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• Environmental Health Perspectives: Can Cigarette Alternatives Deliver a Safer Fix? 

Tobacco harm reduction—encouraging the use of cigarette alternatives as a way to reduce the public health impact of smoking—is the subject of fierce debate in the public health community.1,2 Some believe such alternatives perpetuate nicotine addiction in smokers and may even be manufactured and marketed specifically to keep smokers smoking.3 “The goal should be relief from addiction to nicotine, not long-term maintenance,” says Norman Edelman, chief medical officer for the American Lung Association. . . .

Siegel recently reported on a survey he conducted of smokers who had purchased e-cigarettes for the first time several months earlier.14 Of 216 respondents, 66.8% reported cutting down how many cigarettes they smoked, and 31.0% reported quitting cigarettes altogether for at least 6 months. Of those who reported quitting smoking, 34.3% were using no nicotine at all, while 56.7% were still using e-cigarettes.

Siegel and his coauthors pointed out a number of limitations to the study, including the low response rate (4.5%) and the possibility that smokers who had tried but failed to quit would be less likely to complete the survey. Nevertheless, they write, “The finding that most individuals who used e-cigarettes at least reduced the number of tobacco cigarettes they smoked suggests that if proven safe, e-cigarettes may be a potentially important tool for harm reduction.”14

But Jonathan Winickoff, a Boston pediatrician and former chair of the American Academy of Pediatrics Tobacco Consortium, worries about the public health impact of seeing an influx of people who appear to be smoking. “When these products are smoked in areas where smoking is prohibited, they may cause former smokers to crave cigarettes,” he says. Antismoking advocates also fear that sweet flavors and easy use make cigarette alternatives particularly alluring to teens. Moist snuff, dissolvable tobacco, and e-cigarettes are all available in different flavors, which the FDA prohibits in regular cigarettes to discourage youth from smoking.12

In 2010 the Centers for Disease Control and Prevention reported a nationwide prevalence of smokeless tobacco use of 15% for high-school boys and 2% for high-school girls, with white students using these products the most.15 An earlier study indicated teenage boys who used smokeless tobacco were three times as likely as nonusers to be smoking cigarettes four years later.16 “If I wanted to get large numbers of people addicted to nicotine,” Winickoff says, “I would probably promote these products.”

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