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Making Healthy Public Policy

Introduction to Health Policy on E-Cigarettes

E-cigarettes are battery operated devices that contain a solution which becomes vaporized to inhale. The solution contains nicotine and is said to produce effects of cigarette smoking and nicotine without the smoke. They are also known as vapes, vaporizers, e-hookahs and vape pens. The products of e-cigarettes, their parts and components, and the lack of standard nomenclature around their usage leads to, even the manufacturers using different terms for them at different times (Alexander et al., 2016). The use of vaporized nicotine products more specifically, e-cigarettes have become popularized and more prevalent as replacements for nicotine containing combustible cigarettes especially among the youth. Even though they are becoming increasingly popular, very less is specifically known about their effects on health of individuals, their potential risks and benefits, and varying perceptions about them amongst the public, e-cigarette users, community of public health and health care providers (Eaton et al., 2018). This essay will discuss the same along with the current policy on e- cigarettes and what better alternative can be presented for the same.

Concerns of Public Health Associated with E-Cigarettes

While looking at the public health concerns associated with e-cigarettes, it has to be looked at both the effect directly caused by them and the simultaneous effect they pose on the usage of combustible cigarettes, thereby inducing effects on health as well (Eaton et al., 2018). The net or total public health effect will involve looking at both the aspects. It is noted that e-cigarettes claim to be less dangerous in their effects than the combustible version and the central theme around their marketing, usage and manufacturing runs around them being harmless substitutes of the conventional cigarettes. Although they do not contain specific combustible toxic chemicals, but they most certainly consist of harmful chemicals and potentially toxic substances like metals, nicotine and fine particulate matter (Eaton et al., 2018).

In a report by NAS on the public health consequences of e-cigarettes, it was established that there is no proper and adequate research for the prediction of any long-term outcomes of its use on health, but there is enough conformation which links the usage of e-cigarettes to oxidative stress, dependence symptoms, acute endothelial dysfunction and an increase in heart rate and that chemicals in the e-cigarettes can cause mutagenesis and DNA damage (Eaton et al., 2018). Evidence of increase in blood pressure (systolic and diastolic) is also seen after the use of e-cigarettes containing nicotine. A systematic review was done by the National Academies of Press which lies at the top of the hierarchy of evidence and considered as quality evidence because the researchers have collected data from a range of scientific literature around the usage of e-cigarettes. Around 800 peer-reviewed articles were selected for the same to establish evidence. Also, the results of the study can be applied to the local populace as well which makes it more reliable.

It is said that usage of e-cigarette use propagates either complete abstinence or reduction in conventional, combustible smoking of tobacco in the adult population and therefore, it might help in reduction of health risks (Eaton et al., 2018). They can reduce the risks to the youth who consume e-cigarettes instead of the traditional combustible cigarettes of tobacco. This might be specifically benefitting to vulnerable people, like pregnant women or any smokers with mental health or any physical co-morbidities like respiratory or cardiovascular illness. However, it is said that any kind of dangerous exposure during pregnancy might impact the development of the child in a negative way (Bruin et al., 2010). Certain evidence also depicts that pregnant women switch from the conventional, typical tobacco containing cigarette that is combustible to using e-cigarettes due to the perception of lower harm in their usage (Bruin et al., 2010). This might or might not be true but, since e-cigarettes are also typically found to have nicotine in them, it is increasingly difficult to decide on this since nicotine is said to harm a child’s development in multiple ways. Therefore, the probable effects of the consumption of e-cigarettes on maternal health and the health of the developing fetus and child are still unclear and remain unambiguous (Bruin et al, 2010).

 Next, if we look at conventional smokers with co-morbidities like asthma, cardiovascular disease, cancer and chronic obstructive pulmonary disorder, their health can be worsened with the continued use of cigarettes (Cai et al., 2017). If switching to e-cigarettes can be seen as helpful and effective in the reduction of consumption of the typical, tobacco filled cigarette, then people suffering from medical conditions associated with smoking might be the most benefitted by this switch and actually reduce their over-all risks associated with the usage and consumption of tobacco (Kruse et al., 2017). In a condition like this, the actual health concern might then be the effects of the e-cigarettes on health as compared to the effects on health after usage of the conventional, combustible one.

