Even as states and the federal government crack down on vaping products, conventional cigarettes remain on store shelves—and pose a greater danger to public health than flavored nicotine vapes do. But to acknowledge this is taboo, at least in the United States.
Last month, the Trump administration announced its intention to bar all e-cigarettes that don’t taste like tobacco. Massachusetts recently imposed a four-month ban on sales of all vaping products—a drastic move now under litigation in state court. Other states, including Michigan, Rhode Island, Washington, Oregon, and New York, have banned all fruit and candy flavors or have taken steps to do so. Walmart, Walgreens, and several other major retailers have announced that they will stop selling e-cigarettes altogether. And last week, the company that makes Juul (the sleek device popular with teens who can afford it) volunteered to suspend the sale of all flavors except for tobacco, mint, and menthol.
The Trump administration’s decision came within hours of worrisome news about teen vaping. According to preliminary data collected for the Centers for Disease Control and Prevention and the Food and Drug Administration, one in four teens vaped at least one day in the past month in 2019—a significant increase from 2018. Days later, a study funded by the National Institute on Drug Abuse reported that 11.7 percent of high-school seniors vaped at least 20 days out of the month.
Further galvanizing the e-cigarette debate is the frightening rash of vaping-associated pulmonary injuries. The outbreak started in midsummer and has now afflicted more than 1,400 people, causing 33 deaths. Health officials have traced the majority of these tragedies to vaping with contaminated cannabis products. The FDA has specifically warned against using THC products, especially those purchased on the street, but not against commercial e-cigarettes. Nevertheless, the outbreak has been persistently and wrongly attributed to vaping retail nicotine.
When flavored vapes are no longer available, many nicotine users won’t just quit. Instead, some will use cigarettes. Others will turn to the unregulated black market to continue buying fruit-flavored e-cigarettes, for which adult vapers as well as teens have a strong preference. Politicians who ban flavors should brace for a surge in smoking and the use of questionable bootleg vaping products—not just by adult vapers but by teens, especially those who vape daily.
Why don’t politicians see the damage they are about to inflict? In large part, it is because so many wrongly believe that e-cigarettes are as bad, or worse, than cigarettes.
The difference between conventional, tobacco-burning cigarettes and electronic ones can save lives. Standard cigarettes produce 7,000 chemical compounds, including 70 known human carcinogens. In contrast, electronic cigarettes heat a solution of nicotine, propylene glycol, glycerin, and flavorings. Although the aerosol emitted contains toxins and metals, they are far fewer in number than those found in cigarette smoke and they are present at much lower levels.
When I began following electronic cigarettes in 2014, the technology was being hailed as a major public-health advancement for smokers who could not, or would not, quit. Media coverage was tentatively optimistic. Five years later, vaping’s public image in the United States has changed for the worse.
The relative safety of e-cigarettes has been recognized abroad. Public Health England, the British equivalent of the CDC, has estimated that e-cigarettes are at least 95 percent less hazardous than conventional cigarettes. Some British hospitals house vape shops, and the month-long national anti-smoking campaign, Stoptober, encourages people to vape instead.
The long-term health effects of regularly inhaling propylene glycol, glycerin, and flavors are unknown, so researchers must follow vapers for years to come. But that uncertainty should not discourage smokers who have failed to quit smoking through other means (such as gum, the patch, medications, or behavioral therapy) from switching to e-cigarettes.
The U.S. adult smoking rate has fallen to 14 percent, the lowest ever recorded. Vaping has undeniably helped. Vaping achieved twice the one-year quit rates as gum, patches, and lozenges in a rigorous, randomized clinical trial. Vaping is more popular among would-be quitters than nicotine patches and gum combined, according to research from the CDC. And flavors are key to vaping’s appeal for the country’s 11 million to 14 million vapers. A 2018 preference survey of 70,000 adult vapers found that fruit and dessert flavors are the most popular by far, with only a minority using tobacco flavors. It is virtually inevitable that banning flavors to make e-cigarettes less appealing to teenagers will simultaneously jeopardize adults who vape in place of smoking.
