Over the past five years, tobacco control advocates have begun to strategize about a Tobacco Endgame, which envisions a tobacco-free future. Last week, the surgeon general played a pair of aces: kids and nicotine. This surgeon general’s report was released alongside a public service announcement that added a twist: Nicotine represents the most profound threat to kids because of their developing brains. E-cigarettes, says the announcement, are nothing short of a dangerous experiment with children’s brains.
But while there is good cause for remaining vigilant, neither kids nor nicotine represent a trump card in an ongoing feud about the place of e-cigarettes in the battle against smoking — the major killer of the past century.
In the first federal review of the impact of e-cigarettes on youth, Surgeon General Vivek H. Murthy struck the standard American tobacco control posture: Stress the risks to nonsmokers, bystanders and, above all, youth. He has good reason to be worried. CDC data demonstrate that rates of e-cigarette experimentation have tripled. These figures are notable because nicotine and other drugs are harmful to the developing brain. And addictions formed in adolescence may become lifelong habits.
Yet on Dec. 13, less than a week after the surgeon general’s report was released, the University of Michigan’s Monitoring the Future study showed that e-cigarette use is declining among teens for the first time, suggesting that youth vaping may not be as rampant as feared. This study — now in its 42nd year — surveyed tens of thousands of eighth-, 10th- and 12th-graders across the US.
E-cigarette advocates argue that these devices can play an important role in reducing the harm to 36.5 million American smokers who cannot or will not quit cigarettes. They believe that e-cigarettes are an innovative tool that can allow smokers to satiate their nicotine addiction without exposure to the dangerous chemicals, tars and carcinogens in cigarettes. Opponents worry that e-cigarettes may undermine decades of tobacco control measures. But there is one thing on which both sides agree: Adolescents shouldn’t be vaping, and they shouldn’t be smoking.
But it is also important to put those risks in perspective. The worry that e-cigarettes will provide a gateway to combustible products has so far remained hypothetical. The same CDC report that the surgeon general used to sound an alarm of e-cigarettes demonstrates a steady decline in smoking. Among children and adults, smoking has reached all-time lows.
While the long-term risks of e-cigarettes are not precisely known, the point of comparison is the risk of smoking. And there is broad scientific agreement that e-cigarettes — while not risk-free — represent a far lesser harm. Recently, a group of tobacco scientists from the UK Centre for Tobacco & Alcohol Studies referred to the risks posed by e-cigarettes as “negligible.” Public Health England and the Royal College of Physicians both took a stance in favor of e-cigarettes and tobacco harm reduction in 2015, and Action on Smoking and Health — the UK’s major anti-smoking lobby — supported e-cigarettes as a far better alternative in 2016.
Even the surgeon general’s report notes that e-cigarettes “generally emit fewer toxicants than combustible tobacco products.” But there is a disconnect between its sober, thorough review of the evidence and its ultimate policy posture.
On the one hand, the report cites “insufficient” evidence over whether e-cigarettes represent a revolutionary harm-reduction strategy or a dangerous Trojan horse. On the other, it argues “we currently know enough to take action to protect our nation’s young people from being harmed by these products.” The surgeon general’s recommendations, as a consequence, tend to be prohibitionist when it comes to electronic nicotine delivery systems because of “the potential of a lifetime of nicotine addiction.”
But as the tobacco researcher Michael Russell famously said, “people smoke for the nicotine but die from the tar.” When children who smoke reach adulthood, they join the ranks of millions of smokers. According to the CDC, “Tobacco use remains the single largest preventable cause of death and disease in the United States. Cigarette smoking kills more than 480,000 Americans each year.”
It is tempting to treat kids and nicotine as representing an unbeatable hand. But they don’t justify betting against e-cigarettes, specifically, and tobacco harm reduction, more generally. There are a host of harm-reduction strategies that, by tolerating the lesser harms of e-cigarettes, can reduce overall risks to both kids and current smokers. Public health shouldn’t throw out the harm-reduction card when playing a Tobacco Endgame in which combustible cigarettes still trump when it comes to disease and death.
Fairchild is the associate dean of academic affairs at the Texas A&M University School of Public Health. Green is a doctoral student in the Department of Sociomedical Sciences at Columbia University.