E-cigarettes can help smokers abandon their deadly habit. Unfortunately, that message has been buried under a mountain of anti-vaping messaging promoted by tobacco researchers and reporters.
The evidence is clear at this point: vaping is less dangerous than smoking and helps many people give up their deadly cigarette habit. Nobody who fairly looks at the data can dispute either conclusion, yet tobacco-control researchers, activists, and federal regulators routinely deny or downplay both observations. Science denial is always irritating, but it's especially troublesome in this case because it has polluted the public's understanding of vaping and discouraged smokers from trying an alternative that might save their lives.
As an ex-smoker who quit with the help of an e-cigarette, I have a dog in this fight. But you don't have to take my word for it. The conclusion in the preceding paragraph came from a study recently published in the American Journal of Preventive Medicine. “Adults in the United States increasingly perceive electronic cigarettes, or e-cigarettes, as 'more harmful' than traditional cigarettes," Medscape reported on June 20. More importantly,
... [T]he percentage of people who exclusively used traditional cigarettes almost doubled between 2019 and 2020 among those who perceived e-cigarettes as more harmful, jumping from 8.4% in 2019 to 16.3% in 2020 … Since e-cigarettes entered the US market in 2006, public health experts have questioned claims from manufacturers that the products work as a harm reduction tool to help traditional cigarette smokers to quit.
Questioning the harm-reduction utility of e-cigarettes 16 years ago was reasonable. The fact that researchers continue to express the same doubts today is simply inexcusable. Let's take a closer look at the study.
Why does the public fear vaping?
The authors analyzed data gathered as part of the Health Information National Trends Survey (HINTS), a mail-based, nationally representative survey that asks US adults about their perceptions of cancer and other health-related information. The data were collected in five cycles between January 2018 and May 2020. The answers of more than 3,000 respondents (2018: 3,360; 2019: 3,217; 2020: 3,677) from each year were included in the final analysis. The authors reported that
Relative harm perceptions of E-cigarettes versus cigarettes were assessed with the following question that had a choice of 6 responses: Compared to smoking cigarettes, would you say that electronic cigarettes are.... Respondents were categorized as perceiving E-cigarettes as relatively less harmful (replied much less harmful or less harmful), as harmful (replied just as harmful), and more harmful (replied more harmful or much more harmful) than cigarettes.
The negative shift in perceptions, the authors suggested, was possibly driven by media coverage of the so-called “EVALI epidemic.” Between 2019 and 2020, when more than 2,000 people were hospitalized with vaping product-use-associated lung injuries and 68 died.
I write “so-called” because these cases weren't caused by vaping per se, as the CDC wrongly maintained for months, but by illegally purchased devices that were used to vape THC or CBD. These chemicals, native to marijuana, not tobacco, were mixed with vitamin E acetate, which probably caused the reported lung injuries. Dr. Josh Bloom helpfully explained the chemistry behind this phenomenon in this story; later research confirmed his analysis.
During the EVALI outbreak, reporters did what they usually do when they don't have all the facts: they amplified the risks—again, with the implicit blessing of the CDC—but showed little interest in reporting the resolution to the controversy. According to the study authors:
… more harmful relative perceptions were present at high levels in March 2020 and April 2020, suggesting that misperceptions persisted long after the link to vitamin E acetate … was initially identified in September 2019, possibly because media coverage was not sustained at initial levels after the outbreak source was identified.
The trend continues
EVALI is no longer a major public health concern, but the ideological activism and sloppy reporting that fueled the controversy then continue to undermine vaping as a harm-reduction tool today. Researchers publish low-grade research alleging that e-cigarette use carries severe health consequences and the media dutifully reports the results. ACSH and other science-minded outlets correct the propaganda; unfortunately, this good news doesn't attract nearly as much attention as the sexy, scary headlines did.
Experts recognize this problem and know it needs to be addressed. "We're good in public health about messaging that cigarettes are bad, that tobacco is broadly harmful," Dr. Ashley Brooks-Russell, associate professor at the Colorado School of Public Health, told Medscape Medical News. "We're really bad at talking about lesser options, like if you're going to smoke, e-cigarettes are less harmful."
Dr. Russell is correct, but I'd go further. Even when they document the harm caused by common anti-vaping tropes, tobacco researchers can't abandon their skepticism e-cigarettes. As the study authors themselves wrote,
E-cigarettes … contain high levels of nicotine and youth-appealing flavors that may contribute to addiction and progression to combustible tobacco product use among adolescents and young adults.
Every word of that sentence is at least partially false. Many e-cigarettes contain little or no nicotine. Flavored vapes do not encourage teen use of any tobacco product; there is no sound evidence to justify that speculation. The authors also repeated an anti-vaping claim that has become an article of faith among tobacco researchers: “the risks associated with long-term use are unclear.” That's necessarily true because nobody has a crystal ball, but public health researchers routinely use that statement to imply that we will find some serious vaping-associated risk in the future.
“The long-term risks of exclusive use of e-cigarettes are not fully known,” The American Cancer Society claims, “but evidence is accumulating that e-cigarette use has negative effects on the cardiovascular system and lungs. Without immediate measures to stop epidemic use of these products, the long-term adverse health effects will increase.”
Could you imagine a major medical institution making a similar declaration about COVID-19 vaccines or pubertal blockers used to treat gender dysphoria? After all, we don't know the long-term effects these powerful drugs may have on the people who take them (see here and here). Surely we have to stop the “epidemic use” of these products until we know more about them, right?
If those loaded questions irritate you, then maybe you're beginning to understand why the popular rhetoric about vaping is so absurd. A proper assessment of any product necessitates that we accurately balance the risks and benefits of using it. Nobody asserts that vaping is risk-free; it's an effective intervention designed to reduce smoking, which continues to kill people around the world.
With that standard in mind, speculating about the harms we we might find one day is a foolish thought experiment. Tell the public what we know today: vaping is a low-risk alternative for adult smokers who want to quit cigarettes.