The ethos of vaping is relative risk. E-cigarettes reduce harm, but can’t be called harmless. As a safer alternative than smoking for people addicted to nicotine, they are analogous to prescribing methadone for people addicted to opioids, a strategy called harm reduction. Other kinds of harm reduction, such as giving clean needles to injection-drug users and distributing condoms, pre-exposure prophylactic medication, and safe-sex information for populations at risk for HIV/AIDS, are widely endorsed by the public-health establishment. Yet America’s temperance heritage still exerts a certain amount of force on health policy. Instead of trying to lessen the harm from hazardous behaviors, such as smoking or drug use, some authorities seek to stamp them out altogether.
However, many policy makers and members of the public do not grasp the benefits of nicotine harm reduction, because they simply won’t admit or don’t believe that e-cigarettes are less risky for smokers. A 2019 poll conducted by Morning Consult found that 53 percent of the public disagreed, either strongly or somewhat, with the statement that e-cigarettes are less harmful than traditional cigarettes. (Only 24 percent agreed; 22 percent had no opinion). A different research group found that 11.5 percent of adults in 2012 thought e-cigarettes were as dangerous as smoking, and that 35.7 percent held that belief in 2015.
Why the misperceptions? A thick haze of misinformation about e-cigarettes includes unwarranted claims of e-cigarette-induced heart attacks and “popcorn lung,” an often lethal obstruction of the smallest pulmonary airways, along with the notion that nicotine causes cancer. Such apocryphal medical news is routinely put forth by various advocacy groups and even public officials. A Harvard Medical School pediatrician called vaping “bioterrorism,” while reputable entities such as the Tennessee Medical Association and the University of Rochester Medical Center maintain that e-cigarettes are no safer than smoking. Whom can the public trust?
The antipathy is largely fueled by a long-standing distrust of Big Tobacco. The very name e-cigarette induces flashbacks in many public-health activists. They’re transported to a time when Big Tobacco touted allegedly safer ways to smoke—filtered cigarettes in the ’50s and low-tar cigarettes in the ’60s—that turned out to be nothing but false promises. (The vaping industry long consisted mainly of small- and medium-size independent businesses, but tobacco companies have taken stakes in some players and, Vice recently reported, are using the current health scare to increase its leverage over the vaping industry.)
In light of history, public-health advocates’ skepticism about e-cigarettes, at least when they first appeared, was understandable. But genuine advances really can occur, and the evidence suggests that the shift from smoking to vaping should be celebrated, not decried.
In recent media coverage and in statements by elected officials, though, harms specifically derived from unregulated marijuana-vaping products have brought disrepute on vaping more generally. Confusion in the public mind can lead to genuine health hazards—for instance, if more Americans end up smoking instead of vaping (and if THC vapers keep buying from questionable sources).
While the benefits of vaping to smokers are being downplayed or ignored, the harms to teens are likely being overstated. Smoking among high-school students reached a new low in 2019, with only 5.8 percent reporting that they had smoked at least once in the preceding month—a pattern suggesting that vaping serves as more of an off-ramp from smoking than an entryway for teens. Even so, the acting head of the Food and Drug Administration, Ned Sharpless, just reissued the familiar warning that e-cigarettes could serve as a vehicle to teen smoking.
Claims that nicotine alone leads to brain damage in youth have limited empirical support; most of the relevant literature involves studies of teens exposed to the substance via smoking. I mention this not to dismiss the problem of teen vaping—the FDA and other agencies are rightly trying to curb teen access—but merely to warn against rash, misdirected responses that will prevent today’s smokers from quitting.
Unfortunately, the misconceptions surrounding vaping may be too well entrenched. A Kaiser poll conducted this month revealed that 49 percent of respondents support banning all e-cigarettes, not just flavored ones. That would be a deadly mistake. “If we lose this opportunity,” David S. Abrams, a professor at the New York University College of Global Public Health, told CBS Morning News last month, “we will have blown the single biggest public-health opportunity ever to get rid of cigarettes and replace them with a much safer form of nicotine for everybody.” With 35 million Americans still smoking, the stakes are high.