Balancing Consideration of the Risks and Benefits of E-Cigarettes

Abstract

The topic of e-cigarettes is controversial. Opponents focus on e-cigarettes’ risks for young people, while supporters emphasize the potential for e-cigarettes to assist smokers in quitting smoking. Most US health organizations, media coverage, and policymakers have focused primarily on risks to youths. Because of their messaging, much of the public—including most smokers—now consider e-cigarette use as dangerous as or more dangerous than smoking. By contrast, the National Academies of Science, Engineering, and Medicine concluded that e-cigarette use is likely far less hazardous than smoking. Policies intended to reduce adolescent vaping may also reduce adult smokers’ use of e-cigarettes in quit attempts.

Because evidence indicates that e-cigarette use can increase the odds of quitting smoking, many scientists, including this essay’s authors, encourage the health community, media, and policymakers to more carefully weigh vaping’s potential to reduce adult smoking-attributable mortality.

We review the health risks of e-cigarette use, the likelihood that vaping increases smoking cessation, concerns about youth vaping, and the need to balance valid concerns about risks to youths with the potential benefits of increasing adult smoking cessation.

The use of nicotine-containing electronic- or e-cigarettes has divided the tobacco control community along a spectrum from fervent opponents to enthusiastic supporters. Opponents emphasize that vaping can cause nicotine addiction among young people and could lead some to become dependent cigarette smokers, possibly “renormalizing” smoking. They cite research indicating that nicotine may harm adolescents’ developing brains. Some consider vaping’s health risks substantial, and some question whether vaping decreases smoking cessation.¹ By contrast, proponents present evidence that vaping assists smokers in quitting smoking and believe that vaping poses far less risk to users’ health than does smoking. Smoking among youths, they observe, has declined rapidly during vaping’s ascendancy.²

Many US governmental health agencies^3–6 and nongovernmental medical^7,8 and health organizations^9–12 focus primarily on vaping’s risks for young people. These organizations’ pronouncements and their influence on policymakers and the media have had a profound impact on the public’s understanding of vaping. A study of US news articles on e-cigarettes found that, from 2015 to 2018, 70% of articles mentioned vaping’s risks for youths, while only 37.3% noted potential benefits for adult smokers.¹³ Of respondents to a 2019 national survey, nearly half considered vaping nicotine just as harmful as or more harmful than cigarette smoking. Only 1 in 8 considered vaping less harmful. (The rest responded “I don’t know.”¹⁴) By contrast, the US National Academies of Sciences, Engineering, and Medicine¹⁵ and the British Royal College of Physicians¹⁶ have concluded that vaping is likely far less hazardous than smoking cigarettes.

The public’s inaccurate perception worsened following a 2019 vaping-associated acute pulmonary disease outbreak (named “e-cigarette or vaping use-associated lung injury” [EVALI]) that caused 68 fatalities.¹⁷ Media coverage was extensive. Several states and cities promptly banned retail and online sale of flavored e-cigarettes.¹⁸ In early 2020, however, research attributed the illness to vitamin E acetate, an adulterant in illicit tetrahydrocannabinol (THC) vaping devices shown to produce pulmonary injury in animals.^19–21 A small percentage of patients with EVALI reported vaping only nicotine, but they were primarily in states where THC was illegal, and most had no toxicology testing.²² Once the potential harm of vitamin E acetate was publicized and adulterated THC removed from the market, the incidence of new cases fell precipitously.¹⁹ Yet, after the outbreak, two thirds of respondents to a poll related the lung disease deaths to use of “e-cigarettes such as JUUL.” Only 28% related the deaths to use of “marijuana or THC e-cigarettes.”²³

Scientists differ in their views of the relative risks and benefits of vaping nicotine, and of their implications.^1,2,24,25 Many, including this article’s authors, believe that vaping can benefit public health, given substantial evidence supporting the potential of vaping to reduce smoking’s toll. Our objective is to encourage more balanced consideration of vaping within public health and in the media and policy circles.

In the following pages we address:

• •the health risks of vaping,
• •the likelihood that vaping increases smoking cessation,
• •the principal concerns about youth vaping, and
• •balancing concerns about risks to youths with potential benefits for adult smokers.

