A framework for evaluating the public health impact of e-cigarettes and other vaporized nicotine products

Abstract

The use of vaporized nicotine products (VNPs), especially e-cigarettes and to a lesser extent pressurized aerosol nicotine products and heat-not-burn tobacco products, are increasingly being adopted as an alternative to smoking combusted products, primarily cigarettes. Considerable controversy has accompanied their marketing and use. We propose a framework that describes and incorporates patterns of VNP and combustible cigarette use in determining the total amount of toxic exposure effects on population health. We begin by considering toxicity and the outcomes relevant to population health. We then present the framework and define different measures of VNP use, namely, trial and long-term use for exclusive cigarette smokers, exclusive VNP and dual (cigarette and VNP) use. Using a systems thinking framework and decision theory we considered potential pathways for current, former and never users of VNPs. We then consider the evidence to-date and the likely impacts of VNP use on public health, the potential effects of different policy approaches, and the possible influence of the tobacco industry on VNP and cigarette use.

The potential impact of vaporized nicotine products on vulnerable subpopulations

“…Aggressive tobacco tax increases have the biggest and most immediate impact on smoking rates, but do not 'cure' the population of smoking [1]. Other approaches, such as advertising bans, smokefree environments, on-pack health warnings, mass media campaigns and smoking cessation interventions, contribute collectively to lowering smoking rates by changing the acceptable social norms around smoking and reducing the appeal and demand for tobacco products [2].…”

“…Levy et al's framework for assessing the public health impact of vaporized nicotine products, such as e-cigarettes, provides a useful overview of what data are needed to make an evaluation of the impact of these products on the whole population [1]. As the authors point out, the availability of a less harmful alternative to cigarettes could assist smokers from disadvantaged groups, such as people with mental illness, particularly if their availability is combined with strong policies to discourage tobacco smoking.…”

E-cigarette use among students and e-cigarette specialty retailer presence near schools

“…Despite on-going debates about the harms and benefits of e-cigarettes (Leventhal et al, 2015;Levy et al, 2016;Pisinger, 2014), use has been increasing among adolescents. In 2013, 1% of middle school students and 4.5% of high school students nationally had used ecigarettes in the past 30 days; by 2015, the rates had more than tripled to 5.3% for middle and 16% for high school students (Singh et al, 2016b).…”

A gateway to more productive research on e-cigarettes? Commentary on a comprehensive framework for evaluating public health impact

“…Part of the reason is that opponents and proponents focus upon different parts of the complicated equation that will determine their overall impact on public health, and there have been few attempts to quantify and integrate all the determinants into an overarching population model 4, 5. Levy and colleagues describe a novel and ambitious framework for evaluating the public health impact of e‐cigarettes 6. A particular attraction is that their framework appears comprehensive and necessarily complex.…”

“…Levy and colleagues employ the novel framework to structure a balanced and progressive review of literature that could be used to parameterise the model 6. Greater benefit will arise when using the model to simulate appraisals of overall impact under a variety of different estimates and assumptions.…”