The recently released National Academies of Sciences e-cigarette report leads to an incorrect conclusion that e-cigarette use increases the risk of using traditional combustible cigarettes. E-cigarettes lead many teens away from smoking, but they lead very few teen non-smokers to cigarettes or to long-term use of any other nicotine product.
Despite the Academies’ vigorous and well-intended process to assure independence and unbiased study, they failed on both counts. However, blame does not lie entirely with the Academies; this is the fault of the tobacco control leadership of the United States, in both government and academia.
Long committed to the goal of a “tobacco-free society,” the CDC, FDA and those in academia who depend on federal funding for tobacco-related research have understood their role as protecting the public from harms posed by tobacco-related products. The problem, in the case of e-cigarettes and related vapor products, is their collective refusal to consider the possibility that such products could offer substantial public health benefits not likely achievable by other means.
All this is reflected in the difference between the major findings of the new report and newspaper headlines presenting the results. The report correctly supports the premise that these products are far lower risk than cigarettes and help smokers quit, but then incorrectly claims that e-cigarettes lead teens to smoking. The New York Times headline “Vaping Can Be Addictive and May Lure Teenagers to Smoking, Science Panel Concludes” is reflective of much of what the panel got wrong.
The case in favor of e-cigarettes leading teens to smoke is based on a set of nine similar studies, one of which was authored by a doctor who spoke for the panel on this topic. All these studies had the same set of methodological flaws guaranteeing the same incorrect conclusion. They compared teens who had experimented with e-cigarettes at baseline with teens who had not experimented with any tobacco-related product, then came back six to eighteen months later and saw that those who had experimented with the e-cigarettes had tried at least a single cigarette more frequently than the comparison group. They then erroneously labeled experimentation with a cigarette as “initiation of smoking.” None of the studies followed up to see if any of the teens in question ever smoked even one more cigarette. And shockingly, none compared these rates with teens who had tried cigarettes at baseline to estimate what these rates would have been if e-cigarettes had not been available.
These studies do, however, show that teens inclined to experiment with one tobacco-related product are more likely to experiment with others, compared with teens not inclined to such experimentation. But these studies provide no insight as to whether e-cigarettes lead teens to cigarettes.
Sadly, but perhaps unsurprisingly, the evidence demonstrating that e-cigarettes lead teen smokers and would-be teen smokers away from cigarettes was disregarded by the NAS panel. The strongest evidence comes from nationwide surveys done by the CDC, as well as the Monitoring the Future surveys sponsored by the Substance Abuse and Mental Health Services Administration. Both showed dramatic reductions in smoking prevalence concurrent with the increasing popularity of e-cigarettes. The MTF surveys also showed most e-cigarette experimentation by teens was with products containing no nicotine. Furthermore, almost all e-cigarette experimentation and virtually all continuing use was by teens who were already smokers.
The weight of evidence clearly shows that e-cigarettes and related vapor products pose far less risk of potentially fatal cigarette-related illness than cigarettes, that they are far more effective for long-term smoking cessation than the pharmaceutical options, and that their greatest potential benefit is in diverting teen smokers and those who otherwise would have become smokers away from cigarettes.
Additional research is needed help refine our understanding of the benefits and potential harms of e-cigarettes, how best to regulate them, and how best to incorporate them into ongoing tobacco-control programming. But no additional research is needed to answer the big questions, such as whether e-cigarettes should be promoted as an alternative to cigarettes, or whether e-cigarettes attract teens to smoking.
Despite the evidence, this panel report, the Surgeon General Report, and the websites of the CDC, the FDA, the National Institutes of Health and other tobacco control authorities all demean e-cigarettes and discourage their use.
All this, in turn, strongly suggests that it is tradition—not science—within the tobacco control community that drives their opposition to e-cigarettes.
Image credit: LezinAV