If e-cigarettes help smokers quit, treat them as any other prescription medicine

The secretary of Health and Human Services, Alex Azar and the outgoing commissioner of the Food and Drug Administration, Scott Gottlieb, recently declared the “e-cigarette craze” among teenagers an epidemic. There has been a nearly 80 percent increase in current e-cigarette use among high-school-age teenagers over the previous year, they said, citing the 2018 National Youth Tobacco Survey, and an almost 40 percent increase in teens using e-cigarettes on 20 or more of the past 30 days.

Despite the rapid rise in trial and use of e-cigarettes among youth, this newer nicotine-delivery system has mainly served to supplement the use of other tobacco products among teens. The overall prevalence of tobacco use in youth has not changed in recent years. It's not surprising given the widespread dual and triple use of tobacco products among youth.

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Use of any tobacco product seemingly encourages use of other products and one that delivers such a potent dose of nicotine is likely to make this situation worse. Adolescents who start using e-cigarettes will likely try other tobacco products, including regular cigarettes.

Manufacturers of e-cigarettes clearly try to have it both ways. Juul, manufacturer of the most popular e-cigarette, sells flavors such as mango, crème, fruit and mint, all the while claiming their product is for adult smokers only. In March, the FDA limited retail sales of fruity flavors in an effort to keep them out of convenience stores and gas stations, where teens and children might readily obtain them.

But as the FDA apparently realizes, this will not be enough to keep these products out of the hands of adolescents. Writing in the Washington Post, Azar and Gottlieb recently asked the industry “to step up with meaningful measures to reduce the access and appeal of e-cigarettes to young people.”

The response so far from Juul has been a $10 million TV ad campaign to promote its highly addictive product. These ads claim that their product is an alternative way for adult smokers to transition away from regular cigarettes. And they produce anecdotal evidence that adults have used them to stop using regular cigarettes. They are doing this despite the fact that it has no public health benefit for those not currently using cigarettes – and despite the fact that these devices have not been approved by the FDA as an effective cessation treatment.

So, here’s a suggestion. If these products are meant to shift cigarette smokers away from their habit, and if that is where their value lies, then let FDA evaluate their effectiveness as a smoking cessation device for smokers. If they prove to be effective, make e-cigarettes available by prescription only. A recent trial in the U.K. found that e-cigarettes were about as effective as medications such Chantix in helping smokers to quit. But even this evidence suggests that if it is an effective cessation device, it should only be available by prescription for those addicted to cigarettes.

It is now clearer than ever that the introduction of the e-cigarette as a smoking cessation product should never have been allowed to enter the tobacco market over-the-counter. The widespread availability of e-cigarettes is clearly antithetical to public health even if the product helps some adult users of cigarettes to give up that even more dangerous habit. As a result, the FDA is now forced to spend taxpayer money to design an educational media campaign to be released this summer to warn adolescents about the hazards of nicotine addiction caused by e-cigarettes.

It is also evident that the FDA is conflicted about the best way to stop the use of tobacco. It is pursuing the idea of essentially eliminating nicotine from tobacco products in the hopes of making these products unappealing. But at the same time, it is intrigued by the strategy put forth by the makers of e-cigarettes to allow proliferation of a new product that, when inhaled, delivers high doses of nicotine. At some point, these conflicting strategies must be reconciled.

The makers of e-cigarettes probably welcome the possibility that their product will eventually become the only item on the market that promises to deliver strong doses of nicotine without harm to its users. However, even if e-cigarettes turn out to be free of health costs, something which is far from clear, making it a prescription drug would at least recognize its potential for abuse as an addictive substance that could hook generations of adolescents on this product.

Users of cigarettes should welcome the idea of purchasing e-cigarettes by prescription because as a treatment for a medical condition, it should be covered by health insurance. Getting nicotine at reduced or no cost should appeal to cigarette users. And the tobacco industry should not oppose it because if e-cigarettes can be proven to be an effective cessation device as they claim, the industry will garner profits from it — just as manufacturers of any other popular medical treatment. What the industry should not be permitted to do is to claim that the product is a cessation device and at the same time be allowed to sell it over the counter to current non-users of cigarettes, especially adolescents.

Some may argue that making it available by prescription only will not prevent its misuse by teens. There are certainly cases in which prescription drugs seep into the hands of persons who do not have the condition that the drug is designed for. But this would happen with far less ease for e-cigarettes than occurs today. Imagine if stimulants that are prescribed for conditions such as ADHD were available over the counter. Would we allow this knowing the likelihood of abuse? If not, why should we allow another addictive product marketed as a cessation device for smokers be sold over the counter and made more readily available to teens?

Dan Romer is a research director of the Annenberg Public Policy Center of the University of Pennsylvania. He studies prevention policies for adolescent drug use with particular attention to tobacco. He has no affiliation with the tobacco industry.