Make It Make Sense: The Confusing Terminology Around Safer Nicotine

October 12, 2022

Nicotine vapes contain no tobacco but are routinely called “tobacco products.” A 2019 lung disease outbreak is still known as “EVALI” (e-cigarette or vaping product use-associated lung injury), when nicotine vapes had nothing to do with it. The war of disinformation against tobacco harm reduction relies on a host of inaccurate and outright misleading terms that leave the public asking, “Make it make sense.”

So it’s welcome that a group of researchers from the UK, led by Dr. Sharon Cox, have created an initial version of an ontology of tobacco, nicotine and vaping products with the aim of reducing ambiguity and confusion in the field. “Ontology” means the attempt to categorize things by their nature and properties.

The misunderstandings are on an international scale. Dr. Cox explained on a podcast, “People are using the same terms to refer to different things or using different terms to mean the same thing.” With funding from Cancer Research UK, the group is developing an E-Cigarette Ontology (E-CigO) to include tobacco, nicotine and vaping products.

New nicotine delivery devices have revolutionized the field and made it necessary to develop a logical and consistent nomenclature. A dizzying number of terms are currently used. There’s tobacco harm reduction (THR), electronic nicotine delivery systems (ENDS), e-vapor products, reduced risk and safer nicotine products (SNP), and heat-not-burn or heated tobacco products. Classes of nicotine vaping products, also known as “e-cigarettes,” include “open system” vapes, such as box mods or vape pens, which can be refilled with e-liquids; pod systems that use nicotine cartridges; and disposables such as cigalikes. Other THR options include snus, an oral smokeless tobacco product contained in sachets; pharmaceutical-grade nicotine salt pouches and lozenges; and heated tobacco products containing a ceramic blade. Then there are combustible cigarettes, cigars, cigarillos and bidi. This is just a small sample—there are more!

Would people who smoke be as likely to use nicotine replacement therapies if they were labeled “tobacco products”?

Correct, clear classifications matter when combustible tobacco is estimated to contribute to a staggering global death toll of over 8 million per year. If people are to switch away from cigarettes and other high-risk nicotine options to those that are much safer, they need accurate descriptors. In addition, “How tobacco-related products are labeled influences the conduct and interpretation of scientific research. Lack of clarity around products has led to misunderstanding and disputes over the interpretation of data,” the researchers noted.

The researchers created subclasses of tobacco-containing products; combustible, heated and smokeless. In one figure for nicotine-containing products, they listed the modes of ingestion: inhaled, oral, nasal and transdermal.

In the controversial and divisive world of US tobacco control, standard terms can be utterly confusing and often dead wrong. The US Food and Drug Administration (FDA) classifies nicotine vapes as “tobacco products” because the nicotine in them is derived from the tobacco plant. But it does not classify patches, gums and inhalers (regulated as drugs under a completely different pathway from vapes) as such, even though their nicotine comes from the same source. Would people who smoke be as likely to use these nicotine replacement therapies if they were labeled “tobacco products”?

So why hasn’t the FDA corrected this obvious misnomer? Not doing so has allowed anti-vaping organizations like the Campaign for Tobacco Free Kids (CTFK) to perpetuate, by implication, the lie that vapes contain tobacco. Anti-vaping groups have weaponized this powerful, all-purpose lie at every turn to create confusion, whip up public support for vaping bans, pass restrictions on sales and flavors, and to unleash a drug war on nicotine users. CTFK has seized on this incorrect categorization to frame ending youth vaping as a fight to reduce youth tobacco use. “It sounds really bad when you say youth are using a tobacco product,” Cox said in an interview.

The Centers for Disease Control (CDC) is a powerful purveyor of this lie, too. In her response to the latest National Youth Tobacco Survey (NYTS), Deirdre Lawrence Kittner, director of the CDC’s Office on Smoking and Health, said, “It’s critical that we work together to prevent youth from starting to use any tobacco product—including e-cigarettes—and help all youth who do use them to quit.”

The CDC contributed much disinformation in 2019, when people became sickened with a mysterious lung injury. Originally the agency called it “vaping associated pulmonary injury” (VAPI), before adopting the infuriating and equally inaccurate term, EVALI. It’s built into the label that a cause of the condition is nicotine vapes. But the culprit was tetrahydrocannabinol (THC) cartridges adulterated with vitamin E acetate purchased off the street. There was no evidence that anyone got sick or died from using nicotine vapes.

An August 2021 letter signed by 75 multidisciplinary experts asked the director of the CDC, Dr. Rochelle Walensky, to rename the malady. They wrote, “…the name EVALI is ineffective and misleading as it does not provide health care professionals or the public with clarity and specificity regarding the sources of risk for these harms.” They suggested instead, “Adulterated THC Vaping Associated Lung Injury” (ATHCVALI). Walensky said no.

And as this poll shows, Juul, the media’s favorite scapegoat, was blamed for EVALI.

Creating an accurate ontology will empower people to choose safer alternatives, preventing smoking-related disease and premature death.

Chelsea Boyd asserted in an article for Filter, “The CDC’s failure to differentiate between e-cigarettes that deliver nicotine and those that deliver cannabis compounds, coupled with the insistence that legal nicotine products are involved, despite the lack of compelling publicly available evidence, makes it difficult to believe its actions are not politically motivated.” Boyd is right. Politics often play a role in naming health conditions that misinform, scapegoat and discriminate. HIV was originally termed “Gay-related immune deficiency” (GRID). There are now calls to rename “monkeypox” to avoid any racist insinuations.

Misinformation about vapes harms people who smoke. One study suggested that legislation arising from misstatements about EVALI and vapes in Massachusetts led to an increase in cigarette consumption. Another study concluded that CDC messaging around EVALI contributed to “a substantial portion of consumers believe that e-cigarettes are more harmful than cigarettes.” How many times does it have to be said? They are not. An official UK review of the evidence published this year affirmed once again, “In the short and medium term, vaping poses a small fraction of the risks of smoking.”

An important example of using a set of clarifying terminology can be found in the report Burning Issues: The Global State of Tobacco Harm Reduction 2020, published by Knowledge-Action-Change (KAC). The authors no longer describe nicotine vaping devices as “e-cigarettes,” writing, “The term is misleading for health professionals, politicians and the wider public, as it closely associates these new products with cigarettes.” Instead, the report uses the term “safer nicotine products” as a “collective expression for vaping, heated tobacco devices and Swedish style snus and other safer forms of smokeless tobacco.” Ditching the term EVALI, the authors created a new one: “vitamin E-related lung injury” (VITERLI).

Another new paper meanwhile proposes abandoning the word “smoker” in favor of people-first language.

Creating an ontology that accurately and unambiguously categorizes the wide array of safer nicotine products is vitally important and long overdue. It will empower people to choose safer alternatives, preventing smoking-related disease and premature death.



Photograph by Helen Redmond

Update, October 13: This article was edited to clarify that NRT products are regulated under a different pathway to vapes.

The Influence Foundation, which operates Filter, has received grants from both Juul Labs, Inc. and KAC. Filter‘s Editorial Independence Policy applies.

Helen Redmond

Helen is Filter's senior editor and a multimedia journalist. She is on the methadone, vaping and nicotine train. Helen is also a filmmaker. Her two documentaries about methadone are Liquid Handcuffs and Swallow THIS. As an LCSW, she has worked with people who use drugs for over two decades. Helen is an adjunct assistant professor and teaches a course about the War on Drugs at NYU. She lives in Harlem.

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