In the 1970s, a company called Swedish Match started advertising snus to Swedish men. Snus wasn’t a new product; the pouches of tobacco that users tuck into their cheeks or lips, where they slowly release nicotine, had been around since the 17th century. But snus had fallen out of fashion and been replaced by combustible cigarettes.
At the time, Sweden, like many other countries, had a smoking problem. Forty percent of men smoked. But as sales of snus picked up, smoking rates plummeted. By the year 2000, Sweden was the only industrialized nation to achieve the World Health Organization’s goal of reducing adult smoking to less than 20 percent.
Snus is a great example of a theory called harm reduction which argues that, rather than promoting public health policies that completely eliminate tobacco, addicted users should have access to products that give them the nicotine they crave, but that drastically reduce the health risks posed by cigarettes. Snus delivers a kick of nicotine, but releases chemicals without the dangers of combustion and tar, some of the major contributors to lung cancer.
Sound familiar? When e-cigarettes (also known as vapes) appeared in the mid-2000s, some researchers in the tobacco control community thought young smokers in the US might make a similar choice, causing overall smoking rates to decline. E-cigarettes create an aerosol by heating a nicotine-containing fluid. That aerosol can be inhaled and exhaled like the smoke from a regular cigarette, but it doesn’t contain the tar and many of the toxic chemicals that tobacco smoke does. While research suggests that these devices have their own dangers, including reducing the lungs’ ability to fight infections, a big cause for concern during the Covid-19 pandemic. But even with their risks, e-cigarette supporters believed these products could present a safer alternative to combustible cigarettes, just as snus did for the Swedes back in the 1970s and ’80s. “People were hoping that would happen here,” says John Pierce, a professor at UC San Diego who researchers cancer and tobacco.
But in a paper published in Pediatrics this month, Pierce and his colleagues show that isn’t happening after all. Instead, young people who experiment with e-cigarettes are three times more likely than ones who have never tried vaping to become daily cigarette smokers a few years later. And the more tobacco products young people experiment with, the greater that likelihood becomes. “We haven’t had this harm reduction thing,” Pierce says.
Pierce’s team analyzed data from the US Population Assessment of Tobacco and Health (PATH) study, a survey of nearly 50,000 Americans conducted annually by the National Institutes of Health and the Food and Drug Administration. They looked specifically at people ages 12 to 24 and tracked their responses over the four years between 2013 and 2017, following their use of tobacco products and their progression from occasional experimenters to daily users.
They found that just over 60 percent of respondents in this age group tried a tobacco product at some point and that 30 percent experimented with multiple products like e-cigarettes, hookahs, and cigarillos. Of all the young people in the study, those who experimented with many different products were 15 percentage points more likely to become daily cigarette smokers than those who had only tried one kind of tobacco product. And teenagers who experimented with e-cigarettes before age 18 were more likely to become daily smokers than those who tried vaping later in life. In other words, the theory that this new product would dissuade young people from using cigarettes didn’t hold up.
Pierce says that once people are addicted to cigarettes, it’s incredibly hard for them to quit. So to make a dent in smoking rates in the US, the change has to come from young people who start on e-cigarettes and never switch over to their combustible counterparts. The problem, his study results show, is that they are indeed switching. “Not smoking cigarettes is going to be harm reduction. But that’s not happening so far,” says Pierce.
Still, while the study concludes that vaping doesn’t stop young people from later turning to cigarettes, it’s hard to know whether e-cigarettes alone are leading more of them to smoke, as many health experts and parents worried they would in 2018 and 2019 as rates of vaping skyrocketed among middle and high school students. “If you’ve only tried one product, your chance of becoming a daily smoker is minimal,” says Pierce. And he acknowledges that because most of the young people in his study who became daily cigarette users were also experimenting with several nicotine products, it’s hard to say whether or not they would have started using cigarettes, regardless of whether they’d tried vaping.
That may be the population that was likely to start smoking anyway, says Ken Warner, an emeritus dean of the University of Michigan School of Public Health who was not involved in the study. “The bottom line here is we just don’t know that there’s any real association between vaping alone and trying cigarettes in the future,” he says.
In the meantime, Warner and others who study tobacco use say a growing body of evidence suggests that vaping might help adults quit. One randomized clinical trial from researchers in the United Kingdom, published in 2019 in the New England Journal of Medicine, found that e-cigarettes were more effective than nicotine replacement therapies like patches, gums, and lozenges. Another 2019 study from researchers in New Zealand published in The Lancet found that combining e-cigarettes with other products like patches could lead to a “modest improvement” in quitting outcomes. And an October meta-analysis performed by the Cochrane Review, an independent group of doctors and academics who analyze medical research, reviewed 50 studies and found that “nicotine e-cigarettes probably do help people to stop smoking for at least six months,” and that they are better than nicotine replacement therapies.
“We don’t have a lot of evidence, but the evidence we have is getting better,” says Nancy Rigotti, director of the Tobacco Research and Treatment Center at Massachusetts General Hospital, who co-authored the Cochrane Review assessment. She thinks more evidence will emerge but worries that, in the meantime, concerns about e-cigarettes’ effects on kids have overshadowed their potential benefits for adