Public health’s biggest weakness, as illustrated by e-cigarettes

Recently, I was sitting in a meeting with some people, and during a lull in the conversation, they asked me:

“Hey, you’re in public health. What is the biggest problem you face?”

I paused. That’s a tough question. The Western World is facing a number of issues ranging from social to political, and include areas such as increased inequality, an aging population, rising student debt and the issues associated with young people starting their careers already owing six figures to a bank or their government, among other things. However, while others might pick the more “sexy” health issues of the day such obesity or cancer, I’m going to go off the board. I think the biggest problem public health faces is Time. I’ll explain what I mean through e-cigarettes.

E-cigarettes use battery powered vaporizers that turn a liquid solution into an aerosol that can be inhaled, similar to smoking. The solution can include a range of ingredients, but most importantly, do not (necessarily) include nicotine. Nicotine itself forms one of the addictive elements of conventional cigarettes, and so it has been proposed that these could be used as quitting aids by slowly reducing the dependence people have for nicotine. Plus, in addition to a chemical dependence, there’s also a behavioural element to smoking. My friends who have tried to quit struggle with behavioural cues associated with smoking – having a cigarette with coffee, or while driving to work, or after a long day to unwind. Those environmental cues can be as effective at creating a desire for smoking as the chemical component. For those trying to quit, there are thus multiple issues that need to be addressed. This can be where e-cigarettes become useful. As a quitting aid, e-cigarettes can help step people down from the chemical addiction with lower and lower doses of nicotine, ultimately culminating in no nicotine, as well as provide a way for them to get that feeling of smoking without “all the bad stuff.” Or at least, that’s the theory. However, since these devices are so new, there isn’t much, if any, research to substantiate this (yet).

EDIT: This systematic review  and this study were pointed out to me on Twitter, and reported reductions in conventional cigarette use when e-cigarettes were used. This is a promising finding, and this is something public health professionals can use to build programming and advocate for e-cigarette use (especially if more studies can confirm this experimentally, as well as evaluate them for long term ). However, both highlight the crux of this piece, and that is that these were both only published this year. That delay between the introduction of e-cigarettes, and data suggesting that they can be useful for cessation, is an important issue within public health.

Now, the liquid that gets vapourized comes in a number of different types, but the one that is the most concerning are the flavoured varieties. While the nicotine component could, potentially, help people, the flavouring is a completely separate concern and serves no purpose other than to make the product tastier and more enticing. This is a particular concern, especially among our youth. Dr Leia Minaker and colleagues did a study out of the University of Waterloo and found 52% of Canadian students who identified as smokers in Grades 9 through 12 used flavoured tobacco products. This was even higher among smokeless tobacco users (70%) (1). So not only do we know kids are drawn to these products, we know they’re likely to be using the flavoured versions of them if they do use them.

Flavours such as strawberry, "great grape" and juicy peach are all available for consumption

Flavours such as strawberry, “great grape” and juicy peach are all available for consumption

Now herein lies the problem. We know there are concerns with e-cigarettes. We know there are health problems that are a direct result of smoking, and we know that this is targeting children who will (most likely) become smokers as they grow up. However, we need evidence to make such claims. Tobacco companies follow the law – maybe not the spirit of it (that’s up for debate), but the, written down, carved in stone, law. So if you say you can only have a certain amount of nicotine in a product, they’ll put in less than that. They won’t open the floodgates to lawsuits and litigation. However, due to the lack of regulations on e-cigarettes, suddenly there is an open market available, and so they put energy into marketing them, and selling them to the market that can legally buy them (including children). On top of this, kids will market them to each other. Cigarettes have always had an allure to them, both in terms of making you seem “grown up,” as well as a “rebel.” Those are things that youth crave as they navigate the tempestuous waters of elementary and high school.

However, just because there isn’t evidence they can’t harm you, doesn’t mean they won’t. Indeed, the FDA initially came out against them, banning them back in 2010. However, this was overturned soon afterwards, ostensibly due to the lack of evidence saying they would cause harm (why wasn’t the fact that there was no evidence to the contrary a concern, I don’t know). Research is slowly coming out now that is highlighting the risks of e-cigarettes. In fact, increasing the voltage from 3.2V to 4.8V results in a 4 to 200 fold increase in the amount of formaldehyde, acetaldehyde, and acetone – to levels comparable to that of a regular cigarette (2)

However, this all takes time. Performing these studies, following up users of these products and determining if they can be used as a quitting aid, this all is all required to determine whether or not this is a substantiated claim. And it’s not just the research that has to be performed – the law then has to be amended. The EU decided right off the bat to restrict sales to minors, well before research was available. Even then, it took a bill proposed on the 19th of December 2012 until February 2014 to finally be approved. Thus, e-cigarettes point out a massive flaw in public health, which is ironically its biggest strength. The fact that we take time to collect data before making a decision is essential, but it means we’re waiting months and even years to collect the evidence, analyze the data, write and publish the reports that we can then present to policymakers to say “hey! Fix this!” And it doesn’t stop there. We’re then waiting for policymakers to propose the idea, have them vote on it, fight any backlash from industry or the public (and there will be backlash from the $1.2 billion e-cigarette industry). On the flip side, it means that if there are benefits to use – maybe e-cigarettes can have benefits for those trying to quit – we can’t claim that either. We’re stuck in a holding pattern until the data comes back with an answer.

