When the prime-time cameras caught Julia Louis-Dreyfus “vaping” an electronic cigarette at the 2014 Golden Globes ceremony, cries of disapproval arose from our nation’s capital. Representative Henry Waxman (D., Calif.), then the ranking member of the Energy and Commerce Committee, and Representative Frank Pallone Jr. (D., N.J.) told the president of NBC that they were “dismayed” that the actress was “sending the wrong message to kids about these products.”
In a bruising Senate hearing a few months later, Senator Jay Rockefeller (D., W.Va.) tore into executives of two major e-cigarette companies: “I’m ashamed of you. I don’t know how you go to sleep at night. I don’t know what gets you to work in the morning except the color green of dollars. You are what is wrong with this country.”
To listen to these reactions, you would never guess that e-cigarettes, battery-powered devices that produce an aerosol solution of nicotine free of carcinogenic tar, offer any health benefits to smokers. In truth, e-cigarettes have the potential to ignite a public-health revolution. But thanks to alarm over speculative dangers, misleading spin on facts, and outright misrepresentations of the evidence, various lawmakers and public-health officials threaten to dash that promise.
What is driving the controversy over e-cigarettes? At its core lies a tension between two camps: the precautionists and the pragmatists.
The former have several concerns about e-cigarettes. First, that the health risks of the products haven’t been fully established. Second, that e-cigarettes will “renormalize” smoking and undo the gains of five decades of anti-smoking advocacy. Third, that vaping among teens will serve as a “gateway” to their eventual tobacco smoking.
The critics’ anxieties are not without merit, but they need to be placed in the context of the good that e-cigarettes do by sparing nicotine-dependent individuals from carcinogenic smoke. Precautionists are unmoved by the harm that comes to smokers who have failed to quit but who cannot take advantage of less dangerous ways of using nicotine. Accordingly, this camp seeks heavy regulatory oversight by the FDA and bans on television advertising and on vaping in public.
The pragmatists, who advance a public-health approach called “tobacco-harm reduction,” support electronic cigarettes because the devices are much less harmful than the considerable harms of combustible cigarettes. Pragmatists are not fixated on whether vaping is completely safe but on whether it is safer for smokers than cigarettes are. They are willing to make policy trade-offs on the basis of cost–benefit analyses. Some pragmatists hope that the FDA will go so far as to deem e-cigarettes outside its regulatory purview altogether — a decision that the agency could theoretically make within the next few weeks or months but almost surely will not. Pragmatists also want states to tax e-cigarettes minimally if at all, to incentivize smokers to switch. Pragmatists do agree with precautionists about e-cigarettes on one point: The devices should not be sold or marketed to children.
One of the highest-profile precautionists in the U.S. is Thomas Frieden, director of the Centers for Disease Control, which oversees the nation’s anti-smoking efforts. “There is much we don’t know about e-cigarettes,” he often laments. But we do know quite a bit: foremost, that they don’t combust tobacco and so do not produce carcinogenic tars and disease-producing gases, including carbon monoxide, which increases the risk of cardiovascular disease. This advantage makes vaping at least 95 percent safer than smoking tobacco, according to toxicologists.
E-cigarettes work by heating a nicotine solution, or e-liquid, which contains, in addition to flavoring, a substrate called propylene glycol. The U.S. Food and Drug Administration generally regards propylene glycol as safe; it is used in toothpaste, asthma inhalers, nicotine inhalers, and many other foods and cosmetics. Still, epidemiologists should monitor its long-term effect, if any, on the health of e-cigarette users, since the devices have simply not been around very long.
Vapor can contain other harmful substances, but the amounts are very low compared with those in cigarettes. For example, traces of nitrosamines, which are known carcinogens, can be found in e-liquid, but they exist at levels comparable to those found in medicinal products such as nicotine gum and patches, and at concentrations 500 to 1,400 times lower than those in regular cigarettes. Cadmium, lead, and nickel may be present in e-cigarette vapor, too, but in amounts and forms considered non-toxic.
Formaldehyde, a carcinogen, is low to non-existent in vapor, but a report published in January in The New England Journal of Medicine gave a far different impression. Titled “Hidden Formaldehyde in E-Cigarette Aerosols,” the article demonstrated that when a vaping device was overheated at unrealistically high voltage settings, the vapor was contaminated by levels of formaldehyde five to 15 times higher than those found in cigarette smoke.
