Anti-E-Cigarette Puritans Put Lives at Risk

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Big tobacco companies were publicly pilloried when they were found to have misled the public about the dangers of their products. To this day, that industry remains a touchstone example for corporate malfeasance. But when public health officials use similar tactics to spread the misleading claim that e-cigarettes are “no less harmful” than combustible tobacco products, it can lead to fewer smokers switching to safer alternatives. The result is that more smokers will die, while public health officials face few repercussions.[1]

One reason U.S. health advocates often give to justify their unwillingness to embrace the e-cigarette revolution is that there is not enough evidence that e-cigarettes are effective at helping smokers quit, and could even hook some people onto nicotine who will progress or regress back to smoking. For example, in August 2018 University of California, San Francisco professor and anti-tobacco advocate Stanton Glantz lectured that the evidence shows “smokers who use e-cigarettes quit less not more than smokers who don’t use e-cigarettes.”[2] A statement on the website for the National Institute of Drug Abuse in the National Institutes of Health notes that “e-cigarettes haven’t been thoroughly evaluated in scientific studies” and that “not enough data exists on the safety of e-cigarettes, how the health effects compare to traditional cigarettes, and if they are helpful for people trying to quit smoking.”[3]

Never mind that millions of e-cig users have said that e-cigs were the only thing that helped them quit. Yes, anecdotes, even millions of them, are not strong evidence, but there is a growing body of actual scientific research to back up what ex-smoking vapers have been saying. So why the continuing opposition among health advocates? One reason might be a puritanical mindset against products smokers can enjoy while ceasing to smoke.

E-Cigarettes Have Already Helped Millions Quit Smoking. Of the more than 1 billion people worldwide who continue to smoke, about half will die due to their habit.[4] This number, though high, is much lower than it was in the 1970s thanks to educational efforts. Today, one would be hard pressed to find anyone unaware of the risks of smoking, but despite that and billions in funding tobacco-prevention, the declines in smoking tapered off and flatlined during the mid-to-late 2000s with a stubborn 20-21 percent of adults either unable or unwilling to quit.[5] Among adolescents, the recent history is even worse, with smoking rates among high schoolers even increasing during the late 1990s.[6] Between 2003 and 2009, however, adolescent and adult smoking rates plateaued and declines stalled.[7]

Prevalence of Current Smoking among U.S. Adults Age 18+, 1997–2015

Source: Centers for Disease Control and Prevention, “Tobacco,” page updated December 14, 2017, https://www.cdc.gov/winnablebattles/report/tobacco.html.

Current Smoking among U.S. High School Students

Source: CDC National Youth Tobacco Survey, https://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm.

But around 2009, the smoking rate among both adults and teens suddenly started to nosedive. Since then, smoking has hit records lows every year with just 14 percent[8] of adults and only 7.6 percent of high schoolers classified as current smokers today.[9]

What caused these this miraculous decline? If you ask public health officials, they will likely attribute the drop to their own efforts—to marketing messages, tax hikes, and other tobacco control policies—but most of those policies had been in place in several states long before the declines.[10] For example, half the country had banned indoor smoking before 2008[11] and the federal minimum age for purchasing tobacco has been 18 years since 1992.[12] Yet, they have failed to acknowledge that the rise in popularity of e-cigarettes has helped many people quit smoking, despite thousands of e-cig users saying this is the case[13] and study after study indicates that is what is happening.[14]

E-Cigarettes Help Smokers Quit, Even When They Do Not Want to. The evidence about e-cigarettes’ safety relative to smoking is conclusive. In 2015, after reviewing the evidence, Public Health England declared that the existing e-cigarettes were at least 95 percent less harmful than smoking.[15] The following year UK’s Royal College of Physicians even recommended that doctors encourage their smoking patients to use e-cigarettes.[16] 

Public health officials in the U.S. has been slower to recognize the potential benefits of e-cigarettes, but some health groups have admitted that they are safer than smoking. For example, in early 2018 the National Academy of Sciences, Engineering, and Medicine (NASEM) issued a consensus statement on e-cigarettes after reviewing more than 800 studies on the topic. NASEM found “conclusive evidence” that switching from combustible to vaporized sources of nicotine reduces exposure to harmful toxicants and “substantial evidence” that switching entirely from smoking to vaping results in “reduced short-term adverse health outcomes in several organ systems.” Although the report stopped short of projecting long-term benefits to individuals and public health at large, it did say that “the modeling projects that use of these products will generate a net public health benefit, at least in the short run.”[17]

