Medical Examiner


E-cigarettes have a proven track record of harm reduction. The FDA’s restrictions on how they can be marketed make it easier for misinformation and panic to spread.

Photo illustration: several Juul pens lined up.
Photo illustration by Slate. Photo by Juul.

It’s difficult to say who’s been more addicted to Juul this summer: the teens whose use of the popular e-cigarette has been the subject of countless articles, or the reporters who write them. The sleek device is an easy target for scare stories: It’s colorful, flavorful, and discreet enough to hide from parents and teachers. Health authorities worry that Juul is bringing glamour back to nicotine, as exemplified by extremely 2018 headlines such as “Malia Obama puffing her Juul is summer goals.”

Teenage use of e-cigarettes is a legitimate concern to address, but it’s important not to panic. The media’s alarmism obscures a wealth of good public health news: Smoking rates are lower than they’ve ever been, they’re dropping fastest among young cohorts, and young adults actually have a better understanding of the relative risks of conventional and electronic cigarettes than do their elders.

It’s difficult to have a rational conversation about vaping, especially when teens are involved. But the evidence that e-cigarettes are significantly safer than combustible cigarettes is overwhelming. In the United Kingdom, a comprehensive report by the Royal College of Physicians concluded that long-term vaping is unlikely to exceed 5 percent of the risk of smoking cigarettes. The Cochrane Tobacco Addiction Review Group concurs that “switching to electronic cigarettes is likely to lead to significant improvements in health.” Even the American Cancer Society concedes that individuals who cannot quit smoking by other means “should be encouraged to switch to the least harmful form of tobacco product possible.” As tobacco researcher Michael Russel famously noted in 1976, “People smoke for the nicotine, but they die from the tar.” That’s an oversimplification, but it expresses the truth that while nicotine is what makes smoking addictive, it’s the other components of tobacco smoke that are most deadly.

Unfortunately, much of the public remains unaware of this. In a 2016 survey, nearly 80 percent of American respondents agreed with the statement that nicotine is the primary disease-causing agent in tobacco. And as vaping has grown in popularity, perceptions of its dangers have gotten less accurate. From 2013 to 2015, the proportion of adult smokers who believed that vaping is equally or more dangerous than smoking grew from 43 percent to 53 percent; among all adults, this misperception climbed all the way up to 65 percent. A Rasmussen poll from August found similar results, with a majority of the American public holding beliefs about vaping that are wildly contradicted by the facts.

Younger cohorts in the United States hold more accurate beliefs than their parents or grandparents. A recent Gallup report found that almost half of seniors 65 and older believe that vaping is “very harmful to health,” in contrast to only 22 percent of adults under 30.  Another poll found that 45 percent of adult smokers, the group most in need of accurate information, still believe that vaping is comparable in harm to smoking.

Correcting these misperceptions could persuade more smokers to ditch combustible tobacco, which would certainly be good for their health. Unfortunately, the Food and Drug Administration forbids e-cigarette manufacturers from communicating this information: They may not advertise that their products are safer than cigarettes, that they contain fewer harmful constituents, that switching to e-cigarettes may be beneficial to health, or that the products may aid in quitting or reducing smoking. Law professor Jonathan Adler has argued that the FDA’s speech restrictions are so sweeping as to violate the First Amendment. He suggests that “If the FDA is concerned that e-cigarette manufacturers might oversell their products’ benefits or mislead consumers, it can require disclaimers and qualifications […] What the FDA cannot do is simply require manufacturers to be silent.”

The FDA’s insistence that e-cigarette companies refrain from making factual statements about their products has made it all but impossible to market vaping as a safer alternative to smokers in a straightforward way. It’s true that Juul has advertised its e-cigarettes with alluring lifestyle imagery, especially in its early ads, and received warranted criticism for doing so. But the FDA’s process for getting permission to advertise vaping as a lower risk alternative to cigarettes is so burdensome, expensive, and opaque that no producer has ever gotten through it. In this context, it’s worth recalling that the agency’s authority over tobacco products was granted by a law backed by cigarette giant Philip Morris, a company whose future is imperiled by the vape-enabled dynamic market for nicotine. The anti-competitive nature of FDA regulation was baked in from the beginning. No new vapor products have been permitted since 2016. Virtually all e-cigarettes would have been threatened with removal from the market this year if FDA Commissioner Scott Gottlieb hadn’t pushed back that deadline to 2022.