A huge swirl of media coverage followed: “E-cigarettes Can Churn Out High Levels of Formaldehyde,” said the headline at NPR; “E-cigarettes Can Produce More Formaldehyde than Regular Cigarettes,” warned the one in the Los Angeles Times; “High Levels of Formaldehyde in E-cig Vapor,” announced WebMD.com. In truth, no user would ever heat an e-cigarette high enough to produce the recorded levels of formaldehyde in the study, because the resultant vapor would be intolerably irritating to the throat. Indeed, when the researchers tested the device at a voltage level normally used by vapers, no formaldehyde, none, was detected. This reassuring detail was buried deep in the news stories.
What of nicotine? In its pure form, nicotine is highly toxic, but the level delivered by vapor is low compared with that in cigarettes, and at that low level it is generally benign in healthy people (pregnant women being a major exception). But Frieden of the CDC sounds the alarm: “Nicotine can cause serious damage to the developing brains of teens.” This is a wildly exaggerated statement based on experiments with rat brains. To be sure, no one endorses vaping by non-smoking teens, but to date, no researcher has demonstrated negative or lasting clinical effects of nicotine on adolescent cognition or behavior.
Misrepresenting the facts about e-cigarettes and instilling doubt about their superiority to cigarettes is a dangerous game. It keeps smokers inhaling deadly toxins. After all, why give up the combustible devil you know if vaping is just as bad?
Yet such fear-mongering is now a standard talking point of major health organizations. Here is the American Cancer Society: “Until these things are monitored and regulated, there’s a real potential risk for unexpected exposure to toxic chemicals.” And the American Lung Association is “concerned about the potential health consequences of electronic cigarettes.” Globally, the World Health Organization has called e-cigarettes a “threat.” In response, 53 international health experts wrote a joint letter urging the WHO’s general director to “resist the urge” to “control and suppress” electronic cigarettes by classifying them as equivalent to cigarettes for purposes of regulation.
In the U.S., the CDC, the nation’s lead public-health agency, is the most vocal and visible critic of e-cigarettes. Last March, it launched a 20-week ad installment called “Tips from Former Smokers.” In one of the ads we meet 35-year-old Kristy, who lifts up her pink sweater to reveal a nasty-looking scar on her chest. “I started using e-cigarettes but kept smoking. Right up until my lung collapsed,” she says, unmistakably implying that e-cigarettes made it happen.
But wait. As the CDC explains elsewhere, Kristy’s lung collapsed sometime after she used e-cigarettes for a few months, stopped, and then resumed smoking tobacco. There are no reported cases of e-cigarette use resulting in collapsed lungs. If anything, when smokers with asthma or chronic obstructive pulmonary disease switch to vaping, their lung function tends to improve.
To recruit someone for its ad, the CDC advertised a payment of $2,500 for “ex-smokers of any ethnic background who have been diagnosed with [a serious health condition] while smoking.” The agency could have sought out one of the thousands of smokers who now enjoy easier breathing because they were finally able to quit their cigarette habit by substituting e-cigarettes, but Kristy was a better fit for the CDC’s purposes.
The “gateway” theory mentioned earlier looms large in the CDC campaign. If vaping truly made young people more likely to progress to smoking, this would definitely be worth knowing. But there is no sign of a gateway effect, at least not yet. In fact, while more kids are vaping each year, teen cigarette consumption (measured as use of a conventional, combustible cigarette “at least once within the past 30 days”) continues to fall. Indeed, the latest CDC data, released mere weeks after the campaign launch, show a tripling in the rate of use of e-cigarettes by high-school students, from 4.5 percent in 2013 to 13.5 percent in 2014. Notably, this occurred in the context of a historic drop in the smoking of traditional cigarettes, from 12.7 percent of high-schoolers in 2013 to just 9.2 percent in 2014. (Do note, however, that the CDC measure of frequency — at least once in the past month — does not distinguish among teens who once tried a puff of a friend’s e-cigarette, those who were intrigued and experimenting, and those who were using it specifically to quit smoking.)
One cannot rule out the possibility that a gateway effect will manifest itself in the future — the CDC has been collecting data on e-cigarette use by teens for only four years — but the current numbers indicate that e-cigarettes are a gateway out of tobacco smoking for some teens and are diverting others from taking up the habit. So far, the CDC’s own data are encouraging, yet Frieden called them “shocking” and “alarming.” “This is another generation being hooked by the tobacco industry,” he told the New York Times.
