Tobacco Control Leaders Call for a Balanced Assessment of the Risks and Benefits of Nicotine Vaping

The role of e-cigarettes, or nicotine vaping products, in tobacco control has been controversial from the outset. Early divisions among public health experts led to polarized coverage in the media, confused messages to the public, and inconsistent policymaking between jurisdictions. For many authorities in the United States, the potential health harms of e-cigarettes and youth-vaping concerns were overriding considerations. For others (most notably in the United Kingdom), those risks have been balanced more explicitly against the potential benefits for smokers of easy access to nicotine vaping products. As more and better evidence becomes available and continues to accrue, some consensus should be possible on the individual elements of this complex policy question. It remains, however, a significant challenge to integrate that evidence into a holistic view of the major risks and benefits associated with nicotine vaping products.¹

In this issue of AJPH, 15 past presidents of the Society for Research on Nicotine & Tobacco—the world’s leading scientific society for the study of smoking—review the evidence underpinning US policy on nicotine products, mainly e-cigarettes. They briefly cover the health risks of vaping, the potential for e-cigarettes to increase smoking cessation, and concerns about youth nicotine vaping. The context is staggering success in reducing smoking rates to historic lows, especially among US youths, and the announcement of the aim to reduce tobacco use prevalence to less than 5% by 2030.²

These eminent authors conclude that the “singular focus of US policies on decreasing youth vaping” (Balfour et al. [p. 1661]) has been a distraction from the larger goal of tobacco control, namely reducing smoking and its harms. They point out that despite widespread experimentation, frequent use remains much more common among youths who smoke, and if vaping were to lead to more youth smoking then we would see some evidence of it by now. Population surveillance data show the reverse: youth smoking continues to fall and at a faster rate than before. It seems at least plausible that vaping has contributed to this decline, with vaping replacing smoking among US youths.

The authors also point out that the number of nonsmoking young people who might be at risk from the potential harms of nicotine addiction is far smaller than the number of smokers in the United States (1 in 7 of the population) at real and evident risk of serious harm from their smoking who could benefit from increased smoking cessation. To be clear, they are not arguing that vaping should be promoted as overall beneficial, just that a more appropriate balance should be struck between the likely potential harms and benefits.

The problem with the current focus in the United States on youth vaping is that many measures to discourage vaping, such as flavoring bans, taxes, and e-cigarette sales restrictions, may reduce smoking cessation and effectively protect smoking.^3,4

There is another risk in antivaping policies intended to protect youths. In seeking to tell a strong story, we are in danger of misleading the public. The authors contrast public perception with the conclusions of the US National Academy of Sciences and the Royal College of Physicians. Nearly half of Americans incorrectly believe e-cigarettes to be at least as harmful as smoked tobacco. The effect has been worsened by the EVALI (e-cigarette or vaping use-associated lung injury) outbreak caused by adulterated marijuana products and wrongly ascribed to nicotine vaping devices. The harm to health from this misattribution has had effects far beyond the United States and continues to this day.^5,6 The price is a high one, as smokers, doctors, and governments are put off supporting an approach to quitting that can be twice as effective as licensed medicines.⁷ Overemphasis of the risks of vaping leads to cognitive bias that means we are inclined to reject the benefits highlighted, for example, in the recent Cochrane review.⁸ Public health risks stealing the industry’s clothes, becoming the new merchants of doubt.

Balfour et al. offer a refreshingly clear policy prescription for the United States: the US Food and Drug Administration should implement its plan to reduce the nicotine in cigarettes while ensuring the availability of reduced risk products and should permit advertising only if it encourages smokers to switch; smoked tobacco should be taxed heavily and e-cigarettes only modestly; rather than banning flavored e-cigarettes, their sale should be confined to age-restricted vendors; government Web sites should address the concerns about youth vaping realistically and the benefits of smokers switching separately. In search of a model for a government’s realistic presentation of risks and benefits, we would do well to look to the example of New Zealand’s Quit Strong campaign⁹ and vaping facts Web site.¹⁰

Alas, one of the unintended consequences of highly successful tobacco policies in the United States, the United Kingdom, and elsewhere has been to increase inequalities. As Balfour et al. point out:

African Americans suffer disproportionately from smoking-related deaths. . . . Today’s smokers come disproportionately from lower education and income groups, the LGBTQ community, and populations suffering from mental health conditions. (p. 1667)

The authors suggest that to affluent Americans “today’s smokers may be nearly invisible” (p. 1667). If doctors, academics, and policymakers have few smokers among their friends and families, the task of making smoking obsolete may look almost done. And when they find their adolescent sons and daughters—youths for whom smoking cigarettes had become all but unthinkable—using new nicotine products, it is no surprise that they are alarmed, even though the use may be only short lived or occasional.

Balfour et al. are to be commended for their efforts to bring more light and less heat to tobacco policy. The arguments are framed in the US context but have obvious international relevance. We can only hope that their contribution is received well by open minds. Antivaping policies are underpinned by a commendable passion to protect youth welfare and a fear that the hard-won reductions in youth smoking could be lost. These legitimate concerns about harm must be balanced by recognition of the potential benefits for the multitude of people who still take their nicotine the old way and who are often also experiencing multiple disadvantages.