Many of the activists who fought against the deceptions of Big Tobacco, are the same ones who have thwarted the nascent health revolution of vaping as a harm reduction strategy for smokers, slanting science to fulfil their own mission, writes Sally Satel, a psychiatrist and visiting professor at Columbia University Irving Medical Center.
A very small portion of this long article is reproduced here, to give a sense of its contents. The full, open access article in National Affairs – Number 44, Summer 2020 – may be read [link url="https://nationalaffairs.com/publications/detail/the-e-cigarette-revolution-that-wasn’t"]here[/link].
Satel, who is also resident scholar at the American Enterprise Institute, writes that the e-cigarette story is a dire chapter in the sociology of public health science in the United States.
Any grounds for optimism come from abroad, where England, Canada and New Zealand endorse and promote vaping as a harm-reduction strategy for smokers.
As these nations save smokers' lives – and as illicit vaping markets take root in the US – American policy-makers and the public will be forced to notice. They will need to adjust their risk-benefit calculus and their policies accordingly.
The article
In 2014, the Oxford English Dictionary christened ‘vape’ the Word of the Year. The designation was a tribute to the impressive rise of the electronic cigarette, a battery-powered device that heats a flavoured solution containing nicotine and converts it into an inhalable, or ‘vape-able’, aerosol.
By the close of 2013, six years after e-cigarettes became available in the United States, sales had surpassed $1 billion, prompting financial analysts to proclaim them a threat to cigarette sales. Observers hailed e-cigarettes as "among the most significant public-health innovations of modern times" and a "disruptive technology" poised to "revolutionise" public health.
Invented for smokers who cannot or will not quit, e-cigarettes do not burn tobacco, and therefore emit a mere fraction of the carcinogens and hazardous gases than do conventional cigarettes. This means vaping is substantially less harmful than smoking, which causes roughly 480,000 American deaths each year.
Today, roughly 11 million adults use electronic cigarettes. With the exception of quitting cold-turkey, vaping is not only the most popular strategy but the most effective, continues Satel in National Affairs.
In other welcome news, early fears that e-cigarettes would ‘re-normalise’ smoking among adults and lead teens to take up smoking have not materialised. And if over the next 10 years the nation's smokers switched to vaping, according to conservative demographic estimates, more than 1.6 million premature deaths could be averted by 2100.
Just five years later, in November 2019, several hundred vapers assembled on the White House ellipse. Pink clouds redolent of strawberry cinnamon, and peach hung low in the air. "We vape, we vote," the vapers chanted. "Flavours Save Lives" read their placards.
The messages were aimed at President Donald Trump who had announced weeks earlier that he planned to ban e-cigarette flavours.
His move was just a part of a larger cultural and political campaign against vaping that shifted into high gear last autumn. The drive included congressional hearings with titles like "E-cigarettes: An emerging threat to public health." Angry parents marched in protest. The American Medical Association urged a flat-out ban on vaping. A smokers' helpline run out of a California state university launched a "quit vaping" programme.
Meanwhile, the market value of tobacco companies – which had declined by roughly half since around 2017 – started to rebound, likely due to confidence that vaping would not be a serious long-term competitor with the more lucrative combustible cigarette, Satel writes.
From possible salvation to public health disaster
In a mere half a decade, e-cigarette went from being lauded as a possible salvation from smoking to being denounced as a public health disaster. How did this happen? How could local public health officials in some cities facilitate their removal from store shelves while leaving deadly Marlboros and Newports for sale, waiting to fill the nicotine void?
The answer involves some of the usual culprits – tone-deaf marketing by manufacturers, flawed regulation by government, and scare-mongering by the media. But something more troubling lies at the heart of the story: an extraordinary lack of intellectual integrity in a prominent sector of the public-health community.
Promising innovation or public health menace?
In their campaigns against e-cigarettes, many health agencies and advocates breached two fundamental tenets of public-health practice: dispassionate and nuanced analysis of risk and honest communication about that risk to the public.
Opponents of vaping defined the problem solely as a matter of teen vaping while abdicating their responsibility to address the problem of adult smoking.
Youth should not vape, nor should adults smoke. Both imperatives need to be taken into account and trade-offs made.
Unfortunately, a vast swath of the tobacco control community seemed to forget that the purview of public health is the nation's entire population of vulnerable people, not just youth, and particularly groups that smoke at disproportionately high rates, including people suffering mental illness, working-class men and women, Native Americans, veterans, and lesbian, gay, and bisexual adults.
The ultimate loss of perspective, jarring in its significance to anyone who looks beyond the vaping tumult, is that combustible cigarettes remain untouched and easier to purchase while a safer alternative is under siege.
Truth telling has been a bloody casualty in the vaping wars. "Great is the power of steady misrepresentation," Charles Darwin wrote in On the Origin of Species, "but the history of science shows that fortunately this power does not long endure." In this case, Darwin's outlook may be too optimistic.
Although innovation has always had its enemies, it seems safe to say that this is a unique episode in the history of modern public health, when otherwise respected institutions, doctors and public professionals relentlessly inculcated doubt against a product (e-cigarettes) and a practice (vaping) by disseminating half-truths, non-sequiturs and brazen falsehoods.
Even in the midst of the high-profile, celebrity-studded anti-vaccination crusade, the public could at least turn to trusted sources for sensible and objective information and advice.
These transgressions will have repercussions. Institutions entrusted to inform and guide the public may suffer a serious loss of faith, disaffecting youth as much, if not more, than adults. Tobacco controllers, like tobacco companies before them, obscured, rather than advanced, health literacy.
In the more-immediate policy sphere, bans on flavours and restricted access to e-cigarettes will cause many to revert to smoking or to patronise illicit markets. With policy-makers and politicians so woefully misinformed about the virtues and realistic risks of vaping, it is no surprise if they fail to appreciate the magnitude of the dangers that their restrictive policies pose.
"If we lose e-cigarettes, I think we will have blown the single biggest public health opportunity we've ever had," says David Abrams of the NYU College of Global Public Health.
* Sally Satel is a psychiatrist, a resident scholar at the American Enterprise Institute, and a visiting professor in the Department of Psychiatry at Columbia University Irving Medical Center. For annotations and citations to this article, please see this version.
[link url="https://nationalaffairs.com/publications/detail/the-e-cigarette-revolution-that-wasn’t"]Full article on the National Affairs site[/link]