Electronic cigarettes are currently the subject of much public, media, and regulatory attention. Discussion centres on whether e-cigarettes encourage or discourage smoking. Should they be banned? Should they be regulated as consumer products, tobacco products, as medicines, or a combination of approaches? It seems likely that some countries will opt for the EU approach of regulation as a tobacco product, whereas others will go for medicines regulation which allows claims about smoking cessation to be made. The recent entry of the tobacco industry in the e-cigarette market has caused concern among some public health interests, not least because it enables the industry to present products for medicines regulation and to circumvent the restrictions in the Framework Convention on Tobacco Control on industry engagement with policy makers. Other medical experts have called on WHO to resist the urge to control and suppress e-cigarettes.
This seems to be an issue that has blown up very recently. But responses to e-cigarettes can only be understood in the light of longstanding tensions and debates about smoking and public health. The battle lines currently drawn are imbued with history. Two key historical areas that frame the debate are attempts since the 1950s at product modification to achieve “safer smoking”, and the changing status of nicotine in relation to tobacco since the 1970s.
New technology has always been a driver of change in smoking habits—just think of the arrival of the Bonsack machine in the 19th century and the ensuing mass production of cigarettes. But the technical change with direct relevance was the move from the 1950s both in the UK and in the USA to change the cigarette itself so that smoking it would be “safer”. This product modification was a major driver of smoking policy for two decades. Once the link between smoking and lung cancer had been discovered in the early 1950s, industry, government, and public health interests worked together and aimed to reduce the harm from cigarettes. In the UK, the tobacco industry had a close relationship with government because of the wartime control of tobacco as an essential product for the population. It gave money to the Medical Research Council in the 1950s for a programme of research and set up its own research laboratories at Harrogate in Yorkshire where research was done on the components of the cigarette with the aim of removing what was harmful. Imperial Tobacco, the main UK manufacturer in the 1960s, wanted the publication of tar and nicotine tables and labelling. The government was opposed because the safety implied by labelling could not be supported scientifically. The tactic of differential taxation, also discussed in the 1960s, failed for the same reason. There would need to be a clear scientific distinction between what was and was not harmful if different rates of taxation were to be imposed on different products.
From the 1960s onward, attention focused on the development of the “safer cigarette”. Wills, part of the Imperial Group, was a large producer of filter cigarettes by the mid-1960s, and even tried to produce a filter cigar, codenamed “Pongo”; its low tar product named “Wallflower” never came off the shelf. These were also strategies followed in the USA. There, in the 1960s and 1970s, the National Cancer Institute programme on smoking and health pursued the overall aim of harm reduction. In the UK in 1971, the Royal College of Physicians’ second report on smoking supported “less dangerous forms of smoking”. It called for smokers to change to pipes and cigars or for more research on reduced tar and nicotine cigarettes. By the end of the 1970s, the low tar/low nicotine tactic was out of favour. Smoking researchers criticised the model of smoking behaviour that underpinned it. Low tar and nicotine cigarettes might actually lead smokers to take in more tar rather than less through “compensatory smoking”.
These types of arguments are echoed in current debates about the status of e-cigarettes and the need to research their effects. Then, too, attention shifted to replacement products rather than making smoking safer. But new smoking products proved to be a blind alley. Gallahers and Rothmans worked on a product called Cytrel 361, while British American Tobacco developed a product called BATFLAKE. Imperial joined forces with ICI, the pharmaceutical company, to produce New Smoking Material (NSM) as an economically viable alternative to tobacco. The process led to regulatory developments with parallels with the present day. David Owen, Minister of Health and a keen anti-smoker, aimed to bring the substitutes under medicines regulation in the 1970s, with the implication that tobacco too would ultimately go down the same route. Owen’s departure from the ministry took the political heat out of the issue. When NSM left the warehouse in July, 1977, sales were poor. It was taxed in the same way as tobacco, and so there was no financial incentive for purchase. NSM fell foul of consumer resistance, something which has not been the case with e-cigarettes, which have met with the support of some consumers.