Due to the absence of any long-term studies that are done epidemiologically and absence of any large clinical trials on the usage of e-cigarettes, the implications of using them for a long term and their effect on mortality and morbidity is not clear yet and neither is their claim of being absolutely safe products to use, so the concern about their uptake and usage in the youth and young adults remains. The youth will be considered specifically more vulnerable to engage in behavior that is risky and be more experimental in their attitude towards alcohol and illicit drugs, and be affected by nicotine as well along with other intoxicants as well throughout their development (Murthy 2017). Even though, it is a cross-sectional study which lies on the fifth position in the hierarchy of evidence but still it will be considered as quality evidence because the researchers have collected data from a large number of sample.

A particular public health concern that has come into the picture because of e-cigarette usage is the increasing uptake of these e-cigarettes by children and adolescents in some countries. Most products like e-cigarettes can be manipulated by the user. Some manufacturers have also patented ways to discreetly manipulate the dosages of nicotine and toxicant delivery in the cigarettes. Also, it is evidenced that in some countries, the never-smoker population of adolescents consuming e-cigarettes are doubling their chances of starting to smoke combustible cigarettes later in their lives (WHO report 2020). Exposing children and adolescents to nicotine can have long-lasting, damaging effects on brain development and lead to nicotine addiction.

The Australian Context

Coming to the Australian context, it is found that around 11% of the general people who are aged 14 and above reported the use of ever using e-cigarettes in 2019 (Greenhalgh et al., 2020). The lifetime use was highest in the age group of 18-24 years that is in the young adults at the rate of 26.1% in the year 2019. The lifetime use of e-cigarettes has markedly increased between the year 2013 and 2016 amongst adults who smoke – increase from around 18% to 31% and non-smokers which will include never smokers and ex-smokers from 2% to around 5% and it has increased across all age groups as well except the oldest age group. From the year 2016 to 2019, the trend of using e-cigarettes further increased among adult smokers – an increase from 31% to about 38% and between the non-smokers as well- an increase of 2% seen from 5% to 7% usage (Greenhalgh et al., 2020). The highest rates of ever using cigarettes appeared in 2016 amongst the youth population aged 18-24 year- 49.1% smokers and 13.6% of non-smokers, in comparison to adult population with a rate of 30.8% and 4.7% respectively (Greenhalgh et al., 2020). The rates of usage further increased in 2019 amongst the age group 18-24 at 63.9% of smokers using it and 19.6% of non-smokers consuming it. It is found that the consumption and usage of e-cigarettes is most prevalent in the youth, and more specifically the age group 18-24 in the context of Australia (Greenhalgh et al.,2020).

The youth has been the most affected both in terms of new usage of the e-cigarettes and current smokers switching over to e-cigarette usage. Usage of e-cigarette in young adults and the youth of today is notably worrying if they are responsible for causing dependence on tobacco smoking or making the behavior of smoking normal for them, and subsequently leading the youth to take up smoking the conventional and usually combustible cigarettes having tobacco. There exists specific concerns for the young and the youth who might take up addiction who have never used tobacco in their lives (Brown 2017). A systematic review was conducted which comes at the top of the hierarchy of evidence and is considered as quality evidence and used a lot of articles to establish the findings. This can be considered for evidence-based practice in the field of public health both locally and globally.

Also, of specific concern will be adults who have quit and might go into relapse because of using e-cigarettes. E-cigarettes on their own are now being increasingly associated with greater risk of cardiovascular diseases and lung disorders and adverse effects on the development of the fetus during pregnancy (WHO report 2020).

Stakeholders’ Involved

The main stakeholders involved in this scenario will be members of the community (both smokers and non-smokers), public health researchers, clinicians, research analysts, government officials, tobacco industry, manufacturers of e-cigarettes, consumers and public health organizations.