The complicating factor is that the FDA is mandated to evaluate the risk of products for the population as a whole, not just for individual users. This epistemic hurdle is an obstacle to harm reduction when applied to the current reality around smoking. The agency can ban e-cigarettes even when it’s obvious that they are a far safer alternative for current smokers, withholding approval on the basis that non-smokers may take up vaping, that vaping may act as a gateway to real smoking, or that smokers will use vaping to merely reduce their consumption of cigarettes instead of quitting. Any of these outcomes would at least partially offset the benefits of transitioning smokers to vapor products. “Dual-use” in particular is a bogeyman for harm reduction opponents who fear that maintaining nicotine addiction will sustain smoking habits. For those who favor an abstinence-only approach, e-cigarettes have value only to the extent that they help users stop smoking entirely.

In many cases, though, they appear to do exactly that. About 2.5 million former smokers in the United States now report vaping, and it’s a fair bet that many of them are using the latter activity as a replacement for the former. But what about smokers who can’t or won’t quit? If e-cigarettes help them lower their frequency of actual smoking, that’s still a real benefit. “There’s an all-or-nothing mentality,” says Dr. Michael Siegel, a harm-reduction advocate at the Boston University School of Public Health, “but there’s no question that reducing smoking improves health, especially for lung cancer and respiratory diseases, for which there’s a dose-response relationship.” (Cardiac risks accrue at low levels of exposure and so would be less affected by reduced smoking.)

Another big fear around vaping is that non-smokers will take it up and progress to smoking. Yet despite years of warnings that e-cigarettes will act as a gateway to cigarettes, smoking rates among youth and adults stubbornly keep falling to record lows. In 2017 the youth smoking rate fell to 7.6 percent, down from 12.7 percent in 2013. Youth experimentation with e-cigarettes increased dramatically over the same period: The 2015 National Youth Tobacco Survey, for example, found that nearly 38 percent of high school students had ever tried an e-cigarette. That sounds alarming, but very few of them (2.5 percent) reported regular use—and regular use is particularly rare among non-smoking youth. The latest available figures also suggest that use of e-cigarettes among high schoolers is down from its peak in 2015. That’s no reason to be complacent about teen use of Juul or any addictive substance, but the most current data available suggest that nightmare stories of a vaping-to-cigarette pathway are the exception, not the rule.

And what about just taking up vaping? Although many of the risks are overhyped, there are concerns about irritating respiratory tissues and other potentially unknown long-term effects. The relationship of nicotine without tar to cardiac health is also in need of further study, especially among people with existing cardiac conditions. At a population level, however, the benefits of vaping are clear: If vaping carries just 5 percent of the risk of cigarettes, then for every smoker who switches to e-cigarettes, 20 non-smokers would have to take up vaping to offset the gain in health. Researchers have recently modeled optimistic and pessimistic scenarios surrounding vaping—the pessimistic scenario assumes that e-cigarettes are more harmful than we currently think, that many people who have never smoked will take up vaping, and that vaping will act as a gateway to smoking. Both scenarios still end up predicting big improvements over the status quo. The optimistic scenario suggests e-cigs could prevent 6.5 million premature deaths and 86 million lost years of life between now and 2100; the “pessimistic” scenario still expects the prevention of 1.6 million premature deaths and 20 million lost years of life.

To further gauge the potential for harm reduction in the United States, it’s worth looking into how safer forms of tobacco use have affected health outcomes elsewhere. The best models we have for this are Sweden and Norway, whose residents have taken up snus, a form of oral tobacco that’s much safer than both cigarettes and American-style chew—but is prohibited in most of Europe. These two countries offer a natural experiment in what happens when a population adopts less harmful forms of tobacco.

Swedish males were the first to shift their consumption from cigarettes to snus. More Swedish men born in the 1960s initiated tobacco use with snus than with cigarettes, a preference that has gotten stronger over time. Norwegian adoption of snus began later, but there too, rates of smoking have been falling steadily as use of snus increases. The overall rates of daily smoking in both countries are now among the lowest in Europe. In younger cohorts they are phenomenally low: Among Norwegians aged 16–24, only 5 percent of men and 1 percent of women report daily smoking. In Sweden the rate of smoking among 18-year-olds has fallen to around 4 percent. This has correlated with superior health outcomes over time. Among males in the EU, Swedish men boast the lowest rate of mortality due to lung cancer, at just 42 annual deaths per 100,000 inhabitants, as well as the lowest rates of mortality for all causes of death attributable to tobacco.

