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BMJ 2014;349:g5512 doi: 10.1136/bmj.

g5512 (Published 9 September 2014) Page 1 of 3

Analysis

ANALYSIS

ESSAY

E-cigarettes: the best and the worst case scenarios for


public healthan essay by Simon Chapman
Considerable energy is going into envisioning the likely benefits and harms of the proliferation of
e-cigarettes, the use of which is growing exponentially in some countries. Simon Chapman reflects
on two possible long term patterns of use and argues that we must not repeat the mistakes with the
way in which tobacco was sold and marketed

Simon Chapman professor of public health


School of Public Health, University of Sydney 2006, Australia

The World Health Organizations recent report on electronic vaping in enclosed areas, and vapers would feel less antisocial
nicotine delivery systems repeatedly notes the poverty of and welcomed into areas from which smoking is exiled.
evidence to guide policy. It recommends that governments The tobacco industry, seeing its tobacco sales in free fall, would
regulate the products, their promotion, and where they can be divest itself of smoked tobacco products and drop all global
used in public as well as supporting research into their safety opposition to effective tobacco control, such as standardised
and efficacy in smoking cessation.1 2 The report is due for packs and tax rises.
consideration at the sixth conference of the parties to the WHO
As rates of smoking disease plummet the inventors of
Framework Convention on Tobacco Control, which will be held
e-cigarettes would share the Nobel prize for medicine. The
on 13-18 October 2014 in Moscow.
history of tobacco control would have a final chapter on the
In this essay, I consider the best and worst case scenarios for triumph of harm reduction and the role of innovation.
e-cigarettes; claims that they assist in smoking cessation and E-cigarettes would have made smoking history.
their value if users continue to smoke; and, finally, the tobacco
industrys interests in these products.
Worst case scenario
Best case scenario
The story could, however, be very different. Under the worst
The best outcome with e-cigarettes would be a massive, rapid case scenario global uptake of e-cigarettes would be on the scale
migration of smokers into vaping, akin to the magnitude of the of cell phones. Most smokers would switch, but many who
replacement of film by digital cameras. Unparalleled declines would never have smokedincluding childrenwould start
in diseases caused by smoking would occur, starting with vaping, attracted by its coolness and no risk hype and then
cardiovascular and respiratory diseases and followed years later maintained by nicotine dependency.
by cancers caused by smoking. Overwhelmingly, vapers would However, to the delight of the tobacco industry the long decline
be smokers whose principal motivation was smoking cessation. in the number of smokers would stall because most vapers would
Although some might vape and smoke (dual users) also keep smoking. Many smokers would prevaricate, convinced
temporarily, nearly all would completely quit smoking. that reducing rather than quitting was good enough. The number
Uptake of vaping among former smokers and never smoking quitting would be eclipsed by those taking up vaping who had
children would be extremely low, and longitudinal studies of never smoked. Substantial proportions of non-smoking vapers,
children who started vaping would show negligible transition particularly young people, would drift into smoking. They might
to smoking. Like adults, children would use e-cigarettes as a find the rigmarole of buying and refilling capsules inconvenient,
gateway out of smoking, not into it. or simply be curious about how smoking compared. Many would
Continuing research would affirm that direct and secondhand find the nicotine jolt from cigarettes more satisfying than
vape was inconsequential to any health outcome, despite the e-cigarettes.4 The net impact would be an increase in smoking
particle sizes of vape being comparable with those in cigarette prevalence or a slowing of its decline.
smoke.3 Public awareness of this would reduce antipathy to

simon.chapman@sydney.edu.au

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