THE HEALTH RISKS OF VAPING

According to the National Academies of Sciences, Engineering, and Medicine, “Laboratory tests of e-cigarette ingredients, in vitro toxicological tests, and short-term human studies suggest that e-cigarettes are likely to be far less harmful than combustible tobacco cigarettes.”^15(p1) The British Royal College of Physicians similarly concluded that “vaping isn’t completely risk-free but is far less harmful than smoking tobacco.”¹⁶

High-quality clinical and epidemiological data on vaping’s health effects are relatively sparse. There are no data on long-term health effects, reflecting the relative novelty of vaping and the rapid evolution of vaping products. Determining even short-term health effects in adults is difficult because most adult vapers are former or current smokers.

Some studies find that vaping may worsen asthma, bronchitis, and cough, including among nonsmoking young people.^26,27 By contrast, a few studies found that smokers with asthma or chronic obstructive lung disease see symptoms improve after switching to e-cigarettes.^28,29 Randomized switching trials (cigarettes to e-cigarettes) document improvements in respiratory symptoms.^30,31

Laboratory studies have reported potentially adverse effects of e-cigarette aerosol in cells and animals.^26,32 It is difficult, however, to extrapolate from exposure conditions in cells and animals to humans.²⁶ Human experimental studies have focused on acute effects,³³ which may not predict future disease. For example, e-cigarettes acutely impair tests of endothelial function, a common feature of cardiovascular disease, but when smokers switch from cigarettes to e-cigarettes, endothelial function normalizes.^34,35 A recent study detected no difference in biomarkers of inflammatory and oxidative stress in exclusive e-cigarette users and nonusers of either cigarettes or e-cigarettes.³⁶

There is little evidence that e-cigarettes pose significant cancer risk.¹⁵ However, some studies raise concerns that warrant long-term follow-up of vapers.^37,38

Many scientists have concluded that vaping is likely substantially less dangerous than smoking because of the following^15,16:

• •The number of chemicals in cigarette smoke, greater than 7000,³⁹ exceeds that of e-cigarette aerosol by 2 orders of magnitude.^40,41
• •Among potentially toxic substances common to both products, cigarette smoke generally contains substantially larger quantities than e-cigarette aerosol.^42–44 However, e-cigarette aerosol contains some substances not found in cigarette smoke.⁴⁵
• •Biomarkers reflecting exposure to toxic substances are present at much higher levels in exclusive cigarette smokers than in exclusive vapers, and studies of smokers who switch to e-cigarettes find decreases in toxicant exposures.^31,46–50
• •Tests of lung and vascular function indicate improvement in cigarette smokers who switch to e-cigarettes.^28,29,34 Exclusive users of e-cigarettes (most being former smokers) report fewer respiratory symptoms than do cigarette smokers and dual users.⁵¹

However, questions remain.⁵² Ongoing research will lend further insight into the products’ absolute and relative dangers.

THE LIKELIHOOD THAT VAPING INCREASES SMOKING CESSATION

A growing body of evidence indicates that vaping can foster smoking cessation, although the evidence is not definitive.^53,54

Randomized Trials

In an English smoking cessation randomized controlled trial,⁵⁵ smokers assigned to e-cigarettes achieved nearly twice the rate of biochemically confirmed smoking cessation at 1 year (18%) than smokers assigned to nicotine replacement therapy (9.9%); all received identical behavioral counseling. While 80% of those who quit with e-cigarettes were still vaping, they were no longer exposed to smoking’s substantially higher risk.

A New Zealand trial found that at 6 months, nicotine patch with nicotine e-cigarettes outperformed patch with nicotine-free e-cigarettes and patch alone. Thus, in addition to aiding quitting when used alone, nicotine e-cigarettes may increase the effectiveness of existing cessation aids.⁵⁶

Examining 26 randomized controlled trials, a recent Cochrane Review concluded that “There is moderate‐certainty evidence that ECs [electronic cigarettes] with nicotine increase quit rates compared to ECs without nicotine and compared to nicotine replacement therapy.”⁵³ Another meta-analysis drew similar conclusions, albeit with less certainty.⁵⁷ However, the US Preventive Services Task Force’s smoking cessation practice guideline did not find the evidence convincing.⁵⁸ As such, and for reasons the Cochrane Review describes, more well-designed clinical trials are needed.

Noteworthy is the lack of trials by e-cigarette manufacturers in pursuit of regulatory agency approval to use e-cigarettes for smoking cessation, likely reflecting the profitability of selling e-cigarettes as consumer products, rather than medicinal devices.

