I have drawn the chart above from the US National Cancer Institute HINTS survey, picking up results from 2014, 2017 and the most recent data from 2020. The current situation is shocking and the trend is a disgrace. But how has this happened?
In this blog, I compare the vaping risk communications of four major American health organisations with four similar UK organisations. The comparison is damning.
- What is going on in that chart?
- Are e-cigarettes really safer than cigarettes?
- How did these misperceptions arise?
- Who is causing the public misunderstanding of vaping risks?
- Could vaping risk communication be done better?
- Why has this happened?
- How bad is this?
- Are they as bad as Big Tobacco in the 1970s?
- Postscript: risk perceptions in the UK
What is going on in that chart?
First, let’s summarise the dire findings in that chart.
- We now have 27.7% thinking e-cigs are more harmful or much more harmful than cigarettes, and 62% think as harmful or more harmful. There is absolutely no substantive basis whatsoever to think this.
- Only 2.6% have an approximately accurate perception “much less harmful”.
- “Less harmful” now stands at only 8.6%, but even this is a misperception – less could mean a bit less but far short of much less. 20% less harmful is still wildly inaccurate and would be included in this answer.
- “Don’t know” in this context is probably a significant barrier to switching. Given the conflicting and confusing information circulating, don’t know would be a reasonable answer and a reason not to risk switching.
- The trend is deteriorating but bears no relation to actual knowledge – the biomarker data collected since 2014 suggest very low toxicant exposures and several studies show improving clinical outcomes compared to smoking.
- The 2019 lung injury outbreak in the US officially known as EVALI undoubtedly affected the 2020 results (Darvel et al 2020). That effect may dissipate causing a reversion to the (already deteriorating) trend, or it may have caused both a temporary surge (which may decay over time) and a permanent adverse adjustment. Time will tell.
Are e-cigarettes really safer than cigarettes?
It is unbelievably tiresome that it is still necessary to spell out the obvious. But the chemistry, physics and biology of the processes involved mean that non-combustible smoke-free products will inevitably be much less risky than cigarettes. That is also the conclusion of several expert assessments.
After a lengthy review, here is the United States National Academies of Science, Engineering and Medicine (NASEM) concluding in 2018:
Laboratory tests of e-cigarette ingredients, in vitro toxicological tests, and short-term human studies suggest that e-cigarettes are likely to be far less harmful than combustible tobacco cigarettes.National Academies of Sciences, Engineering, and Medicine. Public Health Consequences of E-Cigarettes. The National Academies Press. 2018. [link]
Or take the recent paper of 15 past presidents of the Society for Research on Nicotine and Tobacco (SRNT) writing in the American Journal of Public Health. These authors, some of the world’s leading authorities, summarise the safety case as follows:
Many scientists have concluded that vaping is likely substantially less dangerous than smoking because of the following:
The number of chemicals in cigarette smoke, greater than 7000, exceeds that of e-cigarette aerosol by 2 orders of magnitude.
Among potentially toxic substances common to both products, cigarette smoke generally contains substantially larger quantities than e-cigarette aerosol. However, e-cigarette aerosol contains some substances not found in cigarette smoke.
Biomarkers reflecting exposure to toxic substances are present at much higher levels in exclusive cigarette smokers than in exclusive vapers, and studies of smokers who switch to e-cigarettes find decreases in toxicant exposures.
