E-cigarettes, children, and adults who like gummy bears? Are e-cigarettes a good thing?

Huge debate

There is enormous debate in the UK public health community about E-cigarettes. It is polarising the health community, leaving smokers confused about whether these relatively new 'aids' for quitting are actually a good thing. We have been accused ourselves of creating 'fear' simply by reporting that young people find 'vaping' highly appealing. You would think we had just started World War 3 with this news looking at the onslaught of abuse from loyal vapers on Twitter. It really was quite astonishing (see 'attack of the vapers').

So why do we have a public health community so divided? I posed this question to scores of Public Health professionals at the Public Health England Conference in Warwick two weeks ago and the majority felt that there was just not enough evidence to make a decision. Since announcing our findings from a local study in North Wales on youth smoking and vaping, more and more evidence has been published both for and against E-cigarettes. It seems that as soon as one document is published saying E-cigarettes are potentially harmful, another is released to say they are saving smokers. Then there is the debate on what constitutes as evidence and what is just a load of tosh. Apparently, our local research in Wales with young people was not peer reviewed (give us a chance!) so some would put our research in the latter category. Not that peer review for our study would make a difference to those supporting E-cigarettes - even senior professors in public health and gurus in tobacco control have been condemned and questioned for raising an eyebrow at the authenticity of E-cigarettes as a tool for quitting smoking.

But what seems to really bother public health professionals is the potential role E-cigarettes might play in introducing people to smoking - otherwise known as gateway effects. Do E-cigarettes encourage people to continue smoking or support people to quit. Crucially, will E-cigarettes introduce young people to smoking. Some studies suggest yes - others no. Some professionals are concerned that E-cigarettes are re-normalising smoking, especially for young people, potentially undoing all the hard work of the last 30-50 years. These are genuine concerns and what worries me the most is the hijacking of forums - both on and offline - limiting the opportunity to have a sensible, reasoned debate about E-cigarettes.

Since the publication of our research on youth smoking (which included a small section on E-cigarettes) we have been subject to a tyrade of Twitter and email abuse. And I found out quickly that we were not the only ones. And it is the brutal and personal attacks on people and organisations who question E-cigarettes that raises alarm bells for me (see 'attack of the vapers'). We should not be scared to talk about E-cigarettes. Lets ask questions. It doesn't always mean we are against them. We just have questions. I wasn't around in the 1950's, but I believe people thought smoking cigarettes was a good thing at one time and the tobacco companies told us as much. In January 1954, US tobacco manufacturers jointly sponsored an advocacy advertisement entitled “A Frank Statement to Cigarette Smokers” which appeared in 448 newspapers in 258 cities reaching an estimated 43,245,000 Americans. The advert questioned research findings implicating smoking as a cause of cancer, promised consumers that their cigarettes were safe, and pledged to support impartial research to investigate allegations that smoking was harmful to human health.

Sixty years later, the E-cigarette is here and I would like to know if they are safe. Safe to use, safe to be around, safe for children. As many suggest, the E-cigarette could be the best invention EVER for getting people off conventional cigarettes, which are still one of the biggest killers. I can't of course answer questions on their safety or whether they are reducing smokers mortality, and I wouldn't even attempt to try and answer some of those questions as I am not a scientist, or a doctor or a guru in anything. And anyway, my view apparently doesn't matter according to many Twitter trolls. But I am principally a marketer, and a researcher, so I know enough about marketing and the tactics used to build emotional connections and get us to buy things so I have taken a keen interest in the marketing of E-cigarettes.

The role of marketing

Over the last 12 months we have seen the marketing of E-cigarettes shifting from being an "aid" to stop smoking to something we must desire, something we must have and something we must taste. Over the past year alone, the E-cigarette market has increased by 340% and it is estimated to be worth £340 million in 2015. This didn't happen without marketing. And the marketing really ramped up when the big players of the tobacco industry started moving into the market buying shares in E-cigarette companies, buying e-cigarette companies outright, or making their own brands. For example, Altria, the owner of Philip Morris International (the company that owns tobacco brands such as Marlboro) created it’s own e-cigarette brand (MarkTen) in 2013. As soon as the tobacco industry became more and more involved in E-cigarettes the marketing efforts appeared to double and the range of flavoured products increased. As I am sure you know, adverts for smoking cigarettes are banned in the UK. Looking at the billboards for some advertisements you wouldn't think so. Take a look at this advert by Rok. On first glance you would think this was a cigarette.

Just to be clear, somewhere in the mist of the bitter rows, the trolling, and the serious debate amongst scientists, researchers and professors there appears to be a consensus that E-cigarettes should not be sold to under 18's. So why have the 11- 12 year old girls I have worked with tried E-cigarettes? I saw an advert on TV recently for E-cigarettes. It was sexual. It was alluring, it was inviting. Are these adverts telling smokers to switch from smoking cigarettes to a 'less harmful' E-cigarette? Are they heck. These adverts are not aimed at the 50 a day smoker desperately seeking to become 'unhooked'. These adverts are creating a desire. Is this ok? Well, most products we buy are desirable. That is why we part with our hard earned cash. But are these marketing efforts appealing to smokers or non-smokers - or both? And critically, are marketing efforts focused on recruiting that next generation of smokers or vapers - the under 18's.

