Anti-smoking has gone too far: Harm reduction is better than prohibition
America’s misinformed war on vaping is helping tobacco companies, increasing crime, and hurting public health.
After decades of declining smoking rates among all ages, smoking is going up again. A combination of life in lockdown and a media inexplicably hostile to safer alternatives has been pushing Americans back to cigarettes. To save lives anti-smoking advocates need to step back and look at harm reduction instead of prohibition to save lives. Hyperbolic rhetoric attacking electronic cigarettes is not defending public health — it’s causing public harm.
Wilting sales of tobacco
Tobacco companies lost more money than usual in 2019. They’d been losing money and customers for decades but that year the trend accelerated. Altria, one of the largest tobacco companies in the world (just their Marlboro brand catches over 40% of the US market), expected sales volumes to shrink over 2018–2019 by the historical average of 3–4%. The actual figure hovered between 8.8 and 9.7%
According to the Financial Times, Billy Gifford, Altria’s chief financial officer, said at a conference in 2020 that the volume decline in tobacco sales had accelerated in 2019 “outside of the 3-to-4 per cent historical range”. The company now expected volumes to fall at an average annual rate of 4–5 per cent over the next five years “as adult smokers continue to explore alternative tobacco categories.”
Altria interpreted a great deal of “alternative tobacco categories” to mean electronic cigarettes. Research in several US states and multiple countries strongly supports this conclusion: People of all ages are choosing to quit regular cigarettes for electronic ones.
Vaping is an effective tool to quit smoking
Electronic cigarettes are so effective in weaning smokers from traditional tobacco that the UK’s National Health Service actually instructs doctors to encourage their smoking patients to switch to vapes. Smokers who want to quit can have them prescribed — and then buy an e-cigarette inside the same hospital. The NHS website explicitly states:
“Many people find e-cigarettes — also known as vapes — helpful for stopping smoking. E-cigarettes aren’t completely risk free but they carry a small fraction of the risk of cigarettes. Quitting with an e-cigarette is particularly effective when combined with expert face-to-face support.” — Britain’s National Health Service
Traditional smoking cessation methods hover far below 10% success rates; according to the European Respiratory Journal from group programs to the patch to medications to nicotine gum, fewer than one out of every ten people who use these will actually quit smoking. Several studies suggest that vapers can see as high as 50% successful quit rates. According to CathLab Digest, smokers are twice as likely to quit if they use vapes than not. JAMA Internal Medicine reports that “Daily electronic cigarette use appears to be helpful in initiating smoking cessation among persons who intend to quit tobacco.” The journal Addictive Behaviors published a study stating “Daily e-cig users were 3 times more likely to be quit than never e-cig users.”
The evidence is overwhelming: Fewer people are smoking in very large part because they vape instead.
At least, that was the case in 2019. Last year tobacco companies were much healthier than expected. In 2020, an economic lockdown, short-sighted government, and a grossly incompetent media have turned many people back to smoking.
A trend reversed
The downward acceleration of tobacco sales has been halted as the Wall Street Journal reports that Altria is now projecting more or less a return to their previous, pre-vaping trends. It seems that placing a stressed out population under house arrest without anything to do or anywhere to go, then making it difficult for them to buy vapes, returns them to smoking. In late May the journal of Nicotine and Tobacco Research published a study of five countries, including the United States, which concluded that nicotine use increased across the board during the lockdown. Besides, as Mr. Gilford explained on an Altria earnings call in June, “Fewer social engagements allow for more tobacco-use occasions.”
The tobacco industry’s good tidings began before the pandemic however. Last February, the Food and Drug Administration, trying to stem youth vaping, banned the sale of certain vape flavors, a move many states followed. State and federal health officials have repeatedly warned that sweet and fruity flavors are especially attractive to youth. Even if these bans didn’t predictably stimulate the black market and criminalize innocent people — a fact admitted even by the Massachusetts Tobacco Task Force — they also relied on ignoring the staggering amount of evidence that adults really like flavored vapes too.