Tests of lung and vascular function indicate improvement in cigarette smokers who switch to e-cigarettes. Exclusive users of e-cigarettes (most being former smokers) report fewer respiratory symptoms than do cigarette smokers and dual usersBalfour, D. J. K.et al. (2021). Balancing Consideration of the Risks and Benefits of E-Cigarettes. American Journal of Public Health, 111(9), 1661–1672. [link]
Or the independent experts for Public Health England reviewed the biomarker data (levels of toxicants in blood, saliva and urine) and other safety data. In 2018, they concluded:
Vaping poses only a small fraction of the risks of smoking, and switching completely from smoking to vaping conveys substantial health benefits over continued smoking. Based on current knowledge, stating that vaping is at least 95% less harmful than smoking remains a good way to communicate the large difference in relative risk unambiguously so that more smokers are encouraged to make the switch from smoking to vaping. It should be noted that this does not mean e-cigarettes are safe.McNeill A, Brose LS, Calder R, Bauld L & Robson D (2018). Evidence review of e-cigarettes and heated tobacco products 2018. A report commissioned by Public Health England. London: Public Health England. [link]
And for all the talk of the long term risks being “unknown”, it may well be that they turn out to be approximately zero in terms of mortality and disease impact – that is one side of ‘unknown future risks’ that is rarely discussed. Except in this comment by the Royal College of Physicians (emphasis added)
Although it is not possible to precisely quantify the long-term health risks associated with e-cigarettes, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure.Royal College of Physicians (London) Nicotine without smoke: tobacco harm reduction 28 April 2016. (Section 5.5 page 87) [link]
I could go on, but that’s enough! Anyone with modest scientific literacy can figure out that vaping risks are likely to be, beyond any reasonable doubt, far less than cigarette smoking.
How did these misperceptions arise?
The immediate reasons for the wild misalignment of public risk perceptions and expert assessments are not hard to understand. Some major factors like EVALI and possibly COVID-related claims, and the way these were played into anti-vaping campaigns. But also endless made-for-media scares and risk communications that are either false (vaping causes heart attacks or broken bones) or, more commonly, technically correct but misleading – see the various forms of “not a safe alternative” narrative, “purported to be safer”, “marketed as safer”, “we don’t know long term effects” (as if we know nothing), and of course always the spectre of the tobacco industry.
EVALI – CDC is an aggressive wholesaler of disinformation
Before we look at what health organisations are saying, it is important to understand the origin of one of the most insidious falsehoods widely peddled by these organisations, the claim that “EVALI” was in part caused by nicotine vaping.
In the second half of 2019, there was an outbreak of severe lung injuries among people using vaping products. CDC eventually named this EVALI (E-cigarette, or Vaping, product use-Associated Lung Injury). CDC followed the outbreak until February 2020 as it dwindled to almost nothing from its peak in September 2019 and has not recurred. But in the few months of the outbreak, it caused 68 deaths and over 2,800 hospitalisations – causing fear and confusing and triggering anti-vaping regulation.
The E in EVALI stands for e-cigarette – but the 2019 lung injury outbreak was not only over by early 2020, it was not caused by e-cigarettes or any nicotine-containing product. See my Qeios analysis: The outbreak of lung injuries often known as “EVALI” was nothing to do with nicotine vaping. The outbreak was localised in time and geography to the United States. It cannot have been a generic vaping issue but a localised supply chain problem. The hazardous agent was soon identified. This was a cutting agent, Vitamin E Acetate (VEA), added to dilute viscous cannabis oils for criminal economic reasons. This agent was identified in September 2019 and confirmed beyond doubt in early 2020 (Blount et al, NEJM, 2020). VEA cannot be added to nicotine e-liquids (Kozlovich et al, 2021) and would serve no useful purpose even if it could. The outbreak ended because US-based illicit THC vape producers removed the harmful agent or ceased production because they were arrested. No remedial action was taken by manufacturers of nicotine vapes because none was necessary or possible, and yet the outbreak still ended.
The name EVALI is a misleading communication courtesy of the CDC (a busy wholesaler in the market for vaping disinformation). I have described this as a public health fiasco caused by agency malpractice and a detailed examination courtesy of Vaping 360 confirms this. We know this is intentional because CDC has done nothing to address the ambiguity and continues to host its page on EVALI under its information about e-cigarettes. When a group of 75 multidisciplinary experts wrote to CDC to point out the problem with the name and CDC’s ongoing ambiguity about the cause, CDC declined to change it or issue a clarification, or to address the public misinformation on websites like those shown below. CDC argues that some people claim not to have used THC vapes. What a surprise! THC is illegal in many jurisdictions and can have school, college, workplace, police or parental implications. As one practitioner wryly put it during the height of the outbreak:
It may turn out there are only two kinds of people who get this disease: those who vape THC and those who won’t admit itDr. Scott Aberegg, a critical care pulmonologist at University of Utah Health as reported in Doctors treating deadly lung disease face a problem: Some patients lie about vaping. CNBC, 20 November 2019.
