Many of my friends, family and co-workers smoke cigarettes. They, like the other 20% of Americans who smoke, do so despite the known health risks and the fact that a pack of cigarettes now runs over $12 in New York. That they continue to smoke given the physical and financial cost demonstrates just how powerful nicotine addiction can be. In fact, some studies suggest that nicotine is more addictive than alcohol, cocaine or heroin. So it's really no surprise that nicotine addiction is the most common form of chemical dependence globally.
Many who do smoke want to quit. Most have tried repeatedly, but have failed despite their best efforts. According to the US Centers for Disease Control and Prevention, nearly half of all smokers are actively trying to quit. In a given year, however, only about 1 in 20 will succeed. Nevertheless, the number of adults who do smoke has decreased steadily over the last several decades. There are now more former smokers than current smokers in the United States.
A lot of this success can be attributed to aggressive anti-smoking campaigns. High taxes, local and state ordinances that limit where people can light up, and graphic advertising campaigns have had an impact.
Most of us have seen, for example, television spots that unabashedly show some of the health effects of smoking - facial disfigurements, stomas and surgical scars. That ad campaign cost $54 million to run, a pittance compared to the $9 billion the tobacco industry spends on advertising cigarettes or the $100 billion in annual medical costs directly attributable to smoking. Yet those advertisements alone inspired more than 100,000 people to stop smoking.
Anti-tobacco efforts have also been bolstered by the increasing number of smoking-cessation aids available to those who want to quit, such as nicotine patches, psychotropic drugs like varenicline, and electronic (or E-) cigarettes. E-cigarettes in particular have become particularly trendy.
Physically resembling a tobacco cigarette, e-cigarettes use a battery-powered heating element to produce an inhalable nicotine-containing vapor. Nicotine cravings can be satisfied, but without exposure to the thousands of other toxic chemicals found in tobacco smoke. E-cigarettes may thus be "healthier" than actual cigarettes, despite the fact they are specifically designed to deliver nicotine, a highly addictive carcinogen and teratogen.
They may also help people stop smoking. Just this week a study published in the British medical journal The Lancet reported that e-cigarettes do help active smokers cut back on actual tobacco use.
So e-cigarettes are a good thing, right? Maybe, but there are a number of reasons to be concerned about their growing use and popularity.
E-cigarettes are largely unregulated. So long as they are not marketed for as smoking cessation aids, a federal court ruled, the US Food and Drug Administration (or FDA) does not have the authority to regulate them as drugs or drug delivery devices. While the FDA can regulate e-cigarettes as a tobacco product under the Tobacco Control Act, they have yet to do so.
In fact, there are currently no federal laws that restrict the sale and use of e-cigarettes, even to children. Nor will be passed in the near future, given that the nation's leading e-cigarette company recently appointed Former U.S. surgeon general Dr. Richard Carmona to its Board of Directors as part of a strategic lobbying and marketing strategy. Thankfully, twenty states (including New York and Vermont) place restrictions on the sale and use of e-cigarettes.
Call me cynical, but I believe that e-cigarette manufacturers want to market their products to minors, despite the health risks associated with nicotine use and nicotine addiction. That they produce a variety of candy-flavored versions suggests a deliberate campaign to target children. That campaign seems to be working. The number of middle- and high-school aged kids who have tried e-cigarettes has doubled in the last four years. Get them hooked on nicotine early and they'll be dedicated customers for life.
Public health officials have voiced similar concerns, calling for tighter restrictions on the sale and use of e-cigarettes, particularly to minors. Of course, manufacturers are resisting this, railing against regulations that "stifle what may be the most significant harm reduction opportunity that has ever been made available to smokers." That argument, however, implies that e-cigarettes are a safer alternative to smoking, even though no studies have yet been done on long-term health effects. It also suggests that e-cigarettes are smoking cessation or reduction aids, which would make them subject to strict FDA oversight.
More clearly needs to be done. E-cigarettes are a good thing in that they seem to help some smokers cut back or eliminate tobacco use. But their use by children and young adults could lead to nicotine addiction, which is a bad thing. At a minimum, the FDA needs to regulate them more tightly to ensure that they are as safe as possible for nicotine-addicted adults and to prevent their use by children.
A public health researcher and ethicist by training, Dr. Sean Philpott is Director of Research Ethics for the Bioethics program at Union Graduate College-Icahn School of Medicine at Mount Sinai in Schenectady, New York. He is also Acting Director of Union Graduate College's Center for Bioethics and Clinical Leadership, and Project Director of its Advanced Certificate Program for Research Ethics in Central and Eastern Europe.
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