The tobacco industry and the manufacturers of e-cigarettes basically rely on marketing the product in a way that it becomes attractive especially for the youth. Their vested commercial benefits lead to a misleading marketing campaign around the benefits and usage of e-cigarettes. As an important stakeholder, their interest and strategy to market e-cigarettes needs to be looked at to understand their viewpoint. The marketing involved around e-cigarette revolves around them being a better option and helping in de-addiction. E-cigarettes have been marketed by the e-cigarette and tobacco industries to existing smokers as both a smoking cessation tool and as a less dangerous option to conventional cigarettes and tobacco smoking. This marketing has been effective as surveys of adult cigarette smokers indicate quitting or reducing smoking as grounds for using e-cigarettes. However, at the population level there is no strong proof which can claim that e-cigarettes assist in cessation of smoking (Van et al., 2019). Also, data from Australia indicates that the use of e-cigarette has led to an increase in the number of first time tobacco users, especially in the age group of 18-24 (Department of health, Australian government. 2020). This type of marketing when on the contrary, e-cigarette usage is showing opposite and harmful effects, highlights the presence of vested commercial leanings of the tobacco industry and the manufacturers of e-cigarettes. Talking about public health organizations and public health researchers, they would want to protect the public health status of the people in general. In the general interest of the public and looking at the harmful effects posed by e-cigarette usage and evidence around it, they would want to protect the society and public health policy from any harm and vested interests of the tobacco industry. Clinicians and research analysts will want to look at the effects that e-cigarette usage puts pertaining to specific aspects of health- cardiovascular, respiratory amongst others. They would also want to look at the toxic effects the harmful chemicals present in the vape liquid produces (Shih et al., 2019).

Incomplete substantiation of the dangers that the usage of e‐cigarette imposes on health can be quoted by the stakeholders from a variety of different categories, and can be utilized to support theories and arguments both in favor and against any kind of regulation, only proving that different stakeholders can use the inconclusive base of proofs in different manners (Shih et al., 2019).

Regulatory bodies, politicians, state and national level governments and health charities can be aligned broadly to show their support in the regulation of marketing and the purchasing age of e-cigarettes along with a regulation on their usage as medicine. These measures and methods will rarely be opposed. Extensive encouragement for the regulation on e‐cigarettes usage as a medicine is maybe based on an apparent requirement to establish the basics of what the e‐cigarettes and its refills may consist of. It will be useful for both -consumer protection, as captured in data, and to make sure a consistent product enters the market for which more directives can be planned. Restrictions on purchasing age and regulation on marketing can be vindicated basis on the requirement to protect children from danger, a reasoning that industry players have been uninterested to oppose in any debates done on tobacco control in the past Van et al., 2019).

Policy Approach

The appropriate policy and regulatory response to e-cigarettes should take into account the national circumstances of the country, which will include taking into context the current approaches and policy that has been taken up by the Australian government and the territory and state governments in the reduction of tobacco smoking consumption and its associated prevalence and related costs and harms (Department of health, Australian government. 2020). Future and current approaches that have been taken up by the other nations towards e-cigarettes are supportive of having a potential public health policy at a national level against them and regulatory responses to these products. Currently, no consensus exists internationally on the most adequate public health policy and regulatory framework towards e-cigarettes. Planned approaches to regulation are considerably varying across countries, and include treating the e-cigarettes as medicine products, tobacco products and consumer products as well. While some countries show complete prohibition on the sale of e-cigarettes like India, in many developing countries, minimal or no regulation or control is applied (WHO, 2020).

The current evidence base supports maintaining and, where appropriate, strengthening the current controls that apply to the marketing and use of e-cigarettes in Australia. Decisions should take into account the conclusions reached by credible health and scientific agencies in relation to the interpretation and advice about that evidence, including for example the WHO, the NHMRC.

A bilateral approach can be used where a balance is maintained between the regulatory aspects and the control usage as well. The policy should look at both- a prevention strategy in terms of usage amongst the youth and the young people and a strategy for effective control in currently smoking population looking for less harmful alternatives for their nicotine addiction (Bhalerao et al., 2019). The aspect of prevention can include regulatory laws on their marketing and advertising campaign, prohibition of sale to minors below 18 years of age and preventing advertising targeting the youth and the young population. It can also include prevention of campaigning them in different flavors along with packaging that is child-safe and also describes the health effects of its consumption. The control aspect can be helpful in including better manufacturing ideas and measures along with stricter licensing laws for both -retail and online sale, selective taxation and subsidy for current smokers as well (Levy et al., 2017). Campaign addressing the awareness and education needs of people towards e-cigarettes should also be included as a part of the policy (Bhalerao et al., 2019). An aspect of the policy can also include the aspect of greater research in terms of long-term epidemiological studies and effects on health so as to remove the ambiguity around its usage and harm as well (Levy et al., 2017).

