Lots of smoke, no fire
The evidence—but not the narrative—presented in the surgeon general’s e-cigarette report supports both potential benefits and potential harms from these relatively new products, both for users and for the public at-large. When one also considers the evidence Murthy’s team opted not to include, the case for potential public health benefits is far stronger than the evidence that suggests e-cigarettes are a threat.
The report frankly acknowledges that e-cigs are far less hazardous to users than traditional combusted tobacco cigarettes. The report also acknowledges that the increase in use of e-cigs has been concurrent with the most dramatic reductions in smoking ever recorded. Moreover, overall use by youth—which includes cigarettes, e-cigs and other tobacco and nicotine products—was essentially flat over the period studied from 2011 through 2015.
Chapter five of the report lists four ways in which availability of e-cigs could harm public health: increased exposure to nicotine; some users being led to start using combustible tobacco; slowing or preventing smokers from quitting; and increasing the likelihood former smokers will relapse to smoking. The facts that the dramatic increases in e-cig use has not increased overall tobacco use and that the vast majority of those who have switched to e-cigs are smokers show clearly that, on balance, e-cigs are reducing exposure to nicotine and, most likely, are a pathway away from smoking.
These findings, which are contained within the report, directly conflict the conclusion that e-cigs are a threat. In fact, the data strongly suggest that e-cigs may be the most means ever tried to reduce smoking and smoking-related addiction, illness and death in the United States.
The case in favor of e-cigs is even stronger when one considers the data that the surgeon general’s team decided not to include. One data point from a federally sponsored study the surgeon general’s report otherwise cites frequently is that about 80 percent of nonsmoking teens who try e-cigs use versions with no nicotine. Also omitted is the strong evidence showing likely benefits for both teens and adults who switch from smoking regular cigarettes.
Murthy’s report also fails to consider major flaws in the studies used to substantiate the conclusion that e-cigs represent a threat. In particular, the finding that heavy smoking was associated with e-cig use was considered as evidence that e-cigs led people to smoke, rather than that heavy smokers are attracted to e-cigs as a less harmful alternative to cigarettes.
The report castigates e-cig companies for promoting e-cigarettes as sexy or cool without recognizing that the Food and Drug Administration will remove from the market any e-cig product that claims possible benefits as a low-risk substitute for cigarettes or value for smoking cessation. This raises the question of what marketing strategies are permissible for e-cig manufacturers to advertise their products.
The surgeon general got it wrong. Rather than demonize e-cigarettes, public health authorities look for ways to partner with e-cig manufacturers to promote tobacco harm reduction, in concert with reasonable regulations to assure the quality and consistency of e-cig products and to prohibit predatory marketing.
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