We can only conclude that CDC welcomes the confusion and is quite content for US health organisations to repeat the risk misperceptions that CDC cynically nurtured and propagated.
Why rehearse the EVALI story here? As we shall see, EVALI still plays an important part in the anti-vaping disinformation operations of major US public health organisations. They continue, even in 2022, to press the false idea that nicotine vaping caused EVALI. It did not, and that has been clear now for at least two years.
Who is causing the public misunderstanding of vaping risks?
It’s hard to attribute cause and effect. But we can look at trusted organisations and see what tone they are setting. Four examples help to explain the wild misperceptions of risk in the United States (and the resulting contamination of risk-comprehension around the world). Let us look at the e-cigarette risk communication of four major US health organisations – American Heart Association, American Cancer Society, American Lung Association, and the American Thoracic Society. These are organisations that command trust and respect. Though, on the basis of what we see here, I would say rather more trust and respect than they deserve.
1. American Heart Association
Risk communication: Is vaping safer than smoking? (accessed 31 Jan 2022). The straightforward answers “yes” or “yes, very much safer” to the rhetorical question posed in the title do not appear on this page. Here is the relevant section:
In fact, the web page stresses “downsides” and only a few “upsides” and even these are only “potential upsides”. One potential upside not mentioned is a study that found cardiovascular outcomes improved in tobacco cigarette (TC) smokers switching to e-cigarettes (EC):
TC smokers, particularly females, demonstrate significant improvement in vascular health within 1 month of switching from TC to EC. Switching from TC to EC may be considered a harms reduction measureGeorge, J., Hussain, M., Vadiveloo, T., Ireland, S., Hopkinson, P., Struthers, A. D., Donnan, P. T., Khan, F., & Lang, C. C. (2019). Cardiovascular Effects of Switching From Tobacco Cigarettes to Electronic Cigarettes. Journal of the American College of Cardiology, 74(25), 3112–3120. [link]
Why would a heart association ignore this in its risk communication?
This whole AHA presentation is profoundly misleading. The idea that vaping is “less harmful” is attributed to an abstract third party “many people” The idea that vaping is useful for smoking cessation is attributed to “e-cigarette promoters”. Not to the scientists and experts that credibly hold these views.
It uses the highly misleading construct “it still isn’t safe”, which is a long-standing form of manipulation by tobacco control activists (the web page title question is actually: Is vaping safer than smoking? not Is vaping safe? ). See Kozlowski and Edwards, 2005, “Not safe” is not enough: smokers have a right to know more than there is no safe tobacco product for a well-established critique of this purposefully misleading language.
AHA makes statements about nicotine effects that are not established in humans and for which there are no detectable traces among generations of nicotine users who grew up as smokers. It lists scary-sounding chemicals without context or quantification, especially quantification relative to cigarette smoke exposures – even though the page is supposed to be comparing vaping and smoking. Even though this statement is current in early 2022, it makes a deceitful link to the 2019 US lung injury episode, referred to as EVALI. Professional risk communicators in large organisations should not need to be told this.
But misinformation is business as usual at the American Heart Association.
There is no credible evidence of a causal link between vaping and strokes, heart attacks or coronary artery disease. All of the evidence that shows a possible association is saturated with confounding by smoking history or reverse causation.
