A recent landmark article offers a rare balanced look at vaping in the U.S.
By Cheryl K. Olson
In the 1930s, there was considerable handwringing among politicians and academics about how gangster films would turn an entire generation of teenagers into thugs and thieves. After a few years, film scholars recognized that it was a moral panic—a widespread and irrational fear supported by emotions rather than by scientific data. They moved on.
In the 1950s, sociologists feared that crime and horror comic books would destroy the morals of that era’s youth. There were U.S. Senate hearings on whether they should be published as well as mass comic book burnings around the country. After a few years, sociologists recognized that it was a moral panic. They moved on.
In the early 21st century, a popular London-based tabloid claimed that video games are as addictive as heroin and that “Britain is in the grip of a gaming addiction, which poses as big a health risk as alcohol and drug abuse.” On the other side of the Atlantic, then-Senator Hillary Clinton claimed that “violent video games increase aggressive behavior as much as lead exposure decreases children’s IQ scores.” It was, psychologists have largely concluded, another moral panic with echoes that remain in today’s public policy.
We may have just seen the turning point on the moral panic surrounding vaping. Writing in the August issue of the American Journal of Public Health (AJPH), 15 former presidents of the Society for Research on Nicotine and Tobacco (SRNT), the world’s leading scientific organization for the study of smoking, concluded that concerns about youth vaping are overblown and may be undermining attempts to get current combustible tobacco users to quit. The much-touted fears are simply not supported by the data.
Rebalancing the Conversation on Vaping
As the title—“Balancing Consideration of the Risks and Benefits of E-Cigarettes”—suggests, the authors were particularly concerned about the public’s misunderstanding of the products’ relative risks.
“Of respondents to a 2019 national survey, nearly half considered vaping nicotine just as harmful as or more harmful than cigarette smoking,” they wrote. “Only one in eight considered vaping less harmful. (The rest responded, ‘I don’t know.’) By contrast, the U.S. National Academies of Sciences, Engineering and Medicine and the British Royal College of Physicians have concluded that vaping is likely far less hazardous than smoking cigarettes.”
In the U.S., youth vaping prevention programs have done their work too well. In recent years, the tone of coverage of vaping, in academic journals and news media, has gone from a mix of curious, skeptical and optimistic to a presumption of acute danger. A 2018 content analysis of 2015 news coverage of e-cigarettes, published in Nicotine & Tobacco Research (the SRNT’s journal), noted that “quoted physicians, researchers and government representatives were more likely to refer to e-cigarette risks than benefits” in the run-up to U.S. Food and Drug Administration regulation.
They presciently cited concerns about harm from this increasingly negative media coverage: “While the news media is an important vehicle for informing the public about the potential risks of these new products, it has also been argued that news stories that focus only on risks without contextualizing their risks relative to cigarettes or discussing their harm reduction benefits may contribute to misperceptions about the risks of these products.”
“Contextualizing the risks”—in other words, framing the issue affects the terms of the debate. For example, we’ve seen the framing of flavored vapes shift as public opinion on vaping soured. The initial focus on eliminating child-attracting names, imagery and packaging (sugary breakfast cereals, cartoons, baby bottle shapes) morphed into suspicion of fruit flavors in general and then to all nontobacco flavors. This gradual shift masks the absurdity of mandating that nicotine stay linked to the taste of cigarettes, when the goal is to wean people off them.
While no one who looks at the data would claim that vaping is safe or that nonsmokers should start, the 15 AJPH authors put our concerns into perspective. The melodramatic public service announcements implying that vaping will disfigure your face and send eel-like creatures to invade your brain or that it “can escalate teen mood swings” are as irrelevant as the much-mocked Partnership for a Drug-Free America’s series of “This is your brain on drugs” public service announcements from the 1980s featuring sizzling fried eggs.
Smokers Are Still Here
Smoking remains a massive and challenging public health problem. In the United States alone, nearly a half-million people will die this year from smoking-related illness. The headlines and health campaigns about smoking may be gone, but smoking is not.
In the AJPH authors’ eloquent phrasing, “To the more privileged members of society, today’s smokers may be nearly invisible. Indeed, many affluent, educated U.S. persons may believe the problem of smoking has been largely ‘solved.’ They do not smoke. Their friends and colleagues do not smoke. There is no smoking in their workplaces nor in the restaurants and bars they frequent. Yet one of every seven U.S. adults remains a smoker today.”