Population Studies

Collectively, population studies’ findings are consistent with a near doubling of quit attempt success, found in the randomized controlled trials, and the fact that e-cigarettes are smokers’ most used aid in quit attempts.⁵⁹ Four studies^60–63 found significant increases in smoking cessation (10%–15%) that the authors associated with vaping. A Centers for Disease Control and Prevention study reported that, in 2018, 15.1% of smokers had quit smoking for 6 months or longer using e-cigarettes, compared with 3.3% using other noncigarette tobacco products and 6.6% using no tobacco products.⁶⁴ Another study identified a near doubling of self-reported cessation among users of e-cigarettes or varenicline compared with smokers not using these products.⁶⁵ Consistent with these population studies, simulation analyses have generally found that vaping increases smoking cessation, avoiding large numbers of premature deaths.^66–69

Other researchers have found regular and frequent e-cigarette use to be associated with increased smoking cessation, while infrequent use was not.^70–75 This could reflect self-selection, with frequent vapers possibly liking vaping more and being more motivated to quit smoking. Infrequent vapers might use vaping as a temporary nicotine source where smoking is prohibited.^73,76

Other researchers have reported reduced cessation rates among smokers who vape.^77,78 However, many failed to distinguish frequency of vaping, introducing the risk of the selection biases just noted. Other studies included only current vapers who also smoke, systematically excluding vapers who had successfully quit smoking.^53,78

An often-cited meta-analysis found vapers’ odds of quitting smoking 28% lower than for nonvaping smokers.⁷⁷ This analysis combined clinical trials, cohort studies, and cross-sectional analyses, an inappropriate practice for meta-analyses.⁷⁹ Furthermore, the individual studies’ sources of bias could be compounded in a meta-analysis, possibly producing an incorrect result.⁷⁶

Cigarette Sales

For years, US cigarette sales declined 2% to 3% annually. More recently, as vaping product sales increased, cigarette sales decreased much more rapidly. Conversely, following the EVALI outbreak and e-cigarette sales restrictions, sales of e-cigarettes fell and sales of cigarettes resumed their prevaping pattern.⁸⁰ Studies finding a positive cross-price elasticity of demand between cigarettes and e-cigarettes support the conclusion that the products are substitutes.^81,82

Support for the plausibility of an inverse causal relationship between vaping and smoking comes from countries in which startling decreases in cigarette sales have accompanied rising sales of another novel nicotine product, heated tobacco products (HTPs). Like e-cigarettes, HTPs expose users to lower levels of toxicants than do cigarettes.⁸³ In Japan, HTP adoption from 2015 to 2019 was accompanied by cigarette sales declining by a third.⁸⁴ In both cases—HTPs in Japan and e-cigarettes in the United States—as sales of reduced-risk products rose, cigarette sales fell.

Unintended Consequences of Policies Restricting Vaping

Studies have found that policies intended to restrict e-cigarette use may have unintentionally increased cigarette smoking. One study associated a Minnesota e-cigarette tax with increased adult smoking and reduced cessation, estimating that taxing e-cigarettes at the same rate as cigarettes nationwide could deter 2.75 million smokers from quitting smoking over a decade.⁸⁵ Two other studies found state restrictions on minors’ access to e-cigarettes associated with higher adolescent cigarette smoking.^86,87

Implications

Although not the final word, the totality of the evidence indicates that frequent vaping increases adult smoking cessation. Smokers unable to quit smoking with evidence-based cessation methods⁸⁸ should be well informed about the relative risks of vaping and smoking and vaping’s potential to help them quit smoking. They should understand that, while the long-term health consequences are unknown, completely substituting vaping for smoking likely reduces health risks, possibly substantially.¹⁵ Dual use of cigarettes and e-cigarettes will not have a comparable beneficial effect.⁸⁸ However, a period of dual use may be necessary for some smokers to transition from smoking. Because vaping itself poses some risk, the best advice is to eventually stop vaping as well.

THE PRINCIPAL CONCERNS ABOUT YOUTH VAPING

The principal objections to vaping regard 3 potential effects on youths:

• •Vaping can cause nicotine addiction among young people who never would have tried smoking.
• •Vaping by never-smoking youths may cause some to try smoking, risking “renormalizing” smoking among young people.
• •Nicotine can harm developing brains, and vaping nicotine may have other adverse health effects.