2. American Cancer Society
Risk communication: Position Statement on Electronic Cigarettes (accessed 31 Jan 2022). Here is the relevant section:
This description fails to convey any sense at all that e-cigarettes are much safer than smoking. It labours the definition of e-cigarettes as ‘tobacco’ presumably because tobacco evokes negative connotations. Even though this is a legal definition, the choice to emphasise it in risk communication is deliberate and serves no purpose other than to confuse and scare. ACS stresses unknowns and negative effects to the heart and lungs without any sense of magnitude or nature of these risks. It would not be possible to conclude from this that one study found cancer potency (mean lifetime cancer risk) for typical e-liquid aerosol consumption is 99.6% lower than smoking 15 cigarettes per day (e.g. see Stephens, 2018 Table 1). Yet this is the American Cancer Society.
Future uncertainty is brought into service by implying that because we don’t know everything we must know nothing about the future risks. However, it is inconceivable that vastly lower toxicant exposures will not lead to much lower health impacts. In fact, there is a large body of toxicology that does not rely on long-term epidemiology to quantify long-term risk. For example, we would not need to wait decades to discover that smoking was dangerous if it was introduced today.
Its story on nicotine is all wrong. The user controls exposure, albeit within constraints imposed by the device. The high strength liquids allow for more compact and lower energy devices that help smokers to switch. Adequate nicotine delivery is an important factor in securing smoking cessation results, but that is not something explained here.
ACS makes no allowance for the quite well-established (and intuitively obvious) idea that e-cigarettes displace smoking among young people and drive out smoking, and therefore may be beneficial for the adolescents most at risk.
3. American Lung Association
Risk communication: What you need to know about e-cigarettes (accessed 31 Jan 2022). Here are the most relevant sections:
What are the irreversible lung damage and lung disease found in vapers they refer to? Surely, another reference to EVALI, which has nothing to do with nicotine vaping, as noted above? Some completely ridiculous studies have failed to notice that many vapers have a long history of smoking and attribute lung damage to the vaping they took up after quitting decades of smoking. Could that be it?
And ALA is very concerned that we may be “losing another generation to tobacco-caused disease“, a dramatic if vague claim. But this easily sounds like an expectation that e-cigarettes will have the same impact on this generation as cigarettes had on past generations. A preposterous assertion with no scientific basis whatsoever.
This is further developed in a drop-down:
Here a completely baseless claim is made about the excipients (PG and VG) used in e-cigarettes based on massive over-interpretation of one study. Here is the key conclusion of that study.
We found that the presence of either vanillin or cinnamaldehyde in e-liquids was associated with higher toxicity values. In addition, our data demonstrated that the PG/VG vehicle by itself was toxic at higher dosesSassano, M. F.et al (2018). Evaluation of e-liquid toxicity using an open-source high-throughput screening assay. PLOS Biology, 16(3), [link].
However, this study is an in vitro (cell study) assay for measuring comparative toxicity, and it does not establish any link from its findings to clinically significant effects on the human body and no comparison is made to cigarettes or any other meaningful frame of reference for risk. I’m not faulting the study, it is just that it isn’t intended for the communication purpose used by ALA. This is pure cherry-picking.
ALA is letting you, the reader, in on its concerns – confiding that it is “very troubled by what we see so far” but without really saying what that is or why it is troubling. What we actually see is not troubling, but a positive story of millions using vaping to quit smoking and greatly reduce their exposure to smoking-related toxicants.
And so on to the misnamed “Learn more…” link. You will learn nothing useful about these products by following this link:
There is so much wrong here. Cigarettes are on the market and regulated by FDA, but they are raising a concern here about FDA’s laboriously ponderous and failing regulatory process for e-cigarettes – that is nothing to do with the products. It does not need FDA to draw scientific conclusions about these products – the NASEM assessment cited above was commissioned by FDA.
Here we see chemicals listed as if their very presence proves a point. But what matters is the exposure experienced by the users, not the detectable presence of a hazardous agent in the aerosol. This is on the well-known principle that “the dose makes the poison”. And that is not a new idea.
