettes, in public places and workplaces
  • Establish or enforce existing regulations on making false or misleading marketing claims

We know too much about tobacco products and the tobacco industry (which now owns many of the e-cigarette manufacturers) to be persuaded that e-cigarettes should remain unregulated, or used as harm-reduction products. On the contrary, if a lack of regulation continues, current trends could result in more youth initiation into tobacco product use and fewer users quitting entirely. We cannot be distracted by reports touting statistics lacking sufficient context. We must protect public health now.

September 21, 2015

Desmond Jenson is a Staff Attorney at the Tobacco Control Legal Consortium at the Public Health Law Center.