Currently, while there might be some good reasons to have e-cigarettes available for people, there’s no evidence to support that claim. There is, however, a growing body of research is showing that there are drawbacks to having them available. In the meantime, people are freely using them and suffering adverse health effects associated with their use. That time delay, between a product being introduced and public health being able to tackle it, is one of the biggest problems that public health faces.


1. Minaker LM, Ahmed R, Hammond D, Manske S. Flavored Tobacco Use Among Canadian Students in Grades 9 Through 12: Prevalence and Patterns From the 2010–2011 Youth Smoking Survey. Prev Chronic Dis 2014;11:140094. DOI:

2. Kosmider, Leon, et al. “Carbonyl Compounds in Electronic Cigarette Vapors—Effects of Nicotine Solvent and Battery Output Voltage.” Nicotine & Tobacco Research (2014): ntu078. Available online at

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9 Responses to Public health’s biggest weakness, as illustrated by e-cigarettes

  1. Joe says:

    We know through early scientific studies that e-cigs are LESS harmful then burning tobacco. And to say flavors attract kids is true but adults like myself also like flavors and would still be smoking if candy type flavors were banned. Also bans don’t stop anything. I started smoking when I was 15, would still be smoking now if not for the less harmful alternative e-cig with candy flavors.

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  3. If FDA had been successful in 2009/2010, my husband would still be smoking deadly combustible cigarettes.

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  4. Bill says:

    I forgot to point out that the second reference you make, Kosmider, Leon, et al., fails to see if the vapor is inhalable. I know from experience that going over 3.4V can lead to a burnt hit if you don’t have the airflow correct and aimed at the coil. Coil temperature determines contaminate levels. Goniewicz called the study an experiment in an interview with Ashley Hirtzel(May 22, 2014) on Buffalo’s NPR news station. The slippery interpretation of the results was to garner newspaper headlines. The results don’t equate to the real world.

    One of the biggest questions asked on the EC forum is how do I keep from getting a burnt hit. Every answer is do the opposite of what Kosmider, Leon, et al. did to create the excessive contaminates. What ever it takes to keep coil temperature down while still maintaining the density of the vapor is the proper answer. Vapers don’t like burnt hits.

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  6. Bill says:

    You have never used an e-cigarette. I haven’t either, but I do use a Mod with a Kanger tank. I DIY my own e-liquid like many vapers do. I read the studies on emissions and the revised LD50 limit for nicotine. Every study is showing e-liquid devices are safe and emissions are below universally accepted workplace safety thresholds. Five studies this year have shown e-cigarettes are effective at smoking cessation, studies in Germany, Britain, France, Korea, and Japan. That only leaves you with the kid angle.

    A kid on a limited budget looks at cost. You would have us believe a kid would spend $6 on one use e-cigarette when they could get 20 cigarettes for the same money. Twenty cigarettes last a while, where an e-cigarette lasts one 1-2 days depending on use. I see a kid buying one only for curiosity and then only one. The evidence is proving this out. In June, CDC Director Tom Frieden was asked why e-cigarettes weren’t included in the teenage smoking report. He said there wasn’t enough evidence of it. The numbers were too variable from one area to another. You bring up the flavor aspect. Taste some e-liquid. It tastes bitter and unpalatable. The flavors when vaporized are not that strong. The names may draw in a kid, but the kid will be disappointed in his expectation.

    New Zealand is running a controlled smoking cessation study that sounds like they are going to use modern 3rd generation devices. It will be interesting to see if my experience with e-liquid devices bares out in a clinical setting.

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  7. karch_buttreau says:

    1. The reason regular cigarettes need lots of regulation is the issue of second hand smoke causing cancer. No such issue with e-cigs.
    2. All you have then is nicotine. I’m not convinced that nicotine is more harmful than caffeine. I avoid both though, myself.
    3. Big tobacco really does not want you to use e-cigs.
    4. Acetone is not toxic.
    5. While not a smoker, I really do not like civil liberties being taken by big business interests.

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  8. Robert Heyes says:

    A pretty much entirely evidence-free piece (or at least that ignores most of the evidence).

    ” and we know that this is targeting children who will (most likely) become smokers as they grow up. However, we need evidence to make such claims. ”

    You know no such thing. You are however right that you need evidence, but don’t worry Stanton Glantz (or any one of a number of other charlatans) will be along any moment to manufacture such evidence out of whole cloth.

    You also say “While the nicotine component could, potentially, help people, the flavouring is a completely separate concern and serves no purpose other than to make the product tastier and more enticing”. This is true, but your implication is way off the mark. It makes vaping tastier and more enticing for smokers – the use of flavourings is a huge part of what keeps us from going back to smoking.

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  9. “…people are freely using them and suffering adverse health effects associated with their use.”

    Could you please clarify what “adverse health effects” are associated with vaping or electronic cigarettes? Earlier in the piece, you stated that there isn’t any evidence that they can harm you, but in your summary you pointed out these so-called “adverse health effects.”

    No one is saying that e-cigarettes are 100% safe, but virtually all of the studies thus far point to their relative safety – especially when compared to traditional cigarettes. The one negative study you mentioned evaluated “advanced” users using higher-power devices, but the vast majority of users stick to products regulated well under 4.8V.

    Although more research is undoubtedly necessary, using just one (limited) study to conclude that e-cigarettes are harmful is just plain wrong.

    You also stated that “while there might be some good reasons to have e-cigarettes available, there’s no evidence to support that claim.” Maybe you’ve missed all the studies showing that e-cigarettes are an effective tool for smoking cessation? It’s important to consider ALL of the research:

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