Imagine a new miracle drug with the potential to prevent one third of fatal cancers, to avoid one in four deaths from cardiovascular disease and to provide relief for six million Americans suffering from serious lung disease. The side effects of this hypothetical treatment appear to be minimal and people can carry on with normal life while under treatment.
Imagine, too, that ordinary people will purchase this affordable drug at their own expense and on their own initiative in order to take personal responsibility for their own health—and even because they like it. That would be quite a breakthrough.
It turns out that such a product exists, but it just isn’t a medicine. The product is the e-cigarette and millions of adults have already benefited by switching from smoking to vaping or are on their way to doing so. These products are among the most significant public health innovations of modern times, and their successors have the potential to render the cigarette obsolete and end the worldwide epidemic of smoking-related disease.
A giant coalition is determined to impose actual or de facto prohibitions.
Of course, that is not the full story. However, preventing the harms of smoking is by far the most important part of the story.
Yet we have reached a point where a giant coalition of well-funded agencies, foundations, academics, activists, and health and medical groups is determined to persuade governments and regulators to impose actual or de facto prohibitions on this innovative and disruptive technology. At its apex, the World Health Organization is applauding and encouraging every country that introduces a prohibition—including India, where there are over 100 million smokers and where vaping, the much safer alternative, is now banned outright while cigarettes are available everywhere.
Their arguments deserve stronger scrutiny.
“Vaping Doesn’t Reduce Risks!”
First, more organizations are claiming that there is no reduction in risk in switching from smoking to vaping. For example, the American Heart Association says: “There are many unfounded beliefs that vaping is safer than combustible cigarettes.” And the chief medical officer for the American Lung Association told the New York Times that he “disputed the perception that e-cigarettes are a safer alternative.”
It is hard to convey just how false and dangerously misleading these statements are, yet they are coming from very large organizations endowed with highly trusted reputations.
We obviously cannot travel 50 years into the future and see what happened after several decades of use. However, we do know enough to be highly confident that the disease risk will be much lower. The evidence comes from the toxicology of e-cigarette aerosol compared to tobacco smoke (e.g., see Goniewicz et al. 2014 and Margham et al. 2016) and measures of exposure to toxins in the saliva, blood and urine of vapers compared to smokers and non-smokers (e.g., see Shahab et al. 2017 and Goniewicz et al. 2017).
The opposing health organizations will, at some point, face a reckoning.
In fact, these “exposure biomarkers” in vapers are reduced to a small fraction of smokers and close to the levels found in non-smokers or ex-smokers. On the basis of an assessment of this evidence, the UK’s Royal College of Physicians has said that the harms of e-cigarettes are “unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure.” The US National Academies of Science, Engineering and Mathematics said, after an exhaustive review, that “while e-cigarettes are not without health risks, they are likely to be far less harmful than combustible tobacco cigarettes.”
These are the best expert judgements available and nothing has changed to affect their conclusions. The opposing health organizations will, at some point, face a reckoning.
“Vaping Causes Lung Injuries!”
Second, there has been an outbreak of severe and sometimes fatal lung injuries associated with vaping, and this has prompted calls for outright prohibition and other tough measures to control e-cigarettes. Doesn’t that mean that vaping is pretty unsafe and invalidate the argument above? The long-term doesn’t matter if you could be struck down dead tomorrow.
Not so. These cases arise from the use of illicit-market THC vapes that contain thickening agents that damage the lungs when inhaled. These agents cannot be used in nicotine e-liquids and would serve no purpose if they were. The tell-tale signs of a discrete supply-chain problem were that the outbreak was specific in time (started in July 2019), place (United States) and symptoms (certain lung injuries).
The injuries did not happen to nicotine vapers in the rest of the world, despite widespread use since 2010. There is a vanishingly small chance that the same problems would appear independently in the completely separate supply chain for nicotine e-liquids.
There is every sign of a deliberate effort to keep doubt alive that nicotine e-liquids could be implicated.