Even the Truth Initiative, an ardently anti-tobacco group funded with tobacco settlement money, admits that “vaping might be safer than smoking,” though it still makes such admissions alongside jeers that “it’s not that difficult to find things that are safer for you than smoking.”[18]

In January 2019, the New England Journal of Medicine published a study in which nearly 900 smokers at stop smoking clinics in the U.K. were randomized into groups receiving e-cigarettes or nicotine-replacement products (NRTs) such as nicotine patches, gum, lozenges, or nasal sprays. After a year the researchers found that participants in the e-cigarette group remained abstinent from smoking at twice the rate of those in the NRT group (18.8 to 9.9 percent).[19]

This is only the latest in a string of studies indicating that e-cigarettes might not only be as effective as other cessation routes, but more effective than traditional nicotine replacement therapy at helping smokers quit and preventing relapse.[20] Why might these “unregulated” devices not approved by the public health police be better able to help even the most hardened smoker quit when all their education has failed? The answer might just be because they are enjoyable. 

It’s the Pleasure, Stupid. For some reason, U.S. public health officials cannot seem to wrap their heads around the idea that people smoke for any reason other than their addiction to nicotine. But the low success rates of nicotine replacement therapies prove that there is something more than just a chemical that keeps people coming back. That something, as e-cigarettes demonstrate, appears to be enjoyment. 

People don’t just consume alcohol because they like the buzz, and they don’t just drink coffee because it wakes them up in the morning. They drink these products because they enjoy the taste and the experience; otherwise we all would just take caffeine pills and drink swill. The same is true for smokers. E-cigarettes give them the nicotine hit they crave, but also mimics the hand-to-mouth habit and pleasing taste. Limited research indicates that it is this “fun” aspect of e-cigarettes that may explain why smokers switch to vaping and why they stick with vaping, even when they did not intend to quit smoking.[21]

A small UK study published in June 2018 found that smokers who vaped were successful at fully quitting cigarettes despite their intent to continue smoking. Of the 40 e-cig users in this study, 31 had fully switched to vaping, five used both e-cigarettes and tobacco cigarettes, three quit entirely, and only one relapsed back to smoking. Notably, seven of the current vapers in the group—17.5 percent—said at the beginning that they had no intention of quitting smoking, but did so anyway.[22]

Those results are similar to an earlier Flemish trial from 2014 comprised of smokers who had never used e-cigs and did not indicate a willingness to quit smoking. The study found that when the participants vaped, their nicotine cravings were reduced as if they had smoked a cigarette, indicating that e-cigarettes are an effective substitute for smoking. Notably, eight months after this initial experiment, researchers observed that nearly a fourth (21 percent) of the participants had quit smoking entirely and another fourth (23 percent) cut their smoking in half—this despite the fact that all participants indicated an unwillingness to quit before trying e-cigarettes.[23]

A 2017 study by researchers at Columbia University found that smokers who vaped on a daily basis were nearly twice as likely to have quit smoking as those who never used e-cigarettes.[24] Months later, another study, published in the International Journal of Environmental Research and Public Health, found similar results.[25] After surveying the habits of thousands of current and former smokers, the researchers in this study found that e-cigarette use was associated with a higher chance of quitting smoking than any other cessation aid. It was not as effective as the “cold-turkey” method, but that may simply indicate that e-cigarettes are less effective a cessation tool for smokers more committed to quitting, but far more effective among smokers who are less willing to quit or have failed using other methods. In other words, e-cigarettes may be the silver bullet for that small, stubborn percent of smokers who cannot quit any other way.