A key outcome of these decades of failed attempts at harm reduction was a growing and emphatic hostility from public health interests to taking them further. The previous desire for cooperation with industry was replaced by an implacable hostility. This explains the vehemence of opposition from some public health interests to e-cigarettes in the present. Back in the 1970s, the UK’s central health education agency, the Health Education Council, called smoking safer cigarettes the equivalent of jumping from the 36th instead of the 39th floor of a tall building. The alliance around product modification came to an end. The public health agenda shifted to abstention with strong opposition to any liaison with industry. It was this stance that has underpinned public health responses since then. In the 1980s, such opposition effectively killed off industry moves to produce and market Skoal Bandits in the UK, a type of oral tobacco. Use of snus, the popular Swedish equivalent, was banned for wider use by the EU because of public health opposition. The default response for public health became opposition to industry and to reduction of harm, a stance displayed across a range of public health issues, from alcohol through to food and diet.
This default position also explained the lack of interest in another development relevant to the e-cigarette. The recategorisation of nicotine and its separation from tobacco as a harm reduction product was the next phase of e-cigarette history. Back in 1971, two Swedish researchers from the department of clinical physiology at the University of Lund appeared at the world conference on smoking in London. They presented their results on “nicotine containing chewing gum as a substitute for smoking”. The chewing gum had been developed because of a request from the Swedish navy, where a strict no smoking policy caused problems for crews during long periods at sea. The Swedish pharmacologist Ove Fernö, director of the Leo pharmaceutical company in Helsingborg, formed an alliance with Michael Russell, head of the smoking research section of the Addiction Research Unit at the Institute of Psychiatry in London. They later launched a product called Nicorette. Nicotine began a process of boundary change.
Russell was a psychiatrist working in an addiction setting, who was critical of the public health emphasis on abstention. In a 1991 piece in The Lancet, he argued the case for nicotine maintenance and asked “Why have governments persisted in allowing the manufacture, extensive advertising, and promotion of such a lethally contaminated drug delivery system as the cigarette, while putting so little pressure on the tobacco industry to develop more purified forms of nicotine delivery?” Russell’s call for a purified form of nicotine delivery and the involvement of the tobacco industry was not to be answered until the arrival of the e-cigarette more than 20 years later. Why this hiatus? His work on nicotine and addiction had begun in the early 1970s, but it carried little weight with public health. His base in psychiatry, the association with the pharmaceutical industry, the emphasis on harm reduction, were all at odds with the dominant public health ethos of abstention and opposition to industry connections.
The convoluted struggles over nicotine and its regulation that followed in the 1980s were far from the public health mainstream. Then further psychopharmacological work on nicotine and on addiction developed in the USA and UK: research on nicotine recognised addiction as a double edged sword, either a reason to maintain nicotine levels in cigarettes or to lower them in order to wean people off the habit. There was also a revival of interest in the public health field in harm reduction. The adoption of the concept of addiction for tobacco as well as for drugs meant that ideas from the drug field spilled over into the tobacco arena. At the same time, drugs were becoming more of a public health rather than a mental health issue; a key issue there was HIV/AIDS, which stimulated a revival of harm reduction strategies including medication with methadone. There were growing parallels between the two sets of substances. Researchers such as Ann McNeill in the tobacco field began to talk about harm reduction, a topic which had been anathema for smoking experts for 20 years. The recognition of a group of smokers who would or could not give up helped to raise the profile of the concept of addiction. Concern about inequality and health also led to support for nicotine from some public health interests. The arrival of e-cigarettes has provided a further stimulus for this emergent discussion.
Research is now underway to examine the health effects of e-cigarettes, and their relation to reductions or increases in smoking, whether they act as gateways to increased consumption, or to abstinence. The position of the pharmacist as a health professional exemplifies this dilemma. In the UK, pharmacists often held tobacco licences until the 1940s. Will their current sale of e-cigarettes build on that legacy, or on the more recent over-the-counter sale of other nicotine-replacement products? There should be a looking back as well as forward in the current debate. E-cigarettes raise some longstanding issues for public health, not least the nature of the relationship with industry interests and whether reduction of harm is a valid strategy.
Virginia Berridge’s research that features in this essay was originally sponsored by the Wellcome Trust.