Senator Richard Blumenthal recently pulled tobacco executives in front of the senate in America and said: "I think we have seen this movie before. It is called big nicotine comes to children near you and you are using the same kinds of tactics and promotions and ads that were being used by big tobacco and proved so effective". The hearing was on marketing practices by the electronic cigarette industry. Senior executives claimed that E-cigarettes are designed to entice those who already smoke to use the product, claiming that they are a valuable public health tool. They were supported in large by public health professionals who wanted to keep an open mind on the potential for emerging technologies to benefit public health but there was a consensus that e-cigarettes are not good for the developing teen brain. Yet, In America, more than a quarter-million youth who had never smoked a cigarette used e-cigarettes in 2013.

The picture appears to be different in the UK. Or so we are told. A recent study by ASH Wales (2014) found that 79.6% of 13-18 year olds were aware of E-cigarettes in Wales. Another study by ASH for England released in September 2014 says awareness is now over 80% but interestingly only 1.8% of children are regular users. However, we conducted a survey in June 2014 with headteachers and teachers across England and of the 72 schools that took part, 53 schools told us that they were confiscating up to 10 E-cigarettes a week. If you do your maths this means that in just 53 schools, up to 500 E-cigarettes are confiscated by teachers EVERY WEEK. Our work with young people in Wales over the last 12 months has found that young people do find E-cigarettes highly appealing - and they are trying them.

So why are they appealing? Other nicotine products are available but we haven't seen young people getting hooked on nicotine gum and patches have we? The allure of the different flavoured e-cigarettes from redbull, strawberry milkshake and gummy bear is proving hard to resist. And with the likes of Robert Pattison, star of the Twilight movies, which were a sensation among teens advertising E-cigarettes for NJOY, there is no doubt that there is a huge push to make these things appear cool and desirable - a million miles from the initial claim put forward by the E-cigarette industry that E-cigarettes are to help smokers quit. The marketing efforts prove otherwise. Now without trying to sound too Mary Whitehouse, I would like to NOT see young people manipulated and sucked into a chemical cloud created in large by the very people who created a large smoke cloud for so many generations.

But lets get back to the crux of this blog. I asked if E-cigarettes are a good thing. As I said, that is not for me to decide. I am just the little person. So who are the big people who can tell us. Who can we trust? Surely, the World Health Organisation? And here is their position. Now, following the publication of their report they too have been critiqued and attacked. How dare they say that E-cigarettes potentially represent an “evolving frontier filled with promise and threat for tobacco control", and that regulations need to be put in place to impede e-cigarette promotion to non-smokers and young people, minimize potential health risks to e-cigarette users and nonusers, prohibit unproven health claims about e-cigarettes, and protect existing tobacco control efforts from commercial and other vested interests of the tobacco industry.

I guess it doesn't matter how big you are, how respected your opinion is, If it doesn't say what you want to hear then you must be wrong.

Notes:

Kelly is a Director at Social Change UK and has been working in public health behaviour change policy and design for over 10 years. The Social Change UK team have been gathering evidence on E-cigarettes and youth smoking behaviour for Public Health Wales. More information on this work can be found here.

Media reaction (updated 02/10/2014)

Following the publication of my original opinion piece in several media, I would like to make the following facts clear to the reader to avoid any doubt:

1. At no time have I called for a ban on e-cigarettes. I do believe however that e-cigarettes should be regulated.

3. At no point have I said that children are 'addicted' to e-cigarettes. Most E-cigarettes do however contain nicotine and a person can become addicted to nicotine.

4. Our work on youth smoking and e-cigarette use is not funded by Pfizer or any other pharmaceutical company.

What are Electronic Cigarettes?

Electronic cigarettes, also known as e-cigarettes or vapours, are electronic devices, which look like tobacco cigarettes. We know that most people who start smoking start as a young person - between 11-14 years. The device heats up liquid nicotine, which is inhaled as water vapour. Seen as "not as bad" as tobacco cigarettes, they do contain liquid nicotine and other chemicals.

How many people use electronic cigarettes in the UK?

A study by Action on Smoking and Health (ASH) estimates that there are approximately 1.3 million e-cigarette users in the UK [1].

What is the government position?

E-cigarettes are not regulated in the same way tobacco is, which is why the government plans to ban e-cigarettes for those under the age of 18.

Currently there is very little regulation in the UK for E-cigarettes. in January 2014, the Medicines and Healthcare Products Regulatory Agency did not place restrictions on the marketing of E-cigarettes. A review of the EU Tobacco Products Directive (2001/37/C) regulation is due to come into action in 2016 which would make any E-cigarette cartridges containing more than 20mg/ml to be regulated as medicines. The purpose of the review of the regulation is to ensure that members of the public remain safe. Under the new regulations, e-cigarette packets will be required to have health warnings on their packaging as well as information on the ingredients and nicotine content.

Links to interesting articles/ research

Simon Chapman: Why is Big Tobacco investing in e-cigarettes?

Simon Chapman: The best and worst case scenarios for public health

E-cigarette uptake and marketing -A report commissioned by Public Health England

Twenty-nine cases of nicotine poisoning specifically from electronic cigarettes were reported this year in Sweden, nearly a tenfold increase from last year's three incidents. A third of the reported cases were children, the Swedish Poison Information Centre (SPIC) stated.

So what should we make of e-cigarettes?

The position on E-cigarettes from the World Health Organization

E-cigarette poisoning in children in America

E‐cigarette access among young people in Cheshire and Merseyside - Findings from the 2013 North West Trading Standards survey

"Most people I know have got one" Young people's experience and perceptions of e-cigarettes

Chemical hazards present in liquids and vapors of electronic cigarettes

Carbonyl Compounds in electronic Cigarette vapors— effects of nicotine solvent and Battery Output voltage