E-Cigarettes and Maintenance Therapy: A Smart Public Health Approach

E-cigarettes illustrate how harm reduction approaches to drug policy, particularly maintenance or substitution therapies, are at once both filled with promise and deeply misunderstood.
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I don't smoke, but I find myself fascinated by and passionate about the debate over e-cigarettes. Why? Because e-cigarettes illustrate how harm reduction approaches to drug policy, particularly maintenance or substitution therapies, are at once both filled with promise and deeply misunderstood.

The U.S., using public health approaches, has made incredible strides in reducing the number of smokers. But 480,000 people in the U.S. will die from cigarette smoking each year, a number that has remained relatively stable since 2004. While education, prevention and cessation programs must continue, these strategies are unlikely to result in the kind of big reductions in smoking at the population level that we have seen in the past. Many of those still smoking simply cannot or will not quit.

E-cigarettes, electronic devices that deliver nicotine via a vapor, eliminate almost all of the harmful chemicals of smoking and are preferred by smokers over nicotine patches or gum (which have not proven successful at helping most people quit long term). Nicotine is an addictive substance but one with relatively few harmful health effects, especially compared to smoked tobacco. While more research is needed and better regulation of the contents of e-cigarettes could improve consumer safety, research to date suggests that neither the secondhand vapor nor the contents of most e-cigarettes themselves is particularly hazardous. They are certainly far less toxic than cigarette smoke. Some have raised concerns that e-cigarettes will increase smoking among youth or people who have never smoked. So far, however, the research does not bear out these fears.

The risks associated with e-cigarettes, which appear at this point to be modest, must be weighed against the potential benefits. On the individual level, there is good evidence to suggest that some people who use e-cigarettes reduce or eliminate their use of traditional cigarettes, decreasing harm to themselves and reducing exposure to secondhand smoke to those around them. It's too early to say, what the impact at the population level will be, but in countries, like Sweden, where smokeless tobacco products, like snus, became popular, smoking rates (along with lung cancer and myocardial infarction) dropped dramatically. A substantial proportion (around 30%) of male ex-smokers in Sweden used snus when quitting smoking, and researchers have attributed the drop in smoking nationwide in part to the increasing use of this less harmful smokeless product.

Despite these potential health benefits, many public health officials have come out strongly against e-cigarettes (see for example, the e-cigarette ban in New York City). Rather than opposing substitution and maintenance therapies, like e-cigarettes, the public health community should be embracing them. It's time for us all to acknowledge that some people will always use nicotine, just as some people will always use other drugs, such as heroin or prescription opioids. They have either tried and failed to quit - often hundreds of times - or they simply choose not to quit.

Julie Netherland is the New York deputy state director for the Drug Policy Alliance.

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