Interacting with the vaping industry was one of my most baffling experiences as New Jersey’s health commissioner.
Gov. Murphy, Acting Health Commissioner Persichilli, and the governor’s Electronic Smoking Device Task Force have taken on this industry in the name of public health, delivering a thorough, yet achievable set of policy recommendations to stem the epidemic of mysterious lung illnesses linked to vaping. And while New Jersey takes on the important challenge of protecting patients while learning as much as possible about the epidemic, many are encountering the industry’s messaging machine for the first time.
My encounters with the industry started earlier. During my final months as commissioner this year, I ventured a light-hearted tweet. I thought it was an innocuous reminder that nicotine vaping should not be considered a safe alternative to cigarettes.
Vaping is a devious delivery system for drugs. While consumption of many drugs usually leads to a negative physiologic response (coughing after smoking, for example), an average “pull” of a vaping device is much smoother. Additionally, vaping devices can contain up to an entire cigarette pack’s worth of nicotine — and while they are meant to be consumed over a longer course of time than a single cigarette, a person can unwittingly multiply their nicotine consumption if switching from cigarettes. Finally, new data was emerging around the content of chemical byproducts in vape flavoring known to be toxic to lungs — not to mention that flavored products are highly preferred by youth who do use.
So, while I was familiar with preliminary evidence that shorter-term health impacts of smoking may be worse than for vaping, I felt it was important to send out a public health message reminding folks that a heavily marketed, recreational, and highly addictive drug whose health effects have yet to be well-described should not be considered “safe.” Moreover, multiple, FDA-approved smoking cessation methods already exist, and nicotine vaping carries neither the appropriate level of evidence nor the legal authority to be marketed as a smoking cessation tool.
Facts and fallacies of ‘harm reduction’
The industry felt otherwise, unleashing a narrative that was admittedly unexpected: that I was harming public health by refusing to endorse vaping as a smoking alternative. In between ad hominem attacks, they did cite some evidence: A professional society in the U.K. did officially endorse vaping over smoking due to a lower side-effect profile; a New England Journal of Medicine study that compared vaping to nicotine replacement therapies found that vaping led to higher rates of smoking cessation; and more boldly, many contended that vaping was effectively “harm reduction,” a public health term that describes evidence-based facilitation of safer avenues of risky behavior, such as needle exchange programs for injection drug use or safe sex.
Here is why they are wrong about each of these points:
- A different, addictive drug with a lower side-effect profile is not necessarily a “treatment” for smoking. The United States has strict regulatory standards defining addiction treatment for a reason. An acceptable treatment should improve a clinical outcome, and its benefits should outweigh the risks of existing methods to quit. That requires large-scale clinical trials submitted to the Food and Drug Administration for approval as a treatment. No trials of that standard currently exist to support vaping as a medically appropriate quitting method. Despite this, Juul and other companies aggressively marketed their products to encourage people to “make the switch” — weasel words that avoid saying “treatment” but still encourage the mindset in smokers. It wasn’t until over a month after the current epidemic of lung illnesses began that Juul finally dropped this ad campaign in the U.S., only doing so after a stern warning from the FDA saying they were breaking the law by falsely advertising their products as appropriate smoking cessation tools. More disturbingly, company education programs in schools, initially branded as a campaign against youth vaping, actually involved some industry representatives claiming that the product was “totally safe.”
- The clinical trial that the industry most frequently cites to support vaping as a smoking cessation tool draws insufficient conclusions at best. Conducted out of the U.K., this study randomly assigned patients who wanted to quit smoking either an electronic cigarette or an approved nicotine replacement therapy. Although a higher percentage of people in the vaping arm of the study quit, a much higher percentage had to continue vaping because they maintained their nicotine addiction; and conversely, of those that were able to successfully quit in the nicotine replacement arm, a much higher percentage were able to get off of nicotine completely. The results for the patients in the nicotine vaping arm are especially concerning now that vaping-associated lung disease is a clear risk. For these reasons, clinicians should be loath to recommend vaping as a smoking cessation tool.
- Vaping is not harm reduction. Harm reduction is a sensitive topic that requires prospective, long-term studies to support techniques in reducing harm. The most effective methods are both intuitive and supported with evidence: clean needles are surely better than dirty ones from the standpoint of reducing the spread of HIV and hepatitis, and condoms prevent the spread of sexually transmitted diseases, with no evidence to support that either method increases the frequency of underlying risky behaviors. By contrast, there are very high rates of concurrent smoking and vaping, which only compounds risks. Furthermore, even if smokers completely substitute, it is now especially clear that we are only beginning to understand comparative risks of vaping, making these claims irresponsible.
It is important to understand that smokers who have since switched to vaping, and found that their symptoms have improved, deserve to be heard and have a valuable perspective. But that is a far cry from the claims the industry has made about the “benefits” of vaping. And it is especially concerning that a broad-based research study found that up to 77% of pro-vaping social media posts were generated by fake accounts, or “bots,” programmed specifically to either spread propaganda or mimic pro-vaping, former smokers. The fact that pro-vaping constituencies are resorting to such tactics underscores the weakness of their arguments.
Even so, this industry and its representatives continue to exploit the positive experiences of some former smokers to make unsubstantiated claims. Financial motivations also continue to encourage industry advocates to harangue public health officials, even in the face of this national epidemic of lung illness. Without new and much more convincing evidence comparing vaping to smoking, the vaping industry’s messaging around the drug’s public health benefits should be seen for what it is: a farce.