Alternative Policy Approach

An alternative policy approach of looking at e-cigarettes could be to put a complete ban on the usage, sale and manufacturing of e-cigarettes. An example of the application of this policy can be seen in the recent policy change in India towards e-cigarettes where it has called upon a complete ban on the same (Rao et al., 2020). A complete ban on e-cigarettes whose harmful effects, public health impacts on youth and the public in general have been proven in a lot of studies but, no long-term epidemiological studies and effects on morbidity and mortality have still not been established as yet as definite. There is still some confusion around it. So, a better approach would be a balance between the preventative and control approach instead of a complete ban when there is only a ban applied on e-cigarettes leaving the major source of ill-health- the combustible, conventional tobacco cigarette (Burki 2019). Moreover, a complete ban might lead to a large number of youth and young people to switch back to the conventional cigarette usage. Also, anything which is less harmful in nature or might not be as harmful as conventional cigarettes should not be banned when something else which is way more harmful and toxic is being allowed and merely regulated (Rao et al., 2020).

Conclusion on Health Policy on E-Cigarettes

E-cigarette and its usage worldwide have been of contradiction and unambiguous in nature both. Its advent has brought along many new dangers along with some promises as well. It has changed the way the world consumes tobacco since the past decade. Both its- usefulness and its harmful effects are debated around and most of the research proves its harmful effects pertaining to its contents and presence of nicotine, it has also been used as a tool for control of conventional tobacco usage. Different studies have shown different impacts on public health due to its usage and its idea of being an alternative for tobacco control as well. Different nations have described it as a different product depending on their understanding of its utility- either a drug/medicine, tobacco product or a consumer product. Various policies to regulate and curb its usage along with a blanket ban on its sales and consumption have been advocated and practiced worldwide with no specific policy measure proving to be more effective than the other. There is a greater need of research in terms of its effects on mortality and morbidity and more emphasis on its comparable effects on health with regards to conventional tobacco cigarette. There is still a long way to go for countries in tobacco control.

References for Health Policy on E-Cigarettes

Alexander, J. P., Coleman, B. N., Johnson, S. E., Tessman, G. K., Tworek, C., & Dickinson, D. M. (2016). Smoke and vapor: Exploring the terminology landscape among electronic cigarette users. Tobacco Regulatory Science2(3), 204-213.

Bhalerao, A., Sivandzade, F., Archie, S. R., & Cucullo, L. (2019). Public health policies on E-cigarettes. Current Cardiology Reports21(10), 111.

Brown, J. (2017). A gateway to more productive research on e‐cigarettes? Commentary on a comprehensive framework for evaluating public health impact. Addiction (Abingdon, England)112(1), 21.

Bruin, J. E., Gerstein, H. C., & Holloway, A. C. (2010). Long-term consequences of fetal and neonatal nicotine exposure: A critical review. Toxicological Sciences116(2), 364-374.

Burki, T. K. (2019). Changes in e-cigarette policies worldwide. The Lancet Oncology20(11), 1487.

Cai, H., & Wang, C. (2017). Graphical review: The redox dark side of e-cigarettes; exposure to oxidants and public health concerns. Redox Biology13, 402-406.

Eaton, D. L., Kwan, L. Y., & Stratton, K. (2018). Public health consequences of e-cigarettes. National Academies Press.

Greenhalgh, EM, Jenkins, S & Scollo, MM. 18B.3 Extent of use. (2020). Tobacco in Australia: Facts and issues. Melbourne

Kruse, G. R., Kalkhoran, S., & Rigotti, N. A. (2017). Use of electronic cigarettes among US adults with medical comorbidities. American Journal Of Preventive Medicine52(6), 798-804.

Levy, D. T., Cummings, K. M., Villanti, A. C., Niaura, R., Abrams, D. B., Fong, G. T., & Borland, R. (2017). A framework for evaluating the public health impact of e‐cigarettes and other vaporized nicotine products. Addiction112(1), 8-17.

Murthy, V. H. (2017). E-cigarette use among youth and young adults: A major public health concern. JAMA Pediatrics171(3), 209-210.

Rao US, V., Arakeri, G., Ravishankar, S., Kar, A., Thakur, S., Li, R. J., & Brennan, P. A. (2020). The E‐cigarette ban in India‐A step in the right direction?. Journal of Oral Pathology & Medicine.

Shih, C. S., & Etter, J. F. (2019). Stakeholders' views on e-cigarette legislation: A qualitative study in Taiwan. Frontiers in Public Health7.

Van Teijlingen, E., Mahato, P., Simkhada, P., van Teijlingen, C., Asim, M., & Sathian, B. (2019). Vaping and e-cigarettes: A public health warning or a health promotion tool?. Nepal Journal of Epidemiology9(4), 792.

WHO Report on e-cigarettes (2020)

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