Top Misconceptions in Tobacco Harm Reduction – 2023

On August 15, Brian King, Director of the Food and Drug Administration (FDA) Center for Tobacco Products (CTP), acknowledged that there are opportunities for the CTP to educate consumers about the relative risks of tobacco products. By communicating that some tobacco products carry less risk with them than traditional cigarettes—such as electronic nicotine delivery systems (ENDS), heated tobacco products and oral tobacco products—the burden of smoking-related death and disease could be significantly impacted. King acknowledged that the CTP saw opportunities to improve how the FDA communicates the tobacco harm continuum to the public, which is a positive step forward. However, over the last decade, there has been an overwhelming onslaught of misinformation from academics, media outlets and public health agencies (including the FDA-CTP and Centers for Disease Control and Prevention), which has created confusion among consumers and significantly slowed tobacco harm reduction (THR) activities. Along with clarifying the existence and potential of switching to reduced-risk products, here are several other misinformation points that need to be acknowledged and incorporated into educational materials.

1. Misconception: Vaping is dangerous. First, if someone states that vaping is dangerous, ask what vaping means to them. Vaping is a verb, not a noun. Are they talking about THC? Nicotine? Or other forms? Many of the risks associated with vaping are not from vaping ENDS, also known as e-cigarettes. This is a crucial distinction to make when thinking about THR approaches. Additionally, there are now a few products that exist in the ENDS marketplace that have yet to be vetted by the FDA; those products should always be questioned until they successfully pass through the FDA evaluation process.
2. Misconception: ENDS products have just as many dangerous chemicals as cigarettes. This is simply untrue. Scientists have evaluated the potential toxicity of ENDS products and have determined that regulated ENDS products have such low levels of toxic substances that they are no different from medicinal nicotine inhalers, and where they do detect toxicity, it is nearly 450 times lower than in cigarettes.
3. Misconception: All tobacco or nicotine-containing products are equally bad for you. There is a continuum of risk used to explain relative risk across the spectrum of tobacco/nicotine products. Cigarettes and other combustible tobacco products are on the most potentially harmful portion of the spectrum. However, the risk levels drop significantly on the lower end of the spectrum, with ENDS, heat-not-burn and oral tobacco/nicotine products. These options approach the same level of risk associated with the use of nicotine replacement therapies (like nicotine patches).
4. Misconception: ENDS products do not help you quit smoking. A recent study has reviewed many publications on this topic and has determined that, for those interested in quitting smoking, replacing cigarettes with ENDS use increases the likelihood that the quit attempt will be successful.
5. Misconception: The e-cigarette- or vaping use-associated lung injury (EVALI) outbreak (2019-2020) was due to the ENDS products. During this period, nearly 3000 people were hospitalized with nearly 70 associated deaths. At the time, the largest medical information organization placed the blame squarely on the new ENDS products on the market, even naming the disorder after e-cigarettes. The cause of EVALI was later determined to be vitamin E acetate, which was an ingredient present in THC vaping products. Though this has been scientifically determined, the information has not been appropriately presented to the general public to dispel this misconception.
6. Misconception: The tobacco industry is targeting teens by introducing kid-friendly flavors and marketing directly to youth to draw them into using cigarettes. There are three misconceptions in this single sentence. First, the overwhelming number of ENDS products in the marketplace are from smaller companies (in the early years, they were small U.S. companies, but now these products are overwhelmingly manufactured in China). The large tobacco and nicotine manufacturers abide by the rules and regulations of the FDA-CTP. In products manufactured by large tobacco companies, non-tobacco flavors ENDS pods are not specifically marketed, and are defined only by the flavor context (i.e. mint, mango, etc.). Finally, there is no data that suggests that, either directly or indirectly, the use of ENDS products leads to initiating combustible cigarette use.
7. Misconception: Young people are attracted to vaping ENDS products due primarily to the flavors. Recent studies have shown that the primary motivation for youth to try vaping ENDS is to relieve stress and influence from their peers. Flavor is on the list but would be listed as a factor well below the first two.
8. Misconception: Non-tobacco-flavored ENDS products are not important tools in aiding adults move from combustible tobacco to reduced-risk products. This claim has been debunked as well. Several recent studies have shown that in those who are interested in quitting smoking, ENDS product users are more successful.
9. Misconception: Nicotine is harmful. Individuals, even well-educated physicians, mistakenly believe that nicotine causes cancer. Nicotine as a chemical (separate from smoking) has been shown to be relatively benign in healthy adults. When nicotine is delivered through reduced-risk products, the potential adverse health effects are greatly reduced, especially compared to continued use of cigarettes.
10. Misconception: Vaping ENDS products leads to more addiction than smoking cigarettes. The question around the potential of addiction to nicotine is a complex one, but in terms of ENDS being “more addictive,” it is inaccurate. Of individuals who try cigarettes, well over half continue to use them, at least temporarily, daily. The data on non-smokers who try ENDS products and become addicted is suspected to be very low, but the health-related consequences of any potential use of ENDS products are much less damaging in comparison to cigarettes.