Beyond the precautionary impulse, the war on vaping is also haunted by the specter of Big Tobacco. (E-cigarettes contain no tobacco leaf, but their nicotine is extracted from the plant.) The major tobacco companies Altria, Reynolds, and Lorillard now have e-cigarette lines and advertise their brands. That connection to the tobacco industry imparts too much of a taint to vaping, some public-health advocates insist. “Given the long history of tobacco-industry deception, such advocates assert that there can be no room for compromise when it comes to a product in which Big Tobacco has any interest,” wrote Amy Fairchild and Ronald Bayer, both of Columbia University’s School of Public Health, in Science.
Such anti-tobacco animus helps explain a glaring paradox within public-health circles: Many public-health experts avidly embrace harm reduction for other conditions — needle exchange and methadone for heroin addicts, “wet” public housing for people who continue to drink, condom distribution and HPV vaccination for sexually active adolescents — but, for nicotine addiction, they urge abstinence and downplay the importance of a less risky alternative.
There is also the question of money. The rise of e-cigarettes means lower profits for the pharmaceutical companies that make nicotine gum, patches, and anti-smoking medications, and less revenue for states that are addicted to cigarette taxes. For tobacco companies, each e-cigarette purchased means fewer cigarettes sold. It’s not surprising, then, that the profit-seekers have aligned with the prohibitionists to promote heavy-handed and costly FDA regulation that would suppress e-cigarette use and overwhelm the budgets of small, upstart vaping companies. Economist Bruce Yandle calls such collaboration between odd bedfellows the “bootleggers and Baptists” model of regulation, reminiscent of the days when both bootleggers and Baptists wanted saloons to be closed on Sunday — the bootleggers to boost illicit sales of alcohol, the Baptists to raise church attendance and preserve the Sabbath from dishonor.
In general, the prospect for electronic cigarettes is not as glowing as it should be. Only 8 percent of the nation’s 40 million smokers use them regularly. There are several reasons for this. For one, even the newest generation of e-cigarettes is not as satisfying as standard cigarettes, many smokers report. Also, the perception that e-cigarettes are dangerous is growing, thanks to menacing portrayals of them by precautionists. A report last year in the American Journal of Preventive Medicine showed that whereas nearly 85 percent of smokers in 2010 believed that e-cigarettes were safer than cigarettes, that number had dropped to 65 percent in 2013.
To be sure, there are instances in which concerns about quality control are warranted. Most vaping products are well made, but there have been reports of inaccurate labeling of e-liquids and of shoddy counterfeits, exported from China, that emit unacceptable levels of toxin in the vapor. The FDA can fix these problems by issuing standards for the production of e-liquids and for battery and electronics safety and by modestly regulating flavoring through a ban on diacetyl, which, when inhaled, can cause a rare form of obstructive lung disease. Also needed is childproof packaging that carries a warning: “This product contains nicotine, which is addictive and intended for adult smokers only.”
And more research on e-cigarettes must be done. We should monitor, for example, the possibility of a gateway phenomenon in case its manifestation lags years behind the documented teen experimentation already under way. Epidemiologists need to refine their survey questions to get a more nuanced understanding of usage patterns. Long-term effects, if any, of propylene glycol must be tracked, and so on.
The standoff between the precautionists and the pragmatists essentially boils down to their orientation toward risk — should we aim for none, or much less than there is now — and the moral connotations they attach to it. The contest will not be resolved readily because any vacuum of information leads those with a precautionary temperament to imagine worst-case outcomes, mass-produce reams of nervous commentary, and sanctimoniously call for tight restriction on the freedom to engage in novel practices.
The CDC falls squarely in the precautionist camp. It gives disproportionate weight to skeptics’ unsubstantiated claims about e-cigarettes as it minimizes their estimable benefit and foments panic. This is bad for smokers who have tried to quit and can’t, bad for the integrity of public health as a field, and bad for the credibility of the CDC, whose tarring of electronic cigarettes is a shameful violation of public trust.
The introduction and technological evolution of electronic cigarettes presents a golden opportunity for the agency to show the public the necessity of weighing tradeoffs. For those who have tried and failed to quit smoking tobacco, the CDC is basically saying, “Drop dead.” Its message to them should instead be “Thank you for vaping.”
– Sally Satel, M.D., is a resident scholar at the American Enterprise Institute. She has received no financial support from e-cigarette companies.