The largest ever survey on the use of e-cigarette flavors by adult vapers reports “that regular use of multiple e-liquid flavors was associated with significantly higher odds of having quit smoking, with fruit and sweet flavors being the most popular choices among established long-term vapers.” Which could explain why, after the FDA halted the sale of those vape flavors, Altria executives recorded a significant number of adult vapers returning to smoking.“That consumer was faced with choices,” Mr. Gifford said. “It benefited the entire cigarette category.”
In the wake of increased taxes on vaping products all across the United States, the Journal of Risk and Uncertainty last year found “that higher e-cigarette tax rates increase traditional cigarette use and reduce e-cigarette use.” States trying to tax vapers into quitting instead turned them back into smokers, driving up sales.
In a bluntly-titled June 30 column “Buy Altria Stock Because Americans Are Smoking Cigarettes Again,” Barron’s reported that tobacco stocks are stronger than they have been for many years while “emerging markets” — like electronic cigarettes — “are weaker than they have ever been before.” And, according to Citigroup analyst Adam Spielman, “In the last two years investors were worried the cigarette industry was being disrupted by e-vapor. Currently, however, e-vapor sales are about 25% below last year’s peak.”
As a Wall Street Journal headline said last week: “During Covid-19, people went back to smoking.” The most perverse aspect, according to that WSJ article, is that many once-former smokers returned to smoking during 2020 in large part out of health concerns over e-cigarettes.
It turns out bad press does hurt
Vaping’s decline can in large part be attributed to a ton of negative press over the last few years. Michelle Minton, senior policy advisor at the Competitive Enterprise Institute specializing in tobacco harm reduction, has been covering tobacco policy for over a decade and says that the news coverage of vaping has been especially abysmal. “Science journalism is almost universally terrible,” she said over Skype, “but reporting on vaping is particularly bad.”
Compounding the bad headlines is the fact that, even after the record is corrected or, as is more likely, the press forgets the issue and moves on, the attitude of the public doesn’t change. “Conflicting headlines,” warns Minton, “inevitably lead to uncorrected headlines and a misinformed public.” When the national press, for instance, spent much of 2019 repeatedly misinforming the public about what was killing some e-cigarette users — they never corrected the facts. When a major study quoted in dozens of major news outlets retracts their major claim, falsely suggesting that vapes cause heart attacks, none of those same outlets reported on it. Of course the public incorrectly thinks that vapes are somehow the same hazardous equivalent to burnable cigarettes. Journalists have spent the last few years telling them exactly that — facts be damned.
To be clear, there is no evidence that would lead any honest person to conclude that e-cigarettes are as dangerous as traditional cigarettes. A short list of the organizations funding and publications showing clinical research stating this without qualification include: Cancer Research UK, Britain’s Royal College of General Practitioners, the British Medical Association, the British Lung Foundation; the New Zealand Minister of Health; the US National Academies of Sciences, Engineering, and Medicine; the American Association of Public Health Physicians; the Royal Australian College of Physicians; the French National Academy of Pharmacy; and the German Federal Institute for Risk Assessment.
To be equally clear, every case of vaping “related” deaths you had heard or read about in 2019, every single one, was caused by illegal usage of or tampering with electronic cigarettes and the liquids they contain. The CDC and the New England Journal of Medicine, while not ruling out the possibility that “something else” may have contributed, appear to be in agreement on this point: There is not a single documented case of a person dying from using an electronic cigarette as the manufacturer intended it to be used. In each and every one of the highly publicized vaping deaths the press breathlessly covered in 2019, the deaths were caused by modifications of the vaping device or the liquid used inside of it; not one of the deaths can be traced back to legal, responsible use of the products as the designer intended.
The rhetoric from tobacco control groups has become increasingly unhinged as of late as well. And with few exceptions, the press uncritically parrots the rhetoric. This isn’t new, it’s been happening for decades. In our national zeal to curtail smoking and eliminate youth tobacco use completely, we’ve gone soft on facts and hard on zero-tolerance.
