We've had 50 years of very-expensive, government-mandated penalties against cigarette companies that have funded programs to reduce cigarette smoking - anything that does so should be welcomed. 

Yet that hasn't been the case for e-cigarettes. While patches have been adored with only modest success in lowering smoking rates - willpower remains the determining factor in smoking cessation - e-cigarettes are being assaulted in a culture war almost as powerful as smoking itself.

At a meeting in San Jose of an organization named AAAS, experts from Germany, New Zealand, South Africa, the UK and USA debated whether electronic cigarettes are just another addiction or a public health opportunity?.

E-cigarettes are already used by tens of millions of smokers around the world. Hundreds of versions are available online or in specialized shops. Analysts at Wells Fargo (2013) predict that sales will outstrip classical cigarettes by 2021. These battery-powered devices work by delivering aerosol ('vapor') containing nicotine to the user. The apparent medical advantage is that the vapor produced contains compounds in the tens to hundreds compared with the 8600 or more produced in cigarette smoke that cause life-threatening diseases.

The American Cancer Society estimates that:

  • One billion people smoke cigarettes and the number is increasing.
  • Half of cigarette users will die early because they smoke.
  • Six million people die every year because of tobacco. This figure includes five million smokers, but also about 600,000 non-smokers exposed to second-hand smoke.
  • It is expected that, without action, eight million people will die annually of tobacco-related causes, by 2030. Over 80% of these deaths will be in low- and middle-income countries.
  • Non-communicable diseases (NCDs) kill 35 million people annually, 80% of which are in low- and middle-income countries. Tobacco is responsible for 1 out of 6 NCD deaths.
  • 100 million people were killed by tobacco in the 20th century - as many as 1 billion are expected to die in the 21st century.

The most recent study undertaken by an independent authority, The Cochrane Collaboration, and published in December 2014 suggests that e-cigarettes have a significant role to play in helping smokers reduce or quit. This independent network includes researchers, health professionals and consumers of healthcare, carers, advocates and people interested in health from 120 countries. It also backs third-party research meeting the high standards it sets. In this Cochrane Review, two randomized trials were conducted with a total of 662 current smokers. Admittedly, the number of studies included was quite small, so the evidence is not yet strong. However, it did find that about 9% of smokers who had used electronic cigarettes were able to stop smoking for up to one year. This compares with around 4% of smokers who used nicotine-free placebo electronic cigarettes. Among smokers who had not quit, researchers found that 36% of electronic cigarette users reduced their consumption of tobacco cigarettes by half. This compared with 28% of users who were given placebos.

Speaker and Chief Executive of Action on Smoking&Health UK (ASH) set up by the Royal College of Physicians, Deborah Arnott, spoke in favor: "Cochrane reviews are world renowned for their systematic analysis of the evidence and our findings at population level are consistent with their conclusions that electronic cigarettes have the potential to help smokers quit. Research by ASH over the last five years has now been supplemented by official UK government statistics to show that almost no-one who is not a smoker is regularly using e-cigarettes. Neither is there evidence thus far from the UK that the growth in e-cigarette use is leading to an increase in smoking, particularly among young people, in fact smoking rates continue to fall. Continued surveillance is clearly needed, as is a considered and objective approach from policy-makers who have very mixed views on what to do about regulation which is all too often informed by prejudice rather than the evidence. There is a danger that the precautionary principle is being used to deny smokers access to products which can save their lives. Over one thousand people will die worldwide from tobacco during this 90 minute session alone. E-cigarettes have the potential to dramatically reduce this deadly toll."

