Uneducating Americans on Vaping: False ideas about comparative risk result in deadly ignorance.

• Author: Rich, Jacob James
• Position: HEALTH & MEDICINE

Cigarette smoking continues to be a leading cause of avoidable death in the United States. Nearly half a million Americans die each year from smoking-related diseases according to the Centers for Disease Control and Prevention. Understandably, this makes reducing smoking and discouraging youth smoking significant public health priorities.

Fortunately, there are less dangerous ways for smokers to satisfy their nicotine habits than smoking cigarettes. Electronic cigarettes and other vaping products (so-called "electronic nicotine delivery devices" or ENDS) appear to be a substantially safer substitute for combustible cigarettes. Such products can even help some smokers quit altogether. Yet too few people know this, and the ignorance appears to be getting worse.

Since the Food and Drug Administration began regulating ENDS as "tobacco products," public understanding of the relative risks of various tobacco products has declined. The FDA and many other expert authorities accept that there is a "continuum of risk" and that vaping is less dangerous than smoking. Yet, a majority of Americans do not understand this to be true. Smokers in particular do not realize there are less dangerous alternatives to combustible cigarettes--alternatives that could save their lives.

What explains widespread and worsening understanding of the relative risks of vaping? And what can be done about it? Improved messaging and public statements from public health authorities could help, but we are unconvinced such efforts would be enough. The ability of government messaging to inform consumers is inherently limited, particularly when public trust in institutions is flagging. As we explain below, educating Americans about the relative risks of tobacco products may require rethinking the way we classify and regulate such products and in particular allowing those with an economic interest in educating Americans about the relative risks of nicotine products to do so.

A LESS UNHEALTHY NICOTINE PRODUCT

ENDS have been available in the United States for over 15 years. What distinguishes these products from traditional cigarettes is that they do not involve combustion. Instead, such products heat a liquid solution, often containing nicotine and some sort of flavoring, to generate a vapor not unlike the vapor generated by the smoke machines used in some theatrical productions and dance clubs. Users inhale the vapor much like a cigarette user would inhale smoke--hence the name "vaping."

Because vaping devices do not involve combustion, they appear to be substantially less dangerous to the user (and others) than traditional combustible cigarettes. The user is not exposed to the myriad contaminants and other combustion byproducts found in cigarette smoke. Thus, as the FDA has acknowledged, consuming nicotine via vaping is "of less risk to the user than the inhalation of nicotine delivered by smoke from combusted tobacco products."

Existing research on ENDS consistently demonstrates that they pose fewer risks to users and others than combustible alternatives. As a 2018 National Academies of Sciences report concluded, "There is conclusive evidence that completely substituting e-cigarettes for combustible cigarettes reduces users' exposure to numerous toxicants and carcinogens present in combustible tobacco cigarettes," and "there is moderate evidence that second-hand exposure to nicotine and particulates is lower from e-cigarettes compared with combustible tobacco cigarettes."

Substantial research further shows that vaping products like e-cigarettes at least have significantly safer short-term outcomes. For example, a 2017 study by Lion Shahab et al. published in the Annals of Internal Medicine concluded that former smokers who completely switched to ENDS had significantly lower levels of carcinogens in their salivary and urinary samples compared to current smokers. Research published the next year by Maciej Goniewicz et al. in JAMA Network Open supported these results, finding that within a year of cessation the levels of carcinogens found in the blood samples of former smokers who completely switched to e-cigarettes closely reflected those of people who were never tobacco users. Such findings (and others) have motivated historically anti-tobacco institutions like Public Health England to make the bold claim that e-cigarettes are 95 percent safer than conventional cigarettes.

Although ENDS' long-term health consequences are largely unknown, there is a fairly broad consensus that vaping devices are significantly safer to consume than conventional cigarettes and that convincing smokers to switch to ENDS would save lives. A 2018 study by David T. Levy et al. in Tobacco Control estimated that if every American smoker switched to e-cigarettes over a 10-year period, approximately 6.6 million premature deaths from tobacco would be avoided.

Not only are ENDS less dangerous than combustible cigarettes, but there is growing evidence that they can help some smokers reduce their cigarette consumption if not quit altogether. Multiple studies have found that ENDS are more effective at assisting smokers to quit than are FDA-approved nicotine replacement therapies (NRTs) such as patches and gum. A literature review by Jamie Hartmann-Boycea et al. for the Cochrane Library concluded that e-cigarettes were approximately 70 percent more effective in helping smokers to quit than traditional nicotine-replacement products. Additional research suggests that the availability of ENDS even helps reduce smoking by adult smokers who had no intention to quit. As a recent review by David J.K. Balfour et al. in the American Journal of Public Health concluded, "Although not the final word, the totality of the evidence indicates that frequent vaping increases adult smoking cessation."

Among the public health considerations for e-cigarettes, the implications for pregnant mothers and their children might be the most visible. An abundance of literature shows that smoking during pregnancy leads to adverse outcomes such as low birth weights, complications that lead to miscarriages and premature births, and obesity during childhood. Some of these effects may be related to nicotine exposure in utero, but most of the research indicates that these adverse outcomes during pregnancy are much more related to mothers inhaling carbon monoxide from combustible tobacco products like conventional cigarettes. In particular, an American Journal of Obstetrics & Gynecology article by Brendan P. McDonnell et al. that reviewed the outcomes of 129 live births at Coombe Women and Infants University Hospital in Ireland among women who exclusively used e-cigarettes found that their babies' measurements were similar to nonsmokers and larger than cigarette smokers, with no cases of serious maternal morbidity. These results have been continuously replicated. A study by Suzanne Froggatt et al. in The Lancets eClinicalMedicine reported:

Birth outcomes, namely birthweight, gestation and head circumference, did not differ for e-cigarette exposed...