Vaping as a Cause of Nicotine Addiction

Vaping likely addicts some young people to nicotine. However, the evidence does not suggest it is addicting very large numbers.⁸⁹ Jarvis et al. concluded that “Data . . . do not provide support for claims of a new epidemic of nicotine addiction stemming from use of e-cigarettes.”⁹⁰ Jackson et al. recently reported that the e-cigarette‒driven increase in nicotine product use among high-school students is not associated with an increase in population-level dependence.⁸⁹ Among tobacco-naïve youths, in addition to low vaping prevalence (9.1% in the past 30 days in 2020) and frequency (2.3% vaping ≥ 20 days in the past 30 days),⁹¹ small percentages exhibited signs of nicotine dependence.⁹⁰

Frequent use is much more common among current or former smoking youths than among never-smokers.⁹⁰ Many former smokers were already addicted to nicotine before initiating vaping. With high-school students’ smoking declining at an increasing rate since youths began using e-cigarettes,^92,93 some may vape to reduce or quit smoking.

Nonetheless, to the extent that vaping creates nicotine addiction among otherwise tobacco-naïve youths, concerted efforts are needed to reduce youth vaping. The new minimum age of 21 years for purchasing tobacco products should help.⁹⁴ Governmental agencies^3,95 and voluntary organizations^12,96 disseminate vaping’s risks to youths through Web sites, social media, and television campaigns. Voluntary organizations lobby Congress and state governments to adopt policies restricting youth access to e-cigarettes.

Recent policy attention has focused on restricting the availability of e-cigarettes with flavors,⁹⁷ a principal attraction for youths.^98–101 While flavor bans could reduce youth interest in e-cigarettes, they could also reduce adult smokers’ vaping to quit smoking.^102–104 Like youths, adults prefer nontobacco flavors,¹⁰⁵ both groups favoring fruit and sweet flavors.^106,107

Policies regarding flavors reflect the more general issue considered in this article: the need to create a balance between the sometimes-conflicting goals of preventing youth vaping and supporting adults’ smoking cessation attempts, particularly for smokers unable or unwilling to quit otherwise.¹⁰⁸

Vaping Causing Smoking Initiation

Prospective studies have found that young people who had vaped but never smoked cigarettes were more likely to have tried cigarettes several months to 2 years later than contemporaries who had neither smoked nor vaped.^15,109–113 Some commentators thus consider vaping a “gateway” into smoking.^114,115

Other observers believe the relationship reflects a “common liability”¹¹⁶: young people who vape are generally more prone to risky behavior¹¹⁷; hence, they might be more likely to try smoking even without vaping.^118–121 Three recent studies have concluded that vaping likely diverts more young people from smoking than encourages them to smoke.^122–124 Conversely, some prospective studies have found the vaping‒smoking relationship strongest in youths at low risk of smoking.^125–127

Obvious plausible correlates are often not considered, however.¹²⁸ Importantly, few studies include youths’ use of other psychoactive substances, including marijuana and alcohol. In 1 study, inclusion of marijuana and 3 other variables eliminated the otherwise statistically significant link between vaping and subsequent smoking.^126,127 Most studies do not even consider previous use of tobacco products other than cigarettes. Adjustment for confounders substantially reduces the relationship between vaping and subsequently trying cigarettes.¹²⁹

Numbers of cigarettes smoked at follow-up are frequently very low, only 1 or 2 in the past 12 months in one study.¹³⁰ Furthermore, the prospective studies generally have not examined progression to regular dependent smoking, with 1 recent exception.¹³¹ Only a small proportion of youths who experiment with smoking become regular smokers. Kim and Selya found that while e-cigarette use was associated with ever trying smoking, it was not associated with current continued smoking.¹¹⁹ Pierce et al. recently concluded the opposite.¹³¹ Shahab et al. reported that less than 1% of US students who initiated nicotine or tobacco use with e-cigarettes were established cigarette smokers.¹³²

If vaping causes some young people to try cigarettes, the aggregate impact must be small. A recent study⁶⁸ estimated that if vaping increases nonsmoking youths’ odds of trying cigarettes by 3.5 (as reported by Soneji et al.¹⁰⁹), smoking initiation among young adults would increase less than 1 percentage point. Furthermore, US survey data demonstrate that smoking among young people has declined at its fastest rate ever during vaping’s ascendancy.^92,93,133 If vaping increases smoking initiation, other unknown factors more than compensate.