The stalled decline in adult smoking rates gets little attention in academic journals. One 2017 study (Zhu S et al. – “Smoking prevalence in Medicaid has been declining at a negligible rate.”) found that about a third of people on Medicaid (who must have incomes below a certain threshold and often deal with chronic physical or mental illnesses) are smokers; their quit rates were basically flat from 1997 to 2013.
As part of restoring balance between vaping’s youth risks and adult smoker benefits, the 15 AJPH authors bring up smoking as a social justice concern. For example, “African Americans suffer disproportionately from smoking-related deaths, a disparity that, a new clinical trial shows, vaping could reduce.”
Further, “Smoking accounts for a significant proportion of the large life expectancy difference between affluent and poorer Americans. For smokers with serious psychological distress, two-thirds of their 15-year loss of life expectancy compared with nonsmokers without serious psychological distress may be attributable to their smoking. Vaping might assist more of these smokers to quit.”
I shared the AJPH article and related material with someone whose business is specially designed e-cigarettes for incarcerated persons, replacing various types of dangerous contraband combustible tobacco. Watching the short video that accompanies the article, produced by the University of Michigan School of Public Health and featuring study co-author Kenneth Warner, made her staff literally stand up and cheer.
The 15 researchers’ conclusions bode well for helping those who are addicted to combustible tobacco and who will not or cannot yet quit. Vaping provides a reduced harm pathway for providing the nicotine that smokers’ brains crave without most of the extremely dangerous combusted byproducts of tobacco. The contents and existence of this landmark article are a reason to celebrate—not for us but for the smokers whose lives may be saved.
Why is it important that these authors are past presidents of the Society for Research on Nicotine and Tobacco? Because this is not an organization known for friendly relations with the nicotine product industry. But they looked at the data and are moving on.
The New Merchants of Doubt
An interesting commentary accompanied that American Journal of Public Health consensus statement by 15 respected experts. In it, Martin Dockrell and John N. Newton worry that the drumbeat of concern about vaping’s risk “leads to cognitive bias” that makes us discount evidence of benefits. For this mindset, they use an interesting and potentially stinging turn of phrase: “Public health risks stealing the [tobacco] industry’s clothes, becoming the new merchants of doubt.” This references the famous 2010 book Merchants of Doubt: How a Handful of Scientists Obscured the Truth on Issues from Tobacco Smoke to Global Warming.*
Dockrell and Newton are not the first to label e-cigarette critics as merchants of doubt (just as I’m far from the only person to call moral panic on youth vaping). But it’s quite another thing to sling that history-laden insult in the editorial pages of the venerable American Journal of Public Health.
Merchants of Doubt tells the story of how the tobacco industry pioneered the creation of controversy and uncertainty in the face of general scientific consensus. “How could the industry possibly defend itself when the vast majority of independent experts agreed that tobacco was harmful and their own documents showed that they knew this?” asked authors Naomi Oreskes and Erik M. Conway. “The answer was to continue to market doubt.”
This approach of creating controversy and marketing doubt was copied by other industries, including to deny global warming. They describe the industry’s “key insight: that you could use normal scientific uncertainty to undermine the status of actual scientific knowledge. As in jujitsu, you could use science against itself.”
For example, longitudinal studies may well uncover yet-unknown health risks of vaping for certain types of products or use patterns or people with certain genetic makeups. Because vaping is new and the technologies are still evolving, it will take decades to collect the kinds of evidence we have now about smoking. The new merchants of doubt take advantage of that to play up the inevitable uncertainty about risks, blowing smoke to obscure the fact that today, the “vast majority of independent experts” agree that vaping is a far less dangerous alternative.
For decades, the hero’s narrative was public health against Big Tobacco, charging ahead, the good guys beating back lies from the bad guys promoting disease and death. Now, 15 Society for Research on Nicotine and Tobacco past presidents invite us to look up from the haze of that long battle and consider how positions have altered. Some public health advocates may now be engaged in the wrong fight. Or worse, we may be fighting on the wrong side. —C.K.O.
*Oreskes N, Conway EM. Merchants of Doubt: How a Handful of Scientists Obscured the Truth on Issues from Tobacco Smoke to Global Warming, Bloomsbury Press, 2010.