Doctors could now prescribe electronic cigarettes as a way to quit smoking, after regulatory authorities have granted a drug licence for one of these products for the first time. This marks an important point in the growing popularity of vaporization, which has created a global market for electronic cigarettes of more than US$6 billion. Yet the technology remains highly controversial.
Proponents of electronic cigarettes claim that they have contributed to increased quit rates. But skeptics fear that steaming may make smoking a more socially acceptable habit, become popular among children who may then switch to conventional cigarettes, and may even pose a direct health risk because of the chemicals involved.
Academics, organizations and governments have identified important areas for research, namely the nature and impact of the dual use of electronic and conventional cigarettes. Rather than simply assuming that steaming is a way for everyone to reduce smoking for health reasons, we should consider that they may be complementary activities for some. Regular smokers are often subject to regulation and social pressure. For example, they may no longer be able to smoke at their workplace or in places where they gather with friends or family.
Substitutes vs. Complementers
Electronic cigarette use, on the other hand, is often unregulated and provides both the solution to the nicotine associated with cigarette use and part of the social element. Smokers therefore now have the opportunity to smoke regular cigarettes whenever possible and to use them with electronic cigarettes when smoking is not possible or appropriate.
If electronic cigarettes were only substitutes and helped more people quit smoking, they could increase the financial and co-benefits of quitting by reducing tobacco use. But when electronic cigarettes act as a complementary product, they could instead blunt the usual anti-smoking regulations and keep people smoking longer.
We conducted an online survey of 2,406 people in the United States and found that 37% of smokers who use them see e-cigarettes primarily as a complement to traditional cigarettes, rather than as a substitute. We also found that while 55% of “substitutes” were trying to quit smoking, only 40% of “complements” were doing so.
Using publicly available data from U.S. and U.K. sources, this research allowed us to calculate a new measure of the financial profitability of electronic cigarettes in terms of public health savings. If 37% of dual users are considered “supplements,” the estimated benefits of electronic cigarettes will drop as low as 57% in the United States – equivalent to savings of $3.3 billion to $4.9 billion per year.
We also found that this problem is unlikely to receive the attention it deserves because non-smokers underestimate the extent to which electronic cigarettes act as a complementary product. While 37% of dual users in our sample viewed vaporization primarily as a complementary activity, only 27% of non-smokers believed that the electronic cigarette would be used in this way rather than as a substitute. This difference in perception suggests that some people overestimate the benefits of electronic cigarettes. This is all the more worrisome since non-smokers make up the majority of the population, which probably includes many policy makers and health experts.
The difference in perception may be due to the early success of smokers who used electronic cigarettes to quit. Similarly, our research found that ex-smokers who had successfully quit smoking were the least likely to have used the electronic cigarette primarily as a supplement (20%). They were followed by dual users who were trying to quit (30%) and finally those who had no intention of quitting (44%).
Bigger than you think
If the public focuses on the success stories of those who have used electronic cigarettes and quit, they underestimate the extent of the complementary vaporization. It is likely that the early years of electronic cigarette use will have been dominated by those who would like to replace them with tobacco to quit smoking . But as these people quit smoking, the proportion of complementary users will increase.
However, it is not because some people use the electronic cigarette as a supplement to tobacco that they do not want to quit smoking. In fact, our research found that complementary users were more likely to use another method or product, such as nicotine gum or patches, in addition to electronic cigarettes. This suggests that for some who are trying to quit smoking, electronic cigarettes may be hindering their progress.
However, since complementary use can significantly undermine the health benefits of cigarettes and make some smokers worse off if they continue to smoke, the product could weaken regulations aimed at reducing smoking. In addition, the increasing regulation of regular cigarettes will have an impact on cigarette use, but may also encourage more people to adopt complementary smoking, thereby reinforcing the impact of the problem. Health authorities such as the NHS need to consider the issue of complementary use when developing policy. For example, offering prescription electronic cigarettes may help some smokers, but harm others.