Last month, for the first time, the U.S. Food and Drug Administration authorized certain electronic cigarette products, citing evidence that the products can help smokers cut back or quit by switching from smoking to vaping.
E-cigarettes are filled with a liquid that typically contains nicotine and flavorings, which is heated during use. Users inhale nicotine as vapor, not smoke — thus the term “vaping.” Since the products don’t burn tobacco, they don’t expose users to the same levels of dangerous chemicals as conventional cigarettes.
The FDA’s decision has left experts divided. On the one hand, smokers should have access to every option that can help them quit, but if young people believe e-cigarettes are “safe,” could they get hooked on vaping and transition to smoking cigarettes?
We asked two local experts to weigh in on whether or not the FDA was right to allow the marketing of some e-cigarette products. Do the potential benefits of e-cigarettes outweigh the potential risks?
Yes: FDA was right. Some e-cigarettes are good for public health.
By Jonathan Foulds
In considering whether a new tobacco product should be authorized to be on the U.S. market, the FDA has to decide whether it is “appropriate for the protection of public health.” If the FDA OK’d these products, that means the agency has likely concluded they are less harmful to users than traditional cigarettes, that adult smokers who use the e-cigarette may cut back on or quit smoking, and that the way the e-cig is marketed is unlikely to get young nonsmokers hooked on nicotine.
The primary benefit of e-cigarettes is that they are a way out of cigarettes, which remain our most lethal legal product. (They’re only legal because many have been “grandfathered in” by the FDA to stay on the market.)
In 2018, the National Academies of Science, Engineering, and Medicine (NASEM) produced a comprehensive report on e-cigs. They concluded that:
“Completely substituting e-cigs for combustible cigarettes reduces users’ exposure to numerous toxicants and carcinogens present in cigarettes,” and that “completely switching from regular use of combustible cigarettes to e-cigs results in reduced short-term adverse health outcomes.”
Shouldn’t nicotine-addicted smokers have the choice to be able to reduce their toxic exposures and health risks by switching to a much less harmful nicotine product?
In 2021, the Cochrane Collaboration published a major review of whether e-cigs can help people quit smoking. It concluded that more people quit smoking using e-cigs than nicotine replacement therapy (like gums or patches) or behavioral support such as counseling.
Some research has suggested that young people who used e-cigs were more likely to try cigarettes and that teenagers were particularly attracted to sweet and fruity flavors in e-cig liquid. However, new laws have restricted tobacco sales until age 21, as well as the flavors that could be sold in e-cig liquid cartridges. The proportion of high school students who say they have used an e-cig (even just once) in the previous 30 days has fallen to 11%. That’s a 60% drop since 2019.
Meanwhile, cigarette smoking by high school students has been steadily decreasing (e.g., only 4.6% in 2020), suggesting that e-cigs are not acting as a gateway to smoking for teenagers — instead, they are replacing smoking. If e-cigs cause more kids to start smoking, we would have seen an increase in smoking in the years since e-cigs emerged; in reality, the opposite has happened.
Some are concerned that many smokers who try e-cigs continue to smoke. Here in Pennsylvania, my colleagues and I at Penn State College of Medicine, in collaboration with Virginia Commonwealth University, conducted a randomized clinical trial of e-cigs in smokers with no plans to quit smoking. We found that use of e-cigs that deliver high levels of nicotine reduced exposure to a major lung-cancer-causing chemical, even with continued smoking. We also found that if smokers continued to use an e-cig with high nicotine delivery, a greater proportion quit smoking and completely switched to e-cigs, as compared with a placebo e-cig or no e-cig.
“Closing this lifesaving escape route from smoking is a bit like locking the door to the fire escape because the steps may be slippery.”
The FDA should be allowed to do its job without ill-informed pressure. This should lead to more e-cigs being authorized, rather than just one out of thousands of applications.
Health policy should be driven by science, not prejudice or dogma. E-cigs have already provided an effective gateway out of smoking for many, many people — millions, I would wager. Closing this lifesaving escape route from smoking is a bit like locking the door to the fire escape because the steps may be slippery.
Jonathan Foulds is a professor of public health sciences at Penn State College of Medicine. He also discusses smoking, e-cigs, and health at @JonathanFoulds.
No: The risk of hooking young people on nicotine products is too high.
By Brian P. Jenssen
While the FDA has made some progress denying marketing applications for certain flavored e-cigarettes, it has allowed others to remain on the market, citing that the potential benefits of these products for current smokers outweigh the risks of introducing young people to vaping and lifelong addiction to nicotine. This is a false choice that overall harms public health. Here’s why.
First, by attracting young people to ingest nicotine, these products may put them on a path to becoming regular smokers. This is not an idle concern: Tobacco use — the leading preventable cause of disease and death in the United States — almost always starts in childhood or adolescence. Among adults who became daily smokers, nearly 90% first started smoking before age 18. While there are several effective, evidence-based treatments to help adult cigarette smokers quit, the most successful treatment has always been prevention or making sure a child never starts in the first place.
» READ MORE: The problem with kids and flavored tobacco
Based on evidence and my personal clinical experience, once a teenager starts vaping or smoking cigarettes, it’s incredibly challenging to help them quit. For the past several years, e-cigarettes have become the most common tobacco product used among youth — as many as 11% to 20% of high school students regularly use e-cigarettes. Why is this concerning? E-cigarettes clearly cause direct harm to youth, including the lung injury epidemic that dominated the news prior to the COVID-19 pandemic. Furthermore, nicotine is damaging to developing brains. Younger users of e-cigarettes are more likely to become addicted, have more difficulty quitting, and may be at increased risk of becoming addicted to other substances. What’s more, youth who use e-cigarettes, compared with those who do not, are four times more likely to become cigarette smokers.
Second, it’s unclear if e-cigarettes actually help adults quit smoking. According to multiple, well-respected institutions, including the U.S. Preventive Services Task Force and the surgeon general, there is inadequate evidence to conclude that e-cigarettes increase smoking cessation, and, because e-cigarettes and vaping devices are all different, it is difficult to make generalizations about how effective they are at helping people quit based on clinical trials involving a particular e-cigarette. No studies to date on the use of e-cigarettes for tobacco cessation reported health outcomes (measures that include conditions like lung cancer, heart attacks, or death), and few trials reported on the potential adverse events (including a range of potential harms that could be mild, like sore throat, to more severe like hospitalization or death) of e-cigarette use when used in attempts to quit smoking. Given the current state of the evidence, for established smokers interested in quitting smoking using e-cigarettes, public health and clinical efforts should instead guide them toward evidence-based, safe, effective treatments, including nicotine replacement therapy, behavioral counseling, and additional pharmacotherapy.
“Let’s not make it any easier for the next generation to get hooked on this deadly product.”
Finally, the FDA could embrace a better public health approach to protecting youth from lifelong addictions to tobacco while exploring the role of e-cigarettes in potentially reducing the harm faced by adults who use cigarettes. Right now, because of a variety of loopholes, the tobacco industry targets e-cigarettes to young people with attractive flavors and easily accessible products. A more evidence-based, effective public health strategy would involve restricting marketing and access of these products to youth, removing all flavors from all tobacco products, and limiting the nicotine content of these products to make them less addictive and potentially more likely to support cessation. Such an approach can better protect youth from targeting by tobacco companies while creating methods to potentially help smokers quit.
Cigarettes are the only legal product on the market that, when used as intended, kills the user. Let’s not make it any easier for the next generation to get hooked on this deadly product.
Brian P. Jenssen is a pediatrician at CHOP and a tobacco use treatment expert.