No smoking and no facts
When the World Health Organization makes demonstrably ludicrous claims about smoking, repeated by the US Surgeon General and many others, such as “There is no safe level of exposure to second-hand tobacco smoke,” the world lets them get away with it. Not one of the innumerable TV anchors and newspaper reporters all over the world, nobody whose job it is to ask questions, stopped to ask, “Wait, aren’t there safe levels of uranium? How is it even possible for tobacco to be more dangerous than cyanide?” After all, even if the sentence itself bears no resemblance to reality, we’re trying to get people to stop smoking. Hyperbole for public health is okay.
Unfortunately, such illogical rhetoric is now presenting a serious problem for public health advocates. Whatever long-term health risks that electronic cigarettes may pose, they are not — literally cannot be — anywhere near as dangerous as combustible cigarettes. An extremely abridged list of the over 7000 dangerous chemicals commonly found in tobacco smoke but completely absent in e-cigarette vapor includes: tar, carbon monoxide, nitrogen oxide, hydrogen cyanide, ammonia, and uranium.
While saying that electronic cigarettes are healthy would be inaccurate, suggesting that they are in anyway equivalent to the dangers posed by traditional smoking is not only inaccurate, it is dangerously wrong. Negative comparisons between vaping and smoking demand a lot of evidence to be taken seriously.
A paper published late 2020 in the Mayo Clinic Proceedings stopped short of endorsing electronic cigarettes as a viable smoking cessation method but actively suggested that “harm reduction,” rather than prohibition, should be looked into by anti-smoking forces. Last month, in Preventative Medicine, another research paper unequivocally concluded that the decline of people ever “cigarette smoking accelerated once e-cigarettes entered the market.”
The National Academy of Sciences, Engineering and Medicine in 2018 released an over 600-page report concluding that vapes “are likely to be far less harmful than conventional cigarettes,” “that risk and severity of dependence is lower for e-cigarettes than for conventional cigarettes,” and that “when adult smokers use them to quit smoking, they offer an opportunity to reduce smoking-related illness.”
Most scenarios result in millions of individuals quitting smoking due to vaping. On average, vaping-induced quitters gain an extra 1.2–2.0 years of life compared to smokers who quit without vaping. — Oxford University’s journal of Nicotine and Tobacco Research, August, 2020
But in the wake of years of, to be undeservedly charitable, skeptical press coverage about the actual harms of electronic cigarettes, factually challenged public health campaigns have encouraged mistaken decision-making at all levels. The United States Postal Service now prohibits shipping vape products. Many states around the country and many countries around the world are raising the age of purchase for vapes, raising taxes on vape products, banning certain flavors, and just generally guaranteeing that more of their smoking citizens will die from an activity that they’re actively trying to quit.
Electronic cigarettes are not good for you. Anyone who isn’t already using a highly addictive chemical like nicotine is well-advised to never start and anyone who is should stop. But it is fundamentally dishonest to suggest that vaping is as bad as smoking. Anyone truly concerned for the lives of smokers should be ecstatic that a product the British government calls 95% safer than cigarettes is available to help smokers quit. The question is not whether or not vapes are completely safe; the question is are they safer than cigarettes. And they are. Demonstrably.
Smoking tobacco remains the single most effective predictor of negative health outcomes later in life. Any product with as great a track record at getting smokers to quit should be embraced by public health advocates. Would it be better if smokers didn’t substitute one addiction for another, even one less harmful? Of course. But spiting electronic cigarettes simply benefits real cigarettes. Vape flavor bans drive smokers back to cigarettes. Sudden and dramatic tax hikes on vapes send more people to buy tobacco. Banning vape shops and online vape sales means more people smoking. Making it harder for people to vape encourages them to smoke again.
Far too often, the perfect really is the enemy of the good: attacking vaping means defending smoking.
Thomas Brown is a writer and history teacher who quit nearly twenty years of smoking through electronic cigarettes. He writes about China, technology, and the media. Buy his first book, read his blog, or block him on Twitter.