All Tobacco Products Are Not Equal. No amount of research, it seems, will convince anti-smoking activists that e-cigarettes are an acceptable alternative. Though they have not succeeded in fully eliminating e-cigarettes as an option—not yet, anyway—they are trying to gin up public panic and scare consumers, including smokers, away from trying e-cigs. Their marketing strategy includes spreading misleading claims. On January 21, 2019, the Pennsylvania Department of Health issued a tweet warning that “E-cigarettes, e-cigs, e-hookahs, mods, vape pens or vapes—whatever you call them, they are NOT safer than other tobacco products.”[26] This is blatantly untrue. Although the Web page it linked to made it clear that they were only saying e-cigarettes are “no safer than other tobacco products for youth,” this clarification is not factually accurate and this type of messaging is being communicated to everyone.[27] [Emphasis added]

This is only the most recent example of egregiously alarmist and incorrect messaging being put out by those health agencies and groups with the greatest amount of public trust. The Centers for Disease Control and Prevention (CDC) has repeatedly made false claims about the evidence, fabricated research, and issued cherry-picked data intended to scare.[28]

The U.S. Food and Drug Administration’s (FDA) Twitter account regularly puts out misleading tweets like one that notes that “e-cigarette use surge led to uptick in overall tobacco use,”[29] without making it clear that e-cigarette use is included in “tobacco use” and that smoking has hit record lows every year since 2010, according to CDC annual surveys.[30] To this day, the FDA website contains a statement that “All tobacco products are harmful to your health, despite what they taste, smell, or look like,” a wildly inaccurate claim that conflates all forms of tobacco—combustible or non-combustible—with smoking.[31]

The World Health Organization also mixes up tobacco and smoking, tweeting on January 5, 2018, that “tobacco is the only product that kills half of its consumers.”[32] However, this statement actually only applies to smoking, not non-combustible products like e-cigarettes or snus. In fact, snus has contributed to Sweden having the lowest lung cancer rates of any European Union (EU) member nation (since it is banned everywhere else in the EU).[33]  But they persist with this messaging that scares the public, including smokers, away from e-cigarettes because, unfortunately, the tactic works.  

In 2012 polls found that only 12 percent of adults thought e-cigarettes were as harmful as or more harmful than smoking, but by 2015 that number had jumped to 35 percent. [34]  By 2018, 50 percent—half of all adults—held this mistaken belief with another 17 percent unsure.[35] Public health activists will insist their messaging is aimed at adolescents and people who have never smoked, but those are not the only ones hearing and believing it. Between 2012 and 2015 the percent of current adult smokers who said that e-cigarettes were as or more harmful than cigarettes increased from under 12 percent to just over 35 percent.[36] In other words, thanks to information disseminated by public health officials, the people most likely to benefit from trying e-cigarettes mistakenly believe there is no benefit in switching to vaping. As a result, fewer will switch and more will die.

When tobacco companies ignored research showing the dangers of their products, they were prosecuted for endangering public welfare. Anti-tobacco activists in health charities and within government are using these same tactics to dissuade people from using a demonstrably safer product and, as a result, people will be harmed and many will die, but these health advocates will face few, if any consequences.

Notes

[1] Pennsylvania Department of Health, “E-cigarettes, e-cigs, e-hookahs, mods, vape pens or vapes—whatever you call them, they are NOT safer than other tobacco products. Learn how you can help protect your child’s health by talking about the dangers of vaping,” Twitter post, January 21, 2019, 11:00 AM, https://twitter.com/PAHealthDept/status/1087424595211083776.

[2] University of California San Francisco, “Back to the Future: Stan Glantz lecture on e-cigarettes and whether they really reduce harm,” lecture, August 18, 2018, https://tobacco.ucsf.edu/back-future-stan-glantz-lecture-e-cigarettes-and-whether-they-really-reduce-harm.

[3] National Institute on Drug Abuse, “Electronic Cigarettes (E-cigarettes), updated June 2018, https://www.drugabuse.gov/publications/drugfacts/electronic-cigarettes-e-cigarettes.

[4] World Health Organization, “Tobacco,” March 9, 2018, https://www.who.int/news-room/fact-sheets/detail/tobacco.

[5] Centers for Disease Control and Prevention, “Winnable Battles,” updated December 14, 2017, https://www.cdc.gov/winnablebattles/report/tobacco.html.

