Abstract and Introduction
The topic of e-cigarettes is controversial. Opponents focus on e-cigarettes' risks for young people, while supporters emphasize the potential for e-cigarettes to assist smokers in quitting smoking. Most US health organizations, media coverage, and policymakers have focused primarily on risks to youths. Because of their messaging, much of the public—including most smokers—now consider e-cigarette use as dangerous as or more dangerous than smoking. By contrast, the National Academies of Science, Engineering, and Medicine concluded that e-cigarette use is likely far less hazardous than smoking. Policies intended to reduce adolescent vaping may also reduce adult smokers' use of e-cigarettes in quit attempts.
Because evidence indicates that e-cigarette use can increase the odds of quitting smoking, many scientists, including this essay's authors, encourage the health community, media, and policymakers to more carefully weigh vaping's potential to reduce adult smoking-attributable mortality.
We review the health risks of e-cigarette use, the likelihood that vaping increases smoking cessation, concerns about youth vaping, and the need to balance valid concerns about risks to youths with the potential benefits of increasing adult smoking cessation.
The use of nicotine-containing electronic- or e-cigarettes has divided the tobacco control community along a spectrum from fervent opponents to enthusiastic supporters. Opponents emphasize that vaping can cause nicotine addiction among young people and could lead some to become dependent cigarette smokers, possibly "renormalizing" smoking. They cite research indicating that nicotine may harm adolescents' developing brains. Some consider vaping's health risks substantial, and some question whether vaping decreases smoking cessation. By contrast, proponents present evidence that vaping assists smokers in quitting smoking and believe that vaping poses far less risk to users' health than does smoking. Smoking among youths, they observe, has declined rapidly during vaping's ascendancy.
Many US governmental health agencies[3–6] and nongovernmental medical[7,8] and health organizations[9–12] focus primarily on vaping's risks for young people. These organizations' pronouncements and their influence on policymakers and the media have had a profound impact on the public's understanding of vaping. A study of US news articles on e-cigarettes found that, from 2015 to 2018, 70% of articles mentioned vaping's risks for youths, while only 37.3% noted potential benefits for adult smokers. Of respondents to a 2019 national survey, nearly half considered vaping nicotine just as harmful as or more harmful than cigarette smoking. Only 1 in 8 considered vaping less harmful. (The rest responded "I don't know.") By contrast, the US 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.
The public's inaccurate perception worsened following a 2019 vaping-associated acute pulmonary disease outbreak (named "e-cigarette or vaping use-associated lung injury" [EVALI]) that caused 68 fatalities. Media coverage was extensive. Several states and cities promptly banned retail and online sale of flavored e-cigarettes. In early 2020, however, research attributed the illness to vitamin E acetate, an adulterant in illicit tetrahydrocannabinol (THC) vaping devices shown to produce pulmonary injury in animals.[19–21] A small percentage of patients with EVALI reported vaping only nicotine, but they were primarily in states where THC was illegal, and most had no toxicology testing. Once the potential harm of vitamin E acetate was publicized and adulterated THC removed from the market, the incidence of new cases fell precipitously. Yet, after the outbreak, two thirds of respondents to a poll related the lung disease deaths to use of "e-cigarettes such as JUUL." Only 28% related the deaths to use of "marijuana or THC e-cigarettes."
Scientists differ in their views of the relative risks and benefits of vaping nicotine, and of their implications.[1,2,24,25] Many, including this article's authors, believe that vaping can benefit public health, given substantial evidence supporting the potential of vaping to reduce smoking's toll. Our objective is to encourage more balanced consideration of vaping within public health and in the media and policy circles.
In the following pages we address:
the health risks of vaping,
the likelihood that vaping increases smoking cessation,
the principal concerns about youth vaping, and
balancing concerns about risks to youths with potential benefits for adult smokers.
Am J Public Health. 2021;11(9):1661-1672. © 2021 American Public Health Association