Are e-cigarettes the new condom?

For anyone who is under the age of 30, you may not remember the time when condom advertising barely existed, let alone cheeky commercials playing over and over on late-night television. The understanding we have today of safe sex practices were actually quite controversial even in an age when HIV/AIDS was at the height of public fear.

The debate

Back in the 1980's, it was the left-leaning progressives (then called "liberals") who led the charge for "harm reduction" practices. Supported by Democrat lawmakers, academics and scientists, the public health groups at the time argued that the public needed to be educated about using condoms to significantly reduce the risk of HIV and other STDs. They encouraged Sex Ed teachers to tell high school students that, if they decided not to remain abstinent, to at least use a condom.

However, they were vehemently opposed by the "religious right," conservative groups and lawmakers, who argued that public health and educators should be teaching abstinence only. It had taken 30 years to start turning back sexual morals to those of the idealistic (and supposedly virginal) 1950's, they argued. Promoting the use of condoms, especially television commercials featuring celebrities, would only "renormalize" promiscuous behavior and set back all of the advances that had been made with their chastity campaigns. Besides, they argued, the term "safe sex" was very misleading. Condoms frequently failed, they said, and with more young people having sex because they think it is safer with condoms, more young people would actually be at risk.

Nonsense, argued the pro-condom side. The risk of failure was tiny. Condoms were up to 99% effective in preventing HIV transmission. The benefits of protecting sexually active adults (and youth) from the high risk of unprotected sex far outweighed the small risk from a few more young people having sex using a condom because they (correctly) believed it to be safer than unprotected sex. Those on the religious right, they countered, should stop trying to force their ideology of 100% abstinence on people and start accepting the fact that people will take risks; and it's the job of public health to reduce those risks, not to cling to an unrealistic belief that they can stop all people from having premarital sex.

My, how times change

Fast forward 30 years and the concept of harm reduction is pretty much accepted as scientifically sound public health practice. It has been extended to drug use in the form of clean needle programs, drunk driving in the form of designated drivers, cycling with helmets and even in the form of car seats for small children. None of these harm reduction practices reduce the risk of disease or injury by 100% (and some even have their own small risks,) but nearly all have been universally recognized as having benefits of reducing greater risks that far outweigh their minor drawbacks.

Safe sex public service announcements are done by celebrities and condom companies even sponsor sporting events and teams. The CDC reports that studies found that harm reduction (also called "prevention") programs had significant impact on reducing sexual risk behaviors and notably, the HIV prevention programs were not shown to hasten initiation of sexual intercourse among adolescents, even when those curricula encouraged sexually active young people to use condoms.

New kid on the block

So, when a new product came on the market, around 2003, that could significantly reduce the risks of smoking, it seemed a no-brainer that they'd be embraced by the same folks who promoted condoms. While e-cigarettes may have some low risks to users and little to no risks to bystanders, clearly the health benefits of millions of smokers using a safer product far outweighed those tiny risks. Tobacco harm reduction (THR) experts estimated the risks to the smoker would be reduced by 99% and to bystanders by nearly 100%.  Now those are numbers a safe sex promoter would obviously understand!

Today, after a decade on the market, there are numerous studies showing smokers are taking to the product better than they ever did to pharmaceutical nicotine products and quitting (or significantly reducing) their smoking. Nearly 100 studies world-wide have found only tiny levels of only a few of the potentially harmful chemicals in cigarette smoke, which significantly reduces the health risks of smokers who cannot or will not quit nicotine to nearly that of non-smokers. One comprehensive review of existing e-cigarette studies, done in 2013 by Dr. Igor Burstyn,  Drexel University School of Public Health, confirmed that chemicals in e-cigarettes pose no health concern for users or bystanders. Are they 100% safe because they still contain "addictive" nicotine? Not for everyone, but like condoms, e-cigarettes are meant to reduce the risks of a potentially dangerous behavior, not eliminate the behavior altogether. Again, a concept that safe sex and condom proponents should be able to easily relate to.

Of course, it makes perfect sense that it's the Democrat lawmakers, progressive public health groups and left-leaning academics (all of the same people who fought for condom use and safe sex campaigns) who are now opposing e-cigarettes as promising, new, harm reduction products. 

Wait, what?

