Research paper
Nicotine control: E-cigarettes, smoking and addiction

https://doi.org/10.1016/j.drugpo.2012.01.006Get rights and content

Abstract

Background

Over the past year or so, electronic cigarettes, more commonly known as ‘e-cigarettes’, have achieved widespread visibility and growing popularity. These products, which deliver nicotine via an inhaled mist, have caused no small amount of controversy in public health circles, and their rise has been accompanied by energetic debate about their potential harms and benefits.

Methods

Interspersed with an analysis of current media coverage on e-cigarettes and the response of mainstream tobacco control and public health to these devices, this article examines the emergence of nicotine as both as an ‘addiction’ and a treatment for addiction.

Results

We argue that by delivering nicotine in way that resembles the visual spectacle and bodily pleasures of smoking, but without the harms of combustible tobacco, e-cigarettes highlight the complex status of nicotine as both a poison and remedy in contemporary public health and tobacco control.

Conclusion

In consequence, e-cigarettes jeopardize the carefully drawn distinctions between ‘good’ and ‘bad’ forms of nicotine.

Introduction

In the recent film The Tourist we first meet Johnny Depp's character, Frank, through the eyes of Elise (Angelina Jolie), as he sits in a train carriage reading a spy novel and puffing on what appears to be a cigarette. For many viewers of the film, this was their first glimpse of an electronic cigarette, or ‘e-cigarette’, a device, as Frank quickly informs Elise, that is “not a real cigarette. It's electronic. It delivers the same amount of nicotine but the smoke is water vapour”.1

Invented by a Chinese pharmacist named Hon Lik in 2003, the e-cigarette was launched by the Chinese electronics company Ruyan Technology 3 years later, and received its first international patent in 2007 (Wikipedia, 2011). E-cigarettes now have a dedicated following amongst a small but growing number of users known as “vapers”. The appearance of the e-cigarette in The Tourist marks a new visibility for the product – a visibility that has been accompanied by energetic debate about its potential harms and benefits.

Opinion on e-cigarettes has quickly polarised. For harm reduction organisations such as the Consumer Advocates for Smoke-Free Alternatives Association (CASAA) and the Australian Tobacco Alternatives Consumer Association (ATACA), along with a growing number of smokers themselves, e-cigarettes have been embraced as a healthier alternative to smoking cigarettes. Advocates also highlight their ability to provide some of the non-nicotine rewards of smoking, such as sensory stimulation, and mouth and throat feel. A few health agencies have followed suit and deemed e-cigarettes a “far safer” alternative to smoking (e.g. NZ Ministry of Health, 2011). However, most mainstream public health organisations have condemned these products, some banning sales altogether (e.g. Health Canada, 2009) and others characterising them as “poison” and warning the public not to use them (e.g. Queensland Health, 2011). For these organisations, e-cigarettes represent the latest incarnation of the tobacco menace: an untested product with the potential to enslave ever-greater numbers of people (especially impressionable youth) to a dangerous addiction.

Despite the fact that e-cigarettes contain no tobacco (and in some cases, no nicotine), the World Health Organization has classified them as a tobacco product much along the lines of smokeless tobacco (WHO, 2011, p. 40). Initially, the US Food and Drug Administration (FDA) attempted to assert jurisdiction over e-cigarettes as a drug device; however, the US Court of Appeals overturned their decision in December of 2010. Therefore, the FDA is currently attempting to obtain jurisdiction over e-cigarettes as a tobacco product (Boen, 2011, Sullum, 2011). The European Union (EU) is similarly grappling with whether to regulate e-cigarettes as medical or tobacco products (Irish Central, 2011). The FDA and EU's difficulty in classifying e-cigarettes reflects the ambiguous middle ground these products occupy between medicinal forms of nicotine (i.e. nicotine replacement therapy, or ‘NRT’) and smokeless tobacco.

