As a family physician practicing in North Carolina, where more tobacco is grown than in any other state, I witness firsthand the pernicious harms associated with its use. Tobacco kills close to half of those who smoke it regularly and is the leading cause of death worldwide.
It’s a no-brainer: Aggressive reduction of tobacco-associated death and illness is a public health imperative. That’s why I am cautiously willing to embrace electronic cigarettes and other forms of vaporized nicotine if such an approach is combined with stepped-up efforts to curtail tobacco use. Although accepting vaporized nicotine while opposing tobacco may sound contradictory, it’s not. Here’s why.
Nicotine is far safer than its parent compound, tobacco. That doesn’t apply to pregnant women or to children – we know nicotine harms them – and it doesn’t mean users suffer no ill effects. Novices can experience transient dizziness, nausea and vomiting, and in large doses nicotine can, in fact, prove fatal, although such poisoning is rare. At the same time, nicotine has not been shown to cause cancer, and associations with other health problems, such as cardiovascular disease, have not been well established.
Nicotine’s relative safety is further underscored by the drug physicians routinely recommend as a proven aid to quitting tobacco. That drug – did you see it coming? – is nicotine. It is available in a variety of FDA-approved formulations (patches, gums and so forth), typically does not require a prescription and has been safely used by millions.
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Like many other drugs, nicotine use breeds dependence through an insidious process that is both physical and psychological. Dependence becomes problematic when it compels us to use harmful substances, yet dependence alone is not necessarily problematic. Many of us are dependent on caffeine, but, coffee-stained teeth notwithstanding, most caffeine users suffer no ill effects.
Thinking about dependence does help explain why “vaping” may better appeal to smokers than do other tobacco replacements. The route of delivery – inhalation – is the same. And because electronic cigarettes mimic the behaviors of smoking, the emotional connections that bond smokers to their habit are maintained.
It’s worth stressing that much is still not known about the long-term safety of vaporized nicotine.
Understandable concern has also been raised about the substances added to liquid nicotine to produce electronic cigarettes, although the list is promisingly short and is comprised of ingredients (glycerol and flavorings) common in commercially prepared foods. Contamination is another worry, as the production of these devices is not well-regulated.
Many warn that vaporized nicotine will serve as a gateway to cigarette smoking, particularly among children. Although it is too soon to tell, preliminary data don’t necessarily support this conclusion. Although use of vaporized nicotine among high school students has increased dramatically (from 1.5 percent of students in 2011 to 13.4 percent in 2014, according to the Centers for Disease Control), cigarette use among high schoolers declined a substantial 58 percent over that the same time period (from 15.8 percent to 9.2 percent).
Don’t get me wrong: Children should neither use nicotine nor be exposed to it, and the recent rise in vaporized nicotine use by children is alarming. The safest choice for all of us is to avoid nicotine in any form.
At the same time, it is wrong to assume that the mere presence of a potentially safer alternative will be sufficient to persuade the bulk of tobacco users to make the switch. To that end, an effective reduction strategy must be aggressively anti-tobacco. For example, increasing the price of tobacco has been shown to be a very effective deterrent to its use. I’d like to see the price of cigarettes incorporate their health-related costs, which the American Cancer Society estimates at approximately $35 per pack.
In June, the FDA is expected to announce plans for regulating vaporized nicotine. I support FDA oversight, including bans on selling electronic cigarettes to children. But because vaporizing is not smoking, the rules that govern electronic cigarettes should probably not be as stringent as those that govern tobacco. Just as important as appropriate regulation is the availability of robust, long-term funding to support research into the safety and effectiveness of vaporized nicotine and other tobacco harm-reduction strategies.
For those who have fought the good fight against a tobacco industry that, like a multi-headed hydra, responds to tobacco control measures with a panoply of subversive marketing ploys –New flavors! Lights! Camel Cash! – anything short of abstinence will be met with well-deserved skepticism. Yet winning the war against tobacco may very well require making peace with nicotine.
Noah Wohlert, M.D., lives in Carrboro.