Note the way that clinical outcomes are attributed by ALA to the chemical “chemical x can cause lung disease”. They are not saying that exposures to chemical x from the use of e-cigarettes does cause disease, just that chemical x is capable of causing disease if you are sufficiently highly exposed to it. The listing of chemicals here is a pure fear play, though communicates nothing useful to the reader. Anyone confronted with a list of chemicals like this should ask “how much is the user exposed and is that a lot or little from a health point of view?”.
4. American Thoracic Society
Risk communication: Vaping: The Threat to Public Health and the ATS Response (accessed 31 Jan 2022). Here is the relevant section:
ATS takes this opportunity to inform us that it is “deeply skeptical” about the safety of e-cigarettes, implying that you the reader should be sceptical too. But little reason or context is offered to justify this deep scepticism: sceptical about safety compared to what? Smoking? Alcohol? Caffeine? Not vaping? Or is it compared to some unstated but implied claim that e-cigarettes are safer than smoking? There is no frame of reference for risk and the reader is left to guess what they mean.
This reference to “short term use of e-cigarettes can send children to the emergency room” and “patients suffering from vaping-related respiratory distress” presumably again refers to the EVALI outbreak of lung injuries in the US in 2019. Yet this had nothing to do with nicotine vaping, something that should be well understood by a thoracic society. Again, see my Qeios analysis: The outbreak of lung injuries often known as “EVALI” was nothing to do with nicotine vaping.
The EVALI episode has been used to surpass concern about the long-term chronic effects of smoking by (falsely) using fear of short term and lethal acute effects of vaping. An agonising fatal respiratory injury in 20-somethings seems worse than a 70-year-old dying of cancer. There is also no sense of proportion here. 480,000 Americans die annually from smoking-related diseases. Approximately zero have died from nicotine vaping. Even the EVALI lung injury outbreak led to a recorded total of 68 deaths among users of illicit THC (cannabis) vape pens contaminated with vitamin E acetate.
Could vaping risk communication be done better?
Yes, obviously. It could hardly be done worse. Here are four examples of risk communication about vaping from major organisations in the UK: the National Health Service, Cancer Research UK, British Lung Foundation, and British Heart Foundation.
1. National Health Service (NHS)
The NHS is the main state-run health care provider in the UK and a highly trusted institution.
Risk communication: Using E-cigarettes to Stop Smoking (accessed 2 February 2022).
Here is the relevant section:
I would say this is a model of clarity and actionable information. Also, a very reasonable and concise summary of the science as we know it. It is designed not merely to be accurate, but to be understood. In comparison, the American communications listed above seem designed to confuse and obfuscate with sciencey-sounding language that conceals a payload of misinformation.
2. Cancer Research UK
CR-UK is the main cancer research organisation in the UK.
Risk communication: Is vaping harmful? (accessed 2 February 2022).
Here are the relevant sections:
Not a bad summary. We may be able to infer more about the long term effects based on what we already know. If cigarettes came onto the market today, we would not need to wait 50 years to know they are harmful. But this is pretty good in three sentences.
Then onto the meat.
I would say this is an excellent account of the science as we know it, clearly setting out why there may be risks but that these will be far lower than smoking. Also, a clear message that EVALI lung injuries are not something to worry about. Finally, a good account of the harm reduction trade-off in the section on benefits of quitting. This is a web page designed to help a smoker decide what to do: reliable information giving a complete picture and a basis for the reader to make decisions.
Finally, some clarity on nicotine risks and environmental vapour exposures.
Again a measured and appropriate rendering of what is known, and a clear effort to dispel confusion about nicotine. All done with enough context to guide behaviour towards better outcomes.
3. British Lung Foundation
Risk communication: How to stop smoking (accessed 2 February 2022)
Here is the relevant section
Short and to the point, but appropriately encouraging and clear that there is a residual risk, but “much lower” than smoking.
