In 1964, the United States surgeon general released the landmark Smoking and Health report, which highlighted smoking-related risks that were then little known. In the 60 years since, smoking rates have dramatically declined. Yet the US continues to struggle to eliminate smoking-related diseases, which still claim over 480,000 lives each year.
US public health agencies are resistant to adopting technological advancements which could reduce harms for tens of millions of people who are unable or unwilling to quit nicotine. These agencies are thereby not only betraying their mission statements, but disregarding decades of their own findings, thanks to a chronic case of mission creep.
The US Department of Health and Human Services (HHS) had been concerned about harms related to combustible cigarette use since at least the 1950s. The 1964 publication of the Surgeon General Advisory Committee on Smoking and Health report, which linked smoking with real health harms, led to the 1965 establishment of the unit that later became the Office on Smoking and Health (OSH) at the Centers for Disease Control and Prevention (CDC), under HSS.
The mission of OSH is to “develop, conduct, and support strategic efforts to protect the public’s health from the harmful effects of tobacco use.” The office envisions a “world free from tobacco-related death and disease.”
It’s notable that while earlier government reports focused heavily on the harms of combustible cigarette use, this later changed.
Since the 1964 report, over 30 more surgeon general reports related to tobacco or nicotine have been published.
Reviewing many of these reports’ hundreds of pages makes it evident that for a long time, US public health agencies have recognized that nicotine, though its use can lead to dependence, is not among the significantly harmful constituents of cigarette smoke.
More recently, we can find years of recognition that nicotine products exist on a continuum of risk, with combustible cigarettes positioned at the most harmful extreme.
It’s notable, however, that while earlier government reports focused heavily on the harms of combustible cigarette use, this later changed.
The most recent surgeon general’s report in which the principal focus was informing the public of harms caused by smoking was in 2014. More recent reports have instead placed a heightened emphasis on youth use of noncombustible nicotine products.
“Ending cigarette use; ending the use of the most harmful tobacco products; or ending the use of all tobacco products?”
That 2014 report—The Health Consequences of Smoking—50 Years of Progress—indicated a “general acceptance of a continuum of risk across tobacco products,” the term used for nicotine products whether or not they contain tobacco. It noted that the “complex chemical mixture of combustion compounds causes adverse health outcomes.”
The same report deliberated on the steps needed to “end the tobacco epidemic.” It presented three differing approaches, asking whether the priority should be: “ending cigarette use; ending the use of the most harmful tobacco products while reducing the harm of remaining products; or ending the use of all tobacco products.”
These approaches were not new 10 years ago, however. Fourteen years earlier, in the 2000 Reducing Tobacco Use report, the surgeon general examined the potential of litigation against the tobacco industry, suggesting that legal outcomes could “encourage the manufacture of safer (to the extent possible) products, which have lower liabilities.”
These products, it suggested, could include “noncarcinogenic nicotine delivery device[s],” which would retain any risks related to nicotine specifically, while creating “less liability both to individual users and to third party health care payers.”
Yet the most recent Smoking Cessation surgeon general report—published in 2020, after the surgeon general and US public health agencies declared a youth vaping “epidemic” in late 2018—erroneously claimed that there is “inadequate evidence that e-cigarettes, in general, increase smoking cessation.”
“The potential benefit of e-cigarettes for cessation among adult smokers,” the 2020 report emphasized, “cannot come at the expense of escalating rates of use of these products by youth.”
This encapsulates US public health agencies’ recent overemphasis on youth use to the point of exploitation.
By the time the last surgeon general’s report was issued, vaping was already decreasing among US middle and high school students, having peaked in 2019. In 2020 13.1 percent used vapes—a 34.5 percent decline from the previous year. Since then, youth vaping has fallen an additional 41.2 percent, with only 7.7 percent of US middle and high school students using nicotine vapes in 2023.
Amid hundreds of thousands of annual smoking-related deaths, US public health continues to fixate on reducing youth vaping, at all costs.
The 1964 surgeon general’s report on smoking was heavily influenced by Smoking and Health, a report published two years earlier by the United Kingdom’s Royal College of Physicians (RCP). In 2016, RCP published Nicotine Without Smoke, examining vapes.
RCP found vapes to be effective smoking cessation tools, with any harms from their use “unlikely to exceed [5 percent] of the harm from smoking tobacco.” RCP even advocated promoting the use of vapes “in the interest of public health.”
If our true priority is a “world free from tobacco-related death and disease,” the path forward should be clear. Yet amid hundreds of thousands of annual smoking-related deaths, US public health continues to fixate on reducing youth vaping, at all costs.
If US public health agencies are to honor their mission statements, they must stop ignoring tobacco harm reduction. They must recall decades of their own findings in pursuing appropriate, up-to-date ways to reduce harms for people who smoke. This will require acknowledging how and why they disastrously lost sight of their original goals.
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