Nicotine Harming Developing Brains

Animal model studies have found that nicotine can affect maturation of brain parts associated with executive function and decision-making, potentially leading to more impulsive behavior, cognitive deficits, and greater likelihood to self-administer other drugs.^134,135 In addition, there is evidence in humans of neurological changes attributed to nicotine in the brains of adolescent smokers, interpreted by some as reflecting similar harmful effects to those in the animal models.^136,137

These studies lead some researchers to suspect that adolescent nicotine use in any form may lead to long-term structural and functional brain changes with associated negative implications for cognition or impulse control.¹³⁸ However, given species differences and questions about the relevance of experimental animal nicotine dosing paradigms to human use patterns, the validity of extrapolation to humans is speculative. Whether impaired brain development with behavioral consequences occurs in young nicotine consumers is difficult to determine because of potential confounding of genetic and socioeconomic factors, the influence of other substance abuse, and the role of preexisting neuropsychiatric problems associated with youth smoking. Research has yet to isolate nicotine use in the adolescent years and then examine later sequelae. Still, concerns about brain function effects of nicotine exposure through vaping deserve serious examination.⁹⁸

Concerns About Youth Vaping in Context

Several considerations raise the question of whether, for youth as a whole, vaping creates dangerous levels of nicotine exposure that would not have occurred in the absence of vaping.

• •The large majority of nontobacco product‒using young people do not vape and, thus, have no nicotine exposure.⁹⁰
• •Among those who vape, most do so infrequently; many are short-term experimenters.⁹⁰
• •Frequent vaping is most common among current or former smokers, individuals already exposed to nicotine.⁹¹
• •The most dangerous form of youth exposure to nicotine, cigarette smoking, has declined at an unprecedented rate during the era of youth vaping.^92,93,133 Use of other tobacco products has declined as well.¹³⁹

Still, concerns emanating from substantial increases in youth vaping in 2018 and 2019 are readily understandable and important to address. A sizable decline in 2020 is encouraging.¹³⁹ We must continue monitoring youth vaping, learning more about potential harms and identifying effective prevention strategies. However, as public health groups, the media, policymakers, and the general public focus on youth vaping, vaping’s potential to help adults quit smoking too often gets lost. That may come at a significant public health cost. Fourteen percent of US adults smoke; smoking annually causes nearly half a million deaths. Anything that can reduce that toll deserves serious attention.

With the focus on youths creating an environment in which smokers believe that vaping is as dangerous as or more dangerous than smoking,¹⁴ many smokers struggling to quit may be unwilling to try vaping as an alternative. This likely translates into less smoking cessation than if smokers correctly understood the relative risks of vaping and smoking.

BALANCING CONCERNS ABOUT RISKS AND POTENTIAL BENEFITS

Research comparing vaping’s risks for youths with potential benefits for adult smokers has found the latter to dominate,⁶⁶ potentially avoiding the smoking-produced loss of tens of millions of life-years.^67,68 Vaping cannot end cigarette smoking. But vaping can complement tried-and-true methods of reducing smoking, including taxes on combustible tobacco products, smoke-free workplace laws, marketing restrictions, plain packaging with graphic warning labels, antismoking media campaigns, tobacco-21 laws,⁹⁴ and evidence-based smoking cessation treatment.⁸⁸

We believe the potential lifesaving benefits of e-cigarettes for adult smokers deserve attention equal to the risks to youths.¹⁴⁰ Millions of middle-aged and older smokers are at high risk of near-future disease and death. Quitting reduces risk.⁸⁸ Young people will not experience smoking-related (and conceivably vaping-related) chronic diseases for 3 decades, and likely not at all if they quit within a decade or 2. Social pressures to quit smoking will probably remain strong, and quitting aids may improve. Furthermore, as noted previously, the rate of smoking among young people has declined while vaping has increased.^92,93,133 Vaping may addict some youths to nicotine, but many fewer than popularly believed.^89,90

Seeking a Sensible Mix of Policies

To date, the singular focus of US policies on decreasing youth vaping may well have reduced vaping’s potential contribution to reducing adult smoking. Those policies include taxing e-cigarettes at rates comparable to cigarette taxes,¹⁴¹ decreasing adult access to flavored e-cigarettes that may facilitate smoking cessation,¹⁰³ and convincing the public—including smokers—that vaping is as dangerous as smoking.¹⁴

The public health objective should be to develop policies and interventions that both reduce youth vaping and increase adult smoking cessation.^{97,120,140,142} While an in-depth discussion of an optimal policy mix exceeds the scope of this article, we here present illustrative policies that would serve this objective. These are all in addition to conventional evidence-based prevention and cessation measures.

