On Jan. 11, 1964, Dr. Luther Terry released the first report of the Surgeon General’s Advisory Committee on Smoking and Health. The report concluded that there was not merely an association between smoking and cancer, but a causal relationship.
It was a watershed moment. When my own grandfather, a UCLA ophthalmologist and a daily smoker from his Army days during World War II, saw the data that lead to the report’s conclusions, he quit cold turkey. A year after it was published, all cigarette packages were required by law to prominently display the now iconic “surgeon general’s warning.” The effort to decrease smoking in the United States has been one of the great epidemiological successes of modern medicine.
So, when it was announced that current Surgeon General Dr. Vivek Murthy was to unveil the first-ever report from the Office of the Surgeon General on e-cigarette use among youth and young adults, I anticipated a compendium of data that could deliver a welcome and possibly fatal blow to the flourishing nontraditional nicotine industry. As a physician, and simply as a person living in the world, I find the increasing pervasiveness of e-cigarettes in otherwise smoke-free environments to be, at a minimum, a nuisance. I also assumed that since e-cigarettes and other similar products contain nicotine mixed with many other additives, they would probably turn out to be almost as harmful as traditional cigarettes or chewing tobacco. Hoping that the report would represent a possible bon voyage to vaping, I decided to take the time to actually read the thing (vast swaths of it, anyway—it is nearly 300 pages).
To my surprise, it is not the kiss of death I had imagined. After reading it, I concluded that e-cigarettes are nowhere near as harmful for most people as traditional cigarettes or chewing tobacco—both of which clearly cause cancer and a host of other long-term serious medical problems. E-cigarettes (and other similar products) so far, according to this report that clearly was created while adhering to the highest standards of research methodology, do not appear to.
Sure, any level of nicotine exposure to youths and young adults is unsafe. But that’s not the whole story.
The report does a great job of assessing what we currently know and what we do not know, neither over nor understating the case. Here’s what we know: We know that e-cigarette use among youths and young adults has skyrocketed in the last five years. We know that additives in e-cigarettes and other “electronic nicotine delivery systems” (ENDS) are not harmless, despite popular belief. The inhaled vapors (which should correctly be referred to as aerosols) are indeed full of potentially harmful chemicals—though again, apparently nowhere close to as nasty as traditional nicotine products. The research was targeted at youths and young adults, and it did find some associations between nicotine use and abnormal brain development (cognition, attention, etc.), mood problems (perhaps even with some potential causal effects), and other drug-seeking behaviors/use of other addictive substances. But there are few signs pointing towards causality. And in fact, it is not surprising that kids who use e-cigarettes would also be likely to already have a host of other problems.
Here’s another issue that the report made clear: Pregnant women should not expose themselves or their fetuses to nicotine, because there could be potentially negative consequences on brain development. But even in fetuses, the evidence for the harms associated with nicotine exposure is not enough to point toward causality.
All in all, though, the evidence is pretty thin. Of course, it amounts to enough reason to highly discourage youths, young adults, and pregnant women from using ENDS. There is certainly no real upside to using them.
Except, sometimes there is. Sure, if you had the choice between having one of your patients not use ENDS or using them, you’d advise that they didn’t. But if the option is between ENDS or, say, cigarettes, the choice is obvious: ENDS are much better for you. Their harmful effects appear to pale in comparison to the tar and other dangerous compounds in traditional cigarettes. Currently, the surgeon general’s report acknowledges that there is inadequate data “to infer the presence or absence of a causal relationship between exposure to nicotine and risk for cancer.” Data cited in the report even suggests that, in adults, nicotine might help people with their attention spans. (Other reports, to be fair, have concluded just the opposite.)
So should we encourage ENDS use? Of course not. But are ENDS a good alternative to smoking? Maybe, though we don’t yet know if they’re actually an effective tool to help people quit smoking. Thus far, the data on that have been mixed. The surgeon general’s report concludes that the data supporting the notion that e-cigarettes might help with smoking cessation is “extremely weak.” But honestly, so is much of the data cited elsewhere in the document that implies harm from e-cigarettes.
An addiction and carcinogen–free society would be ideal. But in reality, most, if not all, societies have one vice or another. If we’re being honest, we have to acknowledge that some exposures are better than others. A mild addiction to caffeine is better than an addiction to, say, cocaine or opioids. Nicotine and e-cigarette vapors, while certainly harmful in comparison to eating vegetables or inhaling purified steam, probably rank among the least damaging exposures to individuals and society. (They’re also substantially less expensive.) In other forms, nicotine can certainly cause great harm to many people. But that’s mainly because of tar and other additives.
At any rate, there’s also something to be said for medical alarm fatigue: the idea that if we cry wolf about the health risks of all potentially harmful things, we’ll ignore serious threats. Carcinogens in general are a perfect example. Cigarettes and tobacco are two of the very few products that are known to have a causal relationship with cancer in humans, a relationship that has been demonstrated again and again. Researchers have found some foods (think bacon) and chemicals (think formaldehyde) to be associated with cancer, but the correlation does not rise to the point where they could reasonably say they cause cancer.
Starting in 2017, the Food and Drug Administration is planning to add a label to ENDS that reads “WARNING: This product contains nicotine. Nicotine is an addictive chemical.” The same warning could be applied to coffee and is hardly a declaration of war. Strangely, the FDA has so far not chosen to ban the products from being marketed directly to kids—and there’s plenty of it, including using sex appeal, rebellion, and over 7000 flavors (including some flagrantly kid-friendly ones like “gummy bear”) to draw young people in. They’ve had the authority to ban this type of marketing since 2009, but so far they haven’t. They should. It’s low-hanging fruit.
For now, it seems they simply don’t have the data to do anything stronger.
Disclaimer: The opinions expressed in this article are solely those of the author and do not reflect the views and opinions of Brigham and Women’s Hospital.