[6] Centers for Disease Control and Prevention, “Trends in Cigarette Smoking Among high School Students—United States, 1991—1999,” MMWR Weekly, August 25, 2000. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4933a3.htm

[7] Centers for Disease Control and Prevention, “Ten Great Public Health Achievements—United States, 2001—2010,” Morbidity and Mortality Weekly Report, Vol. 60, No. 19 (May 20, 2011), pp. 619-623, https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6019a5.htm.

[8] Robert Preidt, “U.S. Smoking Rates Hit Record Low,” WebMD, November 8, 2018, https://www.webmd.com/smoking-cessation/news/20181108/us-smoking-rates-hit-record-low.

[9] U.S. Centers for Disease Control and Prevention, “Youth and Tobacco Use,” January 2, 2019, https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm.

[10] U.S. Centers for Disease Control and Prevention, “Adult cigarette smoking rate overall hits all-time low,” November 26, 2014, https://www.cdc.gov/media/releases/2014/p1126-adult-smoking.html.

[11] Mary Branham Dusenberry, “Butts Out: Many States Now Ban Smoking in Public Places,” Council of State Governments, August 2007, https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUKEwjb7bCCuLTgAhUSMd8KHcfgAakQFjAAegQIABAC&url=http%3A%2F%2Fwww.csg.org%2Fknowledgecenter%2Fdocs%2Fsn0708ButtsOut.pdf&usg=AOvVaw2Wg0FZ6MqMzB6aRT68Y79m.

[12] Dorie E. Apollonio and Stanton A. Glantz, “Minimum Ages of Legal Access for Tobacco in the United States From 1863 to 2015,” American Journal of Public Health, Vol. 106, Issue 7 (July 2016), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4902755.

[13] Public comments submitted  to U.S. Food and Drug Administration, “Regulation of flavors in tobacco products,” Docket ID: FDA-2017-N-6565, https://www.regulations.gov/docketBrowser?rpp=50&so=DESC&sb=postedDate&po=0&dct=PS&D=FDA-2017-N-6565,

[14] Peter Hajek, Ph.D. et al, “A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy, New England Journal of Medicine, January 2019, https://www.nejm.org/doi/full/10.1056/NEJMoa1808779?query=featured_home.

Yadira Galindo, University of California-San Diego, “Americans are quitting smoking in higher numbers,” ScienceDaily, July 26, 2017, https://www.sciencedaily.com/releases/2017/07/170726184442.htm.

[15] Public Health England, “E-cigarettes around 95% less harmful than tobacco estimates landmark review,” news release, August 19, 2015, https://www.gov.uk/government/news/e-cigarettes-around-95-less-harmful-than-tobacco-estimates-landmark-review.

[16] Michelle Roberts, “E-cigarettes should be offered to smokers, say doctors,” BBC News, April 28, 3016, https://www.bbc.com/news/health-36139618.

[17] The National Academies of Sciences, Engineering, and Medicine, “Public Health Consequences of E-Cigarettes,” Consensus Study Report Highlights, The National Academies Press, January 2018, p. 3, https://www.nap.edu/resource/24952/012318ecigaretteHighlights.pdf.

[18] Truth Initiative, “Vaping Might Be Safer than Smoking, but that Doesn’t Make It Safe,” accessed February 8, 2019, https://www.thetruth.com/articles/hot-topic/safer-safe.

[19] Hajek et al.

[20] Konstantinos E. Farsalinos, Konstantinos Poulas, Vassilis Voudris, and Jacques Le Houezec, “Electronic cigarette use in the European Union: analysis of a representative sample of 27,460 Europeans from 28 countries,” Addiction, Vol. 111, Issue 11 (June 24, 2016), https://onlinelibrary.wiley.com/doi/abs/10.1111/add.13506.

[21] Konstantinos E. Farsalinos, Giorgio Romagna, Dimitris Tsiapras, Stamatis Kyrzopoulos, Alketa Spyrou, and Vassilis Voudris “Impact of flavour variability on electronic cigarette use experience: an internet survey,” International Journal of Environmental Research and Public Health, December 2013, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3881166.

[22] Caitlin Notley, Emma Ward, Lynne Dawkins, and Richard Holland, “The unique contribution of e-cigarettes for tobacco harm reduction in supporting smoking relapse prevention,” Harm Reduction Journal, Vol. 15 (May 14, 2018), https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-018-0237-7.