4. British Heart Foundation
Risk communication: Risk factors: smoking (accessed 2 Feb 2022)
Here is the relevant section:
Again, a reasonable account in which the vaping option is less harmful and useful as an alternative to smoking. I would say this isn’t as encouraging as it should be, but it certainly does not try to implant false risk perceptions or lead smokers away from beneficial behaviour change.
Why are the American groups so terrible in comparison?
Why has this happened?
I don’t think there is anything exceptional about AHA, ACS, ALA and ATS other than the scale of the organisations and endowment of public trust. They are reflecting a view and approach to science that is widespread among tobacco control activists and academics, especially in the United States.
In my view, this is not an accident or bad luck – or even a lamentable failure of science communication. These results represent an outcome that many have strived for. I don’t mean a sinister conspiracy, but the aggregate effect of the confirmation biases of thousands of academics and advocates who want, really want, this to be the reality and really do not want e-cigarettes to be much safer than cigarettes.
Why? Because harm gives them a locus and a reason to be. It denies the viability of a solution to a problem that many have spent their careers working on but that does not involve them and empowers its users instead of controlling them. If your culture is steeped in tobacco wars and your institution is geared up to find and fight harm, then these are the risk perceptions you are likely to seek and find.
Also, I am usually doubtful about “follow the money” arguments, but let’s not overlook the effect of giant sums of money from FDA/NIH and foundations like Bloomberg Philanthropies. Many grant givers are looking for problems and reasons to regulate. Contrary to their obligation to serve the public good, they are basically uninterested in opportunities that would challenge the established smoking cessation business model, based on medicalising the problem.
How bad is this?
Very bad. Big Tobacco circa 1970s bad.
Tobacco companies earned the epithet “merchants of doubt“. They played on every last possible uncertainty, every definitional sleight of hand, every possible alternative hypothesis. They were playing mercilessly into the cognitive dissonance of smokers, so often subconsciously looking for reasons not to quit, while consciously knowing that they should.
How is this carefully constructed mendacity on the part of these tobacco control organisations any different?
I see symmetry in the ethics of misleading smokers.
- Tobacco company PR misled people at risk by downplaying the risks of smoking to encourage continued use of cigarettes they sell.
- Tobacco control PR misleads people at risk by exaggerating the risks of vaping and other smoke-free alternatives to discourage uptake of much safer products they oppose.
In both cases, if the behavioural outcomes follow the risk perceptions, then the misleading PR leads to more death and disease. In both cases, there are self-interested motives.
The big difference is the abuse of trust. No one ever really trusted Big Tobacco. But these health organisations get an easy ride because they come with an endowment of public trust. Regrettably, they are squandering it on misleading people about life-or-death risks and discouraging life-saving behaviour change.
Are they as bad as Big Tobacco in the 1970s?
What they are doing is unethical and will maintain smoking, leading to more death and disease. Their best defence is to plead a kind of corporate negligence – not having the governance or scientific stewardship to ensure that what they say is both correct, up-to-date and not easily misunderstood. But I think the word negligence is too gentle to describe what is going on here.
Postscript: risk perceptions in the UK
Colleagues have asked me a good question… what is the risk perception position in the UK?
The excellent annual ASH/YouGov survey is informative: Use of e-cigarettes among adults in Great Britain, 2021. The data is for Great Britain, which is the UK minus Northern Ireland.
The advancing black bars at the top left of the chart (e-cigs are more or equally harmful) show what is almost certainly an EVALI effect in 2020, with some decay of that in 2021 but still a visible effect.
- The proportion of Brits believing e-cigarettes are more or equally harmful than cigarettes was 37% in 2020 and 32% in 2021. For the US in 2020, that figure is 62%. So a lot more wrongness in the US, but still an alarming level in the UK.
- Just 11-12% Brits believe (correctly) that e-cigarettes are a lot less harmful, but that compares to only 2.6% in the US in 2020.
So the risk perception position in the UK is pretty bad, just not as bad as the US.
Global media outlets, notably the Mail Online, ensure hapless Brits are served plenty of disinformation with its origins in the United States.