It would be a mistake to attribute this success entirely to snus, but the Nordic experience should help alleviate the concerns of harm reduction opponents. By way of contrast we might look to Australia. That country has followed the advice of abstinence-only tobacco control to a T, implementing plain packaging, imposing graphic warnings, increasing taxes, and banning e-cigarettes containing nicotine. These are “endgame” policies designed to bring tobacco consumption to near zero. Yet although the smoking rate in Australia has fallen, it may be stalling out around 12 percent. Cigarette sales actually increased at the end of 2017, indicating the limited potential of these strategies to change the behavior of committed smokers.

It’s worth noting too that the brunt of these policies falls upon a population that’s disproportionately poor and undereducated and that the measures favored by abstinence-only tobacco control activists are harsh and stigmatizing. Smokers are banished to the fringes of society, accused of being contaminated and emitting toxins, taxed regressively, and forced to gaze upon ghastly medical imagery while often struggling with a physiological addiction. After decades of beating smokers with progressively heavier sticks, we should welcome the chance to offer them a carrot. (Not literally, although a carrot-flavored Juul is not outside the realm of possibility.)

But allowing adults to make informed choices about nicotine frightens regulatory gatekeepers. The abstinence-only and harm reductionist camps have different visions for combating smoking, but both believe that their visions should be imposed via legislation or through agencies like the FDA. They share a technocratic approach that tolerates change only when it’s tightly managed. As Virginia Postrel described technocracy in her insightful 1998 book The Future and Its Enemies, “Technocrats are ‘for the future,’ but only if someone is in charge of making it turn out to plan.” That there must be a plan is never questioned: “The issue isn’t whether the future should be molded to fit one static ideal. It’s what that static ideal should be. There must be a single blueprint for everyone.”

Opposition to technologies like Juul must be understood in part by the ways that they upset that static vision. Technocracy depends on central planning and top-down control. E-cigarettes, in contrast, are all bottom-up and unruly. They arose in vape shops and strip malls hacked by users mixing flavors, components, and nicotine concentrations to meet their individual needs. This messy disorder made room for an evolutionary process that refined innovations that worked and discarded those that didn’t. While no one could have predicted the spectacularly sudden rise of Juul in particular, it’s not so surprising that the leading e-cigarette company turns out to be a total newcomer rather than one of the pharmaceutical or tobacco companies that have profited from decades of stasis.

The hardest case to make to technocrats is that they should relinquish their control. As Karl Lund, senior researcher at the Norwegian Institute of Public Health, noted earlier this year, “It is difficult for us to realize and accept that these products may have greater potential to make smoking obsolete than the regulations many of us have spent a lifetime fighting for.” American legislators should look to the accidental Nordic experience for guidance, or to a shockingly sensible report issued in July by England’s House of Commons Science and Technology Committee that suggests reducing taxes on e-cigarettes, relaxing bans on where people can vape, and better communicating the lower risks of vaping via targeted advertisements inserted into cigarette packs. More open and transparent processes at the FDA would allow innovation to continue and enable e-cigarette companies to speak directly about the benefits of switching away from combustible tobacco.

The electronic cigarette may turn out to be the most significant innovation in the nicotine market since the Bonsack machine automated cigarette-rolling in the 1880s. Vaping arose while mainstream tobacco control activists obsessed over changing the colors of cigarette packaging; that it arose at all is thanks to a decade of permission-less innovation before the FDA could say “Stop.” Embracing dynamism entails accepting that people will use new technologies in unpredictable ways. Some will use e-cigarettes to quit tobacco entirely. Others will reduce their smoking. And yes, some who may have never smoked to begin with may be attracted to products like Juul, and become either casual or addicted users. This is unacceptable to endgame activists, but nicotine has been subverting the desires of social controllers since the Spanish Inquisition. If this time around that subversion comes in a form that doesn’t put millions of lives at risk, we should count that as a win.

Disclosure: I worked at the Cato Institute almost a decade ago when it received some tobacco company donations.