[23] Karolien Adriaens, Dinska Van Gucht, Paul Declerck, and Frank Baeyens, “Effectiveness of the Electronic Cigarette: An Eight-Week Flemish Study with Six-Month Follow-up on Smoking Reduction, Craving and Experienced Benefits and Complaints,” International Journal of Environmental Research and Public Health, Vol. 11 (October 29, 2014), https://www.mdpi.com/1660-4601/11/11/11220/htm.

[24] Daniel P.Giovencoa and Cristine D.Delnevo, “Prevalence of population smoking cessation by electronic cigarette use status in a national sample of recent smokers,” Addictive Behaviors, Vol. 76 (January 2018), pp. 129-134, https://www.sciencedirect.com/science/article/abs/pii/S0306460317302915. 

[25] Brad Rodu and Nantaporn Plurphanswat, “Quit Methods Used by American Smokers, 2013–2014,” International Journal of Environmental Research and Public Health, Vol. 14 (November 17, 2017), https://www.mdpi.com/1660-4601/14/11/1403.

[26] Pennsylvania Department of Health, “E-cigarettes, e-cigs, e-hookahs, mods, vape pens or vapes—whatever you call them, they are NOT safer than other tobacco products.

[27] Pennsylvania Department of Health, “E-cigarettes: Information and Resources for Parents,” accessed February 8, 2019, https://www.health.pa.gov/topics/programs/tobacco/Pages/E-cigarettes.aspx.

[28] Michael Siegel, “CDC Makes Startling Proclamation: Electronic Cigarette Aerosol is Not as Safe as Clean Air,” The Rest of the Story: Tobacco and Alcohol News Analysis and Commentary, December 14, 2014, http://tobaccoanalysis.blogspot.com/2014/12/cdc-makes-startling-proclamation.html.

[29] U.S. Food and Drug Administration, “NYTS KEY FINDING: E-cigarette use surge led to uptick in overall tobacco use #YouthTobaccoUse,” Twitter post, January 15, 2019, 1:03 PM, https://twitter.com/FDATobacco/status/1085281220320202753.

[30] Centers for Disease Control and Prevention,

National Youth Tobacco Survey (NYTS). https://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm

[31] U.S. Food and Drug Administration, “Health Fraud,” accessed February 8, 2019, https://www.fda.gov/TobaccoProducts/PublicHealthEducation/HealthInformation/ucm255658.htm.

[32] World Health Organization, “Tobacco is the only product that kills half of its consumers,” Twitter post, January 5, 2018, 7:45 AM, https://twitter.com/who/status/949305779630362626.

[33] Chris Weller, “Sweden cut its smoking rate to just 5%—here’s what the rest of the world can learn,” Business Insider, June 14, 2017, https://www.businessinsider.com/sweden-smoking-rate-what-world-can-learn-2017-6.

[34]  Ban A. Majeed, Scott R. Weaver, Kyle R. Gregory, Carrie F. Whitney, Paul Slovic, Terry F. Pechacek, and Michael P. Eriksen, “Changing Perceptions of Harm of E-Cigarettes Among U.S. Adults, 2012–2015,” American Journal of Preventative Medicine, Vol. 52, Issue 3 (March 2017), pp. 331–338, https://www.ajpmonline.org/article/S0749-3797(16)30443-3/abstract.

[35] “Most Say E-Cigarettes No Healthier than Traditional Ones,” Rasmussen Reports, August 16, 2018, http://www.rasmussenreports.com/public_content/lifestyle/general_lifestyle/august_2018/most_say_e_cigarettes_no_healthier_than_traditional_ones.

[36] Ban A. Majeed, Scott R. Weaver: PhD, Kyle R. Gregory, JD: Carrie F. Whitney, MPH: Paul Slovic, PhD: Terry F. Pechacek, PhD; and Michael P. Eriksen, “Changing Perceptions of Harm of E-Cigarettes Among U.S. Adults, 2012–2015,” American Journal of Preventive Medicine, Vol. 52, Issue 3 (March 2017), pp. 331–338, https://www.ajpmonline.org/article/S0749-3797(16)30443-3/abstract.