These tragic injuries and deaths have nothing at all to do with the legal, regulated supply chain for the nicotine e-liquids that smokers are using to switch. It is always hard to prove intent, but there is every sign of a deliberate effort to keep doubt alive that nicotine e-liquids could be implicated, and that continues. The underlying problem is THC prohibition. This created an illicit market in THC vapes and made some people reluctant to tell investigators that they were using these products.
“Vaping Causes Widespread Addiction in Youth!”
Third, the anti-vaping advocates point out, the use of e-cigarettes has risen sharply among adolescents since 2017, reaching over one in four (27.5 percent) of US high school students in 2019.
This headline number, however, refers to “use at least once in the past 30 days”—so it covers some very different behaviors. A more detailed drill-down for 2018 shows that most of these adolescent vapers are infrequent users, and that their behavior is experimental and unlikely to lead to long-term dependence.
Further, the more frequent adolescent vapers are mainly those who also have used tobacco products. These young people may benefit if they are diverted away from smoking. Contrary to the “reefer madness” clarion calls about an epidemic of youth nicotine addiction, researchers have found little sign of teenage vaping uptake causing addiction (if dependence without significant harms can even be classified as addiction, which both I and the American Psychiatric Association’s diagnostic criteria for substance use disorders would dispute).
According to the authors of the drill down on 2018 youth data:
Data from the [US] Youth Tobacco Survey do not support claims of a new epidemic of nicotine addiction stemming from use of e-cigarettes […] Among current e-cigarette users who had never tried tobacco products, responses consistently pointed to minimal dependence.
“Vape Flavors Entice Youth!”
Fourth, authorities from the president of the United States down have suggested that e-cigarette flavors like mint, fruit, candy and desserts are the cause of adolescent vaping and that banning these flavors may stop teen vaping. In one trivial sense they are right: All vaping products are flavored and these flavors are integral to the product in much the same way that toppings are an essential part of pizzas.
Banning flavors is a small step short of a total prohibition. Research shows that non-tobacco flavors are extremely important to adults who are trying to migrate away from smoking. The issue is that while flavors are one factor in youth vaping, they are not the most important factor by far.
Research recently published by the US Centers for Disease Control and Prevention shows the most important reason given for vaping was “I was curious about them,” cited by 56.1 percent of adolescents who were exclusive e-cigarette users. “They are available in flavors, such as mint, candy, fruit, or chocolate” came a distant third, at 22.3 percent.
Academic work suggests that uptake of vaping is driven by two broad and more complex ideas: replacing cigarettes and by the “wider social environment.” Again, flavors play a role in each, but they are far from the most important factors. Without flavors, these products would lose most of their appeal to adults and no longer function as an effective alternative to cigarettes.
“Banning Vapes Is the Answer!”
Finally, we must beware of the harmful unintended consequences of dramatic and eye-catching policy interventions. We know from the War on Drugs and alcohol prohibition (and much else) that simply banning a product by law does not make it disappear: a common fallacy among lawmakers.
Instead, flavored e-liquids will be supplied by an illicit market, backyard mixing and internet imports from China. There may also be unwanted behavioral responses—adolescents may return to cigarettes, or adopt other risky behaviors. None of those making proposals for dramatic policy action have the faintest idea what would actually happen in practice. But more likely than not, more than 12 million adult vapers in the United States will be put at additional risk for minimal public health gain with youth.
The challenge is to make nicotine available in the least dangerous forms in a way that competes effectively with the most dangerous.
Adolescents are trying to do what adults do and we will never be wholly successful in stopping them. We should rely on three approaches: restricting access by controlling the age for legal sale and venues where products can be sold; preventing marketing, branding and packaging that is aimed at adolescents; and the use of communications about the risks of tobacco products targeted at young people.
The strategic question is whether nicotine is to be treated like a legal recreational drug and to take its place alongside caffeine and alcohol. In this case, the challenge is to make it available in the least dangerous forms in a way that competes effectively with the most dangerous.
If the prohibitionists just see e-cigarette and flavor bans as a step towards outlawing nicotine, they have a lot to learn and much harm will be done while they figure it out.