The rise and fall of e-cigarettes according to Aesop

In a famous fable by Aesop (620–560 BC), ‘The Tortoise and the Hare’, ¹ one learns that it takes patience and persistence to reach the goal, a lesson highly valid in scientific research. When reading the position paper by the Population Science and Public Health Section of the European Association of Preventive Cardiology (EAPC) it might be worthwhile to remember the wisdom of Aesop. ²

Why? Let’s assume that in the past century a ‘Hare’ created and mass-produced a highly profitable product by the name of cigarette (small cigar) using all available methods of advertisement. Soon the cigarette was on each man’s (and woman’s!) lip. Film stars, sport idols and even politicians all joined in, a great start for the run by the Hare. A tremendous economic success. After a few decades a tortoise called ‘Science’ appeared on the track, accepted the challenge from the Hare and could prove that burning tobacco leaves was obviously detrimental for health. Many years later even his slower tortoise brother ‘Legislation’ joined in and managed with a variety of public health measures to curb the cigarette saga. Tobacco smoking has now decreased significantly worldwide but remains a significant global health issue.

The Hare realized that the race was lost and, not surprisingly maybe, decided to invite for a new race. He sponsored a large campaign for ‘A Smoke Free World’ ³ and thereby promoted the global use of electronic nicotine delivery systems (ENDSs) also called ‘e-cigarettes’, popularly called ‘vaping’. This initiative by the major tobacco producer Phillip Morris provoked strong protests, from the World Health Organization (WHO), ⁴ from the Good Governance in Tobacco Control ⁵ and in The Lancet. ⁶

Initially the new product ‘e-cigarette’ was marketed as a smoking cessation aid for habitual smokers. Gradually the focus for promotion shifted: the tobacco industry had identified young people as part of a fast-developing market to increase sales and recruit new users. The consequences: promoting selling a toxic and highly addictive central stimulant, nicotine, to a predominantly young public worldwide.

An appealing design, a variety of added flavours (mint, cherry and chocolate) and wide exposure in the social media all contributed to the growing popularity. The recent and most often sold model in the United States of America (USA), a USB-like vaping machine called JUUL, provides in one filling as much nicotine as a 20-cigarette pack! And there are more models in the pipeline.

This time the Tortoise ‘Science’ reacted faster, which is clearly demonstrated in the timely EAPC position paper. The authors reviewed the growing base of evidence against the continued sale of ENDSs, thus joining hands with the recommendations from the WHO ⁷ and the US Centers for Disease Control and Prevention. ⁸ Significant gaps in knowledge remain as there is insufficient data to understand the full breadth of their impact on health. Devices have not been on the market long enough in order to guarantee the safety of long-term use of e-cigarettes or being exposed to them. The potential risks of heating up the added flavours and the consequences of inhaling significant numbers of small particles in the airways produced by the ENDS remain to be studied.

The outcome of using ENDS as a smoking cessation method has not been promising; only in combination with behavioural support at a dedicated clinic did the method prove to be superior to conventional therapy. However, a majority of the participants continued with e-cigarettes long term. Furthermore, e-cigarettes do not replace or limit tobacco smoking as half of its users will transfer later in life to conventional smoking.

Where do we stand in the new nicotine turtle race? So far, the ‘Hare’ has been running fast, as shown in the sales records, especially in the younger ages: in Canada the sales to teens have doubled over the past two years. Yet his opponent, the Tortoise ‘Science’, is gaining speed, as can be observed in the concise position paper with relevant recommendations as well as in a recent review on this topic. ⁹ Now he has gathered at present enough scientific evidence to ask ‘Legislation’ to enter the track and commence acting.

The result? According to the US Food and Drug Administration it is, since December 2019, illegal for a retailer to sell any tobacco product – including cigarettes, cigars and e-cigarettes – to anyone under 21 years old. In Europe, as a first step, in May 2020 EU member states asked the European Commission to place novel tobacco products, electronic cigarettes and heated tobacco products under the EU Tobacco Excise Directive. They would be taxed just like traditional tobacco products.

Furthermore, it may be noted that this year’s theme of World No Tobacco Day is ‘protecting youth from industry manipulation and preventing them from nicotine and tobacco use’, which poses important questions to politicians on how the public health community can protect youth from novel products.

Will Aesop’s fable once more predict the outcome? The EAPC authors conclude: ‘Awaiting further scientific research, caution is needed when consuming e-cigarettes’. Yet, the WHO is more outspoken in its conclusion: ‘ENDS are undoubtedly harmful, should be strictly regulated, and, most importantly, must be kept away from children. E-cigarettes pose risks to health and the safest approach is not to consume them at all’.

In other words, our Tortoise ‘Science’ is heading for a new win, thereby contributing to the fall of ENDS.