Yep, you read that correctly. Using nearly all of the same arguments the conservatives used against condoms and safe sex education, the folks who advocate all kinds of other harm reduction practices are now doing everything they can to stop people from using a safer alternative to smoking.

Do these points sound familiar?

• They argue that e-cigarettes shouldn't be used because they still have some risks and "safer doesn't make it safe" (see poster below.) 
• They fear that promotion of a safer alternative and permitting use in public places (a huge incentive for smokers to switch) will "renormalize" smoking and set back all of their efforts promoting 100% abstinence for the past 30 years. 
• They ignore that the benefits of millions of smokers quitting far outweigh the miniscule risks of bystander exposure to a little vapor in public. 
• They complain that celebrity endorsements and pleasant, non-tobacco flavors (an important feature that helps smokers move away from the taste of conventional cigarettes) will entice youth use. They argue that young people will try them because they (correctly) believe them to be safer than smoking. 
• They point to scientifically tiny risks compared to smoking as reason to "err on the side of caution."

On the other hand, conservative groups and lawmakers have taken a surprisingly libertarian view of e-cigarettes, argue for light-touch regulation and call for lawmakers to avoid knee-jerk legislation that could have unintended consequences.

When propaganda takes over science

The facts are on the side of e-cigarettes as being a viable harm reduction product for smokers. While the anti e-cigarette crowd are pointing out the tiny, trace chemicals detected in some e-cigarettes, they downplay how low those traces are. This graph shows just how low:

They also wring their hands over youth use, worrying loudly that kids will try e-cigarettes and then move on to the more risky behavior of smoking. (Like anti-safe sex folks argued kids learning about safe sex would lead to more un-safe sex, leaving many people scratching their heads with that logic.) However, after 10 years on the market and increased use by (mostly smoking) youth being widely reported, CDC statistics show that youth smoking continues to decline significantly:

Worrying over increased youth use of e-cigarettes while smoking rates are declining is akin to worrying about more teens having sex using condoms while STD and unwanted pregnancy rates are declining.

It's a mad, mad world
For those of us who lived through the endless debates on changing attitudes about safe sex education and promoting condom use, we are now living in a bizzaro world that has flipped everything on it's head. The very people we thought would "get it" have become our greatest opposition. 

By "we" I mean supporters of tobacco harm reduction policies. THR proponents believe existing tobacco control policies - such as public smoking bans, high taxes and public education - have mostly reached their limit for preventing and reducing smoking any further. In spite of all of their efforts, there will always be a small (yet very significant) portion of the public who will choose to use tobacco and nicotine products, as long as they remain available for purchase legally or on the black market. THR policies aim to reduce the health risks of those inveterate smokers by offering them safer alternatives:

• Low risk alternatives significantly reduce the risks of the nearly 14 million U.S. smokers who aren't part of the 70% who say they want to quit. 
• Low risk alternatives significantly reduce the risks of the 42 million U.S. smokers who say they want to quit, but are still smoking because they are between quit attempts or have given up trying to quit after too many failed attempts. 
• Low risk alternatives could also significantly reduce the risks of the nearly 800,000 people in the U.S. who become new, daily smokers every year - should they choose e-cigarettes before trying traditional cigarettes.

The point is, tobacco harm reduction and low-risk products like e-cigarettes are not intended for those who are trying to quit smoking now or for those who never intend to start. They are for those who cannot or will not quit - maybe not this year, maybe not ever - and as an alternative for someone who would otherwise become a new smoker today. However, the risks of these products are so low that for every smoker who switches it would take hundreds, if not hundreds of thousands, of non-smokers to start using them or bystanders to be heavily exposed to vapor to offset the health gains of just that one smoker quitting smoking. And the head-in-the-sand idea of telling people to "just quit or never start" obviously isn't working.

This is something the people who fought for harm reduction policies, safe sex education and promoting the use of condoms should easily understand. Unfortunately, their apparent hatred of everything tobacco related seems to blind them from seeing the irony and the unintended consequences of their actions. Actions that are guaranteed to keep way too many smokers still smoking.

Maybe they should take the advice they gave to the religious right 30 years ago (and still even today) and stop trying to force their ideology of 100% abstinence on people and start accepting the fact that people will take risks; and it's the job of public health to reduce those risks, not to cling to an unrealistic belief that they can stop all people from having premarital sex using tobacco and nicotine.