POLICY RECOMMENDATIONS 23 - UCSF WHO Tobacco Control Papers

promote long-term cigarette abstinence.

• Short- and long-term studies on the health effects of e-liquid aerosol in humans.

• Effects of short- and long-term exposure to fine particles by e-cigarette aerosol 5

• How e-cigarette advertising is perceived by all segments of the population – youth, naïve 6

nicotine users, smokers and former smokers, both recent and long-term – and how 7

advertising exposure impacts behaviors.

• Studies of the engineering design and functioning of e-cigarettes, including impact of 9

heating temperature, battery size, puffing characteristics and e-liquid composition on the 10

nature of the aerosol and systemic exposure of users to aerosol constituents.

• Policy research on the impact of the different approaches being taken around the world 12

on conventional smoking, e-cigarette use, and the overall burden of nicotine-induced 13

disease.

• Studies of the nature of the reinforcing effects of e-cigarettes, including influences of 15

nicotine content, flavorants and other constituents, and abuse liability.

• Studies to determine optimal nicotine delivery to support transition away from tobacco 17

products but avoid recruitment of new users.

While important research questions, the evidence summarized in this report is adequate to guide 19

policy makers in responding to e-cigarettes. These policies can be refined over time as more 20

research becomes available.

21 22

POLICY RECOMMENDATIONS 23

As noted above, e-cigarettes deliver lower levels of most of the toxins found in cigarette 24

smoke; the main impediment to e-cigarettes making a contribution to reducing the harm caused 25

by cigarette smoking arise from the effects on youth, dual use (among both adults and youth) 26

and renormalization of smoking behavior. The ultimate effect of e-cigarettes on public health 27

will depend on what happens to the tobacco product market, particularly with combustible 28

products. There are conditions in which e-cigarettes could be a public health benefit on a 29

population level:

• No initiation with e-cigarettes 31

• No youth use of e-cigarettes 1

• Cigarette smokers switch completely and not continue a dual use pattern of consumption 2

• Use of e-cigarettes does not negatively impact current cigarette denormalization efforts 3

• E-cigarettes do not deliver harmful substances besides nicotine 4

• No youth-oriented marketing 5

• No secondhand delivery of nicotine 6

As of November 2013 this situation did not exist. This situation could change if the following 8

policies were implemented:

• Prohibit the use of e-cigarettes anywhere that use of conventional cigarettes is prohibited 10

• E-cigarettes should not be sold to anyone who cannot legally buy cigarettes or sold in any 11

venues where sale of conventional cigarettes is prohibited 12

• Ban conventional cigarettes or regulate nicotine to non-addictive levels 13

• Apply the same restrictions on e-cigarette advertising and promotion as apply to 14

conventional cigarettes 15

• Ban the use of characterizing flavors in e-cigarettes 16

• E-cigarettes should not be co-branded with cigarettes or marketed in a way that promotes 17

dual use 18

• Prohibit claims that e-cigarettes are effective smoking cessation aids until such time as 19

there is convincing scientific evidence that such claims are true for e-cigarettes as they 20

are actually used in the general population 21

• Regulate e-cigarettes to set standards for product performance in order to minimize risks 22

to users and bystanders 23

Should these policies be put in place, it is possible that current conventional smokers who 25

will not quit nicotine would shift to e-cigarettes without major dual use or youth initiation to 26

nicotine addiction with e-cigarettes. Absent this change in the policy environment it is reasonable 27

to assume that the behavior patterns that have been observed for e-cigarettes will persist, which 28

makes it unlikely that they will on balance contribute to reducing the harm of tobacco use and 29

could increase harm by perpetuating the life of conventional cigarettes.

91 Because the product, the market, and the associated scientific evidence surrounding e-1

cigarettes are all evolving rapidly:

• All legislation and regulations related to e-cigarettes should allow for flexibility to adapt 3

regulations expeditiously in response to new science, including evaluation of different 4

models for regulating e-cigarettes, as it accumulates 5

• No country or subnational jurisdiction should be compelled to permit the sale of e-6

cigarettes 7

• Legislation and regulations regarding e-cigarettes need to take into account the fact that, 8

unlike conventional cigarettes and other tobacco products and medicinal nicotine 9

replacement therapies, e-cigarettes can be altered by users to change the nicotine delivery 10

and be used to deliver other drugs 11

• There should be transparency in the role of the e-cigarette and tobacco companies in 12

advocating for and against legislation and regulation, both directly and through third 13

parties 14

• FCTC Article 5.3 should be respected when developing and implementing legislation and 15

regulations related to e-cigarettes 16

ACKNOWLEDGEMENTS 18

The authors greatly appreciate the contributions and consultations of the following 19

individuals to this report: Cort Anastasio, PhD, John Balmes, MD, Thomas Glynn, PhD, Cynthia 20

Hallett, MPH, Sara Kahlkoran, MD, Lauren Lempert, JD, MPH, C. Arden Pope, III, PhD, 21

Martina Pötschke-Langer MD, M. A., and Prue Talbot, PhD.

22 23

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