Speaker and Deputy Director of the US National Institute on Drug Abuse (NIDA), Dr. Wilson Compton advocated the middle ground: "Electronic nicotine delivery systems have both promise and concern. Let's remember that cigarette smoking causes one in five deaths in the US every year. Every approach to reducing cigarette smoking should be considered, and e-cigarette use by smokers attempting to quit is promising. Nevertheless, advances in brain and gene research are showing that adolescent exposure needs closer attention. Nicotine is addictive and addiction is a developmental disorder with an abuse trajectory that predominantly starts in one's youth. And addiction has its dark sides. The NIDA-funded Monitoring the Future (MTF) survey shows that daily cigarette smoking by teens has decreased almost 50% over the past 5 years. Yet, measuring e-cigarette usage for the first time in 2014, MTF found that over 17% of 12th graders had used them in the past month and many of these e-cigarette users had no reported prior use of tobacco cigarettes or smokeless tobacco. My plea is for an appropriate, rational, scientific appraisal of likely risks and benefits. Above all, we must do more to dispel any youth perception that e-cigarettes cause no harm - they do - while encouraging adults to do everything they can to stop using tobacco products."

Discussant and Chief Science Adviser to the Prime Minister of New Zealand, Sir Peter Gluckman commented: "What is clear is that unless we obtain robust scientific evidence both as to short and long-term effects, we will remain confused as to whether e-cigarettes can be a positive or negative contribution to public health and whether their use can be regulated in such a way as to promote positive rather than negative outcomes. We need to keep gathering evidence while being prudent from normative arguments as to what to do with this technology. The realpolitik of policy formation in emotionally charged areas where there is strong advocacy for different positions from differing perspectives and interests is complex. There are some inherently very difficult trade-offs in the debate from what we currently know. What would be unfortunate is policy based on unscientific positioning as a result of strong advocacy and selective use of evidence and a failure to continue research. This can only lead to ongoing confusion in policy formation and regulation".

Speaker and Chief Medical Officer and Director of Compliance at Nicovations Ltd, a subsidiary of British American Tobacco, M.D. Kevin Bridgman added: "There is growing consensus among public health professionals that e-cigarettes are significantly less risky than conventional cigarettes. However, we believe that, in order to realize their full potential, e-cigarettes should be regulated to ensure appropriate quality and safety standards, whilst also allowing sufficiently wide retail availability, appropriate lifestyle positioning and flexibility for the rapid introduction of product innovation. This would provide greater confidence without stifling innovation, while enabling these products to compete effectively with cigarettes".

Discussant and Chair of Evidence-Based Toxicology at Johns Hopkins University, Dr. Thomas Hartung felt the whole question of e-cigarettes comes down to new testing standards: "This is a tremendous public health opportunity, which we can easily block by applying traditional toxicity testing. If you insist on this, you are essentially killing off the sector. Flavors added to some e-cigarette brands such as pop-corn or bubble-gum or even gin&tonic are a big issue and one wonders why they are there. What is safe in food is not safe if inhaled. We need data fast, but we must re-think how to go about it, as traditional toxicology is not fit for this purpose. To do so, we must find new ways to combine the knowledge and vested interests of an industry which is no longer old-school and old-science tobacco, but highly modern and on a par with pharma, with the opportunities of new approaches coming from academia and regulatory science. To get there, we have to resist the reflex of discrediting each-others respective scientists. Time will tell if we are able to put the smoker's health first".

Panel Moderator and President of the European Group on Ethics in Science and New Technologies (EGE), reporting to European Commission President, Jean-Claude Juncker and to the European Parliament, Professor Julian Kinderlerer, summed up by advocating for great understanding and compassion for the addicted person: "Society both professes intolerance for the use of 'drugs' and provides the social settings to enable and make legitimate their use. We talk of the rights and responsibilities of citizens and of how important the individual is in society, but the inconsistencies in treatment and punishments for various lifestyle choices are manifest. I wonder are we really individuals anymore.

Autonomy arises from the concept of dignity as the capacity of a rational individual to make informed, un-coerced decisions. As science walks a dangerous line between persuasion and informing, we must be mindful of society stepping in and requiring individuals to accept norms regardless of their own beliefs. In the case of cigarettes and e-cigarettes, history will judge us harshly as to how we answer this billion person question. It may also look back in anger at policy-making amounting to institutionalized manslaughter".