August 1, 2019

The Surprising Public Policy Case for Electronic Cigarettes

Read the report: The Impact of Electronic Cigarettes on Cigarette Smoking By Americans and Its Health and Economic Implications

For more than a half-century, federal, state and local governments have adopted a variety of strategies to discourage Americans from smoking cigarettes – from health warnings on cigarette packaging, advertising restrictions and anti-smoking public education campaigns, to multiple taxes and bans on smoking in buildings and other public spaces.  Getting people to quit and stay off cigarettes is a steep climb, because tobacco contains the addictive chemical nicotine, along with the dangerous carcinogens inhaled from smoking cigarettes.  Moreover, manufacturers have reinforced the addictive hold of their cigarettes by artificially increasing their nicotine content and adding more chemicals that reinforce the effects of nicotine. As a result, cigarette smoking by Americans has declined quite slowly: From 1964 to 2011, nearly a half-century, the share of American adults who smoked fell from 42 percent to just under 20 percent.

Given the cynical practices of the cigarette manufacturers, the logical alternatives to further reduce smoking rates entail either reducing the nicotine, so people can quit more easily, or eliminating the carcinogens. The first approach has been tried and doesn’t work very well:  People using low-nicotine cigarettes often maintain their nicotine fix by smoking more or inhaling more deeply.  The second option is more promising: Electronic cigarettes or e-cigarettes eliminate the carcinogens while leaving intact the addictive nicotine.

With my colleague Siddhartha Aneja, I recently conducted a study for the Progressive Policy Institute evaluating the promise and possible dangers of rising e-cigarette use. The data from the Centers for Disease Control and Prevention (CDC) clearly suggest that as e-cigarettes or “vaping” have become popular, starting around 2013, cigarette quitting rates have accelerated.  Smoking rates among adults fell more than 20 percent in four years, from 18 percent in 2013 to 14 percent in 2017.  While high school students have the highest rates of vaping – a matter of s concern to many — their use of cigarettes fell more than 40 percent over those years, from 12.7 percent in 2013 to 7.6 percent in 2017.

A number of factors apart from e-cigarettes have contributed to this encouraging news, from higher cigarette taxes to smoking bans in many public spaces.  To learn more about the impact of e-cigarettes, we performed statistical analyses of CDC data on the changes in rates of smoking and vaping by age, gender, race and ethnicity.  The results suggest that the rising use of e-cigarettes can explain about 70 percent of the acceleration in the decline in cigarette smoking from 2013 to 2017.

With the recent substantial rates of vaping among adolescents, some analysts speculate that the sharp decline in adolescent cigarette smoking could be temporary, if e-cigarette use is a gateway to cigarette smoking.  Happily, statistical analysis also indicates that those concerns are misplaced.  At a minimum, rising rates of vaping among adolescents have not been followed a few years later by any moderation in the declining smoking rates of adolescents and young adults now a few years older.  

Moreover, statistical analysis and studies also confirm that e-cigarettes are an effective tool to help people stop smoking. This suggests that vaping could be an instrument of public policy, however politically incorrect it may be to say so.  The British government, for one, urges organizations that provide smoking cessation services to offer up e-cigarettes as a viable way to quit smoking.  Further, Public Health England has concluded that “the evidence does not support the concern that e-cigarettes are a route into smoking among young people” and estimates that using e-cigarette is 95 percent safer than smoking regular cigarettes. 

That finding is an important public policy matter, because treating cigarette-related diseases accounted for nearly nine percent of U.S. healthcare spending, or more than $310 billion in 2018.  Further, depending on age, the annual per capita healthcare costs of cigarette smokers are 9 percent to 10 percent greater than those of nonsmokers and e-cigarette users, and the annual per capita healthcare costs of ex-smokers are 20 percent to 34 percent higher than those of nonsmokers and e-cigarette users.

Ironically, the use of e-cigarettes actually increases lifetime healthcare costs, because their use reduces cigarette smoking rates, and ex-smokers and nonsmokers on average live longer than smokers.   Moreover, the economic value of their additional years of life far outweigh the additional healthcare costs that arise from living longer.  Nonsmokers and vapers also are more economically productive than smokers, all other factors being equal, because cigarette smokers miss more work due to illness and come to work impaired by illness more often.  

While e-cigarettes do not deliver the deadly carcinogens that come with smoking cigarettes, there has been little scientific study thus far of any long-term health effects of vaping.  We need more.  Similarly, while smoking rates among high school students have fallen sharply, their high rates of vaping and associated nicotine dependence suggest that the restrictions on the age of people purchasing cigarettes and the places they can smoke should apply to e-cigarettes. 

Having said that, future regulation of e-cigarettes should also take account of their positive impact on declining rates of cigarette smoking, their effectiveness in helping people stop smoking, and the annual healthcare savings and productivity benefits that come from stopping smoking.