• •Tax cigarettes and other combustible tobacco products heavily; impose a more modest tax on e-cigarettes. Taxes should be proportionate to risk. A much higher tax on combustibles will encourage adult smokers to quit smoking or to switch to less expensive e-cigarettes. By raising the price of e-cigarettes, a modest tax will discourage their use by price-sensitive youths.¹⁴¹
• •Because both youth and adult smokers find e-cigarette flavors attractive,^{98   –107} banning all (or most) flavors risks reducing smokers’ use of e-cigarettes to quit smoking^102–104 at the same time that it reduces youth vaping.^99,101 An alternative would be to limit the retail sale of flavored e-cigarettes to adult-only outlets such as vape shops. An imperfect policy for either goal, this approach could benefit both.
• •Government agencies and health organizations should develop nuanced, targeted communications that emphasize the realistic concerns about youth vaping and, separately, the potential benefits of e-cigarettes as less-risky (but not risk-free) alternatives for adult smokers otherwise unable or unwilling to quit smoking.
• •The US Food and Drug Administration (FDA) should strictly regulate e-cigarette advertising and marketing, prohibiting all marketing directed at, or attractive to, youths and young adults, including all “lifestyle” advertising. They should limit advertising to a “switch” theme directed clearly, and exclusively, to adult smokers otherwise unable to quit smoking.
• •FDA should implement its thoughtful comprehensive 2017 plan,¹⁴³ mandating reduction of nicotine in cigarettes to levels incapable of sustaining addiction, while ensuring the availability of consumer-acceptable reduced-risk nicotine products. To achieve the latter, the agency should develop product standards for products like e-cigarettes, ensuring minimization of risk associated with the product class while maintaining consumer acceptability.

The Role of Nicotine in Tobacco-Produced Disease

FDA predicated its comprehensive plan on recognition of the continuum of risk in nicotine products.¹⁴³ Nicotine is the chemical in tobacco that fosters addiction. However, toxic constituents other than nicotine, predominantly in smoked tobacco, produce the disease resulting from chronic tobacco use.^143,144 Nicotine-yielding products vary in risk from FDA-approved nicotine replacement therapy products at the lowest end of the risk continuum to combustible cigarettes at the highest.

Unfortunately, the public has a distorted view of the dangers associated with nicotine per se. In a recent survey, 57% of respondents incorrectly agreed that “nicotine in cigarettes is the substance that causes most of the cancer caused by smoking.” Only 18.9% disagreed. (The rest answered “Don’t know.”)¹⁴ In a recent survey of physicians, 80% strongly, but incorrectly, agreed that nicotine causes cancer, cardiovascular disease, and chronic obstructive pulmonary disease.¹⁴⁵

CONCLUSIONS

We share the very legitimate concerns about youth vaping with the entire field of public health. Our goal is to put those concerns in perspective. We agree with former Surgeon General C. Everett Koop who, in 1998, urged that “[A]s we take every action to save our children from the ravages of tobacco, we should demonstrate that our commitment to those who are already addicted . . . will never expire.”¹⁴⁶ The latter appears at risk today.

While evidence suggests that vaping is currently increasing smoking cessation, the impact could be much larger if the public health community paid serious attention to vaping’s potential to help adult smokers, smokers received accurate information about the relative risks of vaping and smoking, and policies were designed with the potential effects on smokers in mind. That is not happening.

The need to pay attention to adult smokers is particularly important from a social justice perspective. African Americans suffer disproportionately from smoking-related deaths, a disparity that, a new clinical trial shows, vaping could reduce.³¹ Today’s smokers come disproportionately from lower education and income groups, the LGBTQ (lesbian, gay, bisexual, transgender, and queer or questioning) community,¹⁴⁷ and populations suffering from mental health conditions¹⁴⁸ and from other drug addictions.¹⁴⁹ Smoking accounts for a significant proportion of the large life expectancy difference between affluent and poorer Americans.^150,151 For smokers with serious psychological distress, two thirds of their 15-year loss of life expectancy compared with nonsmokers without serious psychological distress may be attributable to their smoking.¹⁵² Vaping might assist more of these smokers to quit.^148,153

To the more privileged members of society, today’s smokers may be nearly invisible. Indeed, many affluent, educated US persons may believe the problem of smoking has been largely “solved.” They do not smoke. Their friends and colleagues do not smoke. There is no smoking in their workplaces, nor in the restaurants and bars they frequent. Yet 1 of every 7 US adults remains a smoker today.

Smoking will claim the lives of 480 000 of our fellow citizens this year alone.