This paper examines the reception of e-cigarettes and seeks to understand why mainstream public health agencies and tobacco control advocates have been so quick to condemn these products. Our analysis involves a critical reading of a range of texts, including media reports, policy briefs from health agencies and harm reduction organisations, vaper websites and blogs, journal articles and commentaries. Bill Godshall's Tobacco Harm Reduction Update listserv, which provides a weekly compilation of media coverage and policy developments regarding e-cigarettes (amongst other topics),2 provided a key resource in identifying literature, supplemented by searches of Google Scholar. Although we have tried to capture the tenor of current debates about e-cigarettes, we make no claims to the comprehensiveness of our examination – an impossibility given the topicality of this issue and the speed with which new developments are occurring. Moreover, we have not restricted ourselves to literature on e-cigarettes, but have sought to locate our examination within a broader historical and cultural context, recognising that current responses to e-cigarettes are inextricably bound up with older debates about nicotine and the concept of addiction.

This article begins with an historical overview of tobacco and nicotine's distinctive relationship with the concept of addiction, and the rise of medicinal nicotine as a treatment for tobacco dependence and its perceived relationship to other forms of nicotine such as smokeless tobacco. Following this contextualisation, the second half of the paper focuses on the reception of e-cigarettes, which we suggest cannot be reduced exclusively to the untested nature of these products. Rather, much of the hostility e-cigarettes have engendered, we argue, stems from the instability these products crystallise in the ideological distinctions drawn between nicotine as either a ‘poison’ or a ‘cure’.

Section snippets

Nicotine as an addictive drug

As is now well established, although nicotine is the addictive ingredient in tobacco, the harms associated with tobacco smoking stem primarily from the carcinogens in cigarette smoke (tar, carbon monoxide, etc.) rather than nicotine itself. The long-term effects of nicotine have not been well studied, and both its potential therapeutic benefits and its carcinogenic properties remain contested. Moreover, although nicotine addiction has become central to explaining the resilience of smoking

Nicotine as remedy

The idea of using nicotine to reduce cigarette cravings was evident from at least the 1940s, as Johnston's (1942) work on the effects of hypodermic nicotine delivery attests. However, it was not until the late 1960s that the first commercial nicotine replacement therapy (NRT) products were developed. According to the website of Nicorette, Nicorette gum was initially developed by Swedish scientists in 1967 in order to overcome challenges experienced by the Swedish Royal Navy in the face of new

E-cigarettes as a dangerous, untested product

Amongst public health organisations, the most commonly stated concerns about e-cigarettes relate to their safety. For example, the WHO (2008) and the FDA (2011) have decried the lack of “safety and efficacy” of e-cigarettes in contrast to “proven” alternatives such as NRT. There has been a particular focus on the toxicity of the liquid nicotine solution used in e-cigarettes and the potential for users to spill the liquid on their skin, or for children to accidentally swallow it and overdose

‘Good’ nicotine does not signify smoking

One of the most obvious differences between e-cigarettes and NRT is that a person vaping an e-cigarette looks much the same as a person smoking a cigarette in so far as all of the visible signifiers of the cigarette are present: from its thin, white cylindrical shape and ‘lighted’ tip, to the plumes of ‘smoke’ that emanate from the vaper's mouth. In contrast, the most popular forms of NRT (and the two on the WHO's list of essential medicines) are discreet: the gum looks like an innocuous

‘Good’ nicotine is medicinal, not recreational

Also central to the differing legitimacy accorded to NRT and e-cigarettes is the specified purpose of these products. Theoretically at least, the use of NRT is temporary: it is a ‘medicine’ that ‘cures’ smokers of their nicotine addiction. NRT products are thus marketed as smoking cessation aids, not maintenance therapies. For example, users of Nicorette products (gums, inhalers and patches) are advised to undertake a tapering 16-week programme, from beginning their use of the product, “until

Conclusion

By delivering nicotine in way that resembles the visual spectacle and bodily pleasures of smoking, but without the harms of combustible tobacco, e-cigarettes highlight the complex status of nicotine as both poison and remedy in contemporary public health and tobacco control. The introduction of NRT and its visibility in smoking cessation campaigns established nicotine as a remedial substance, and the non-cigarette-like nature of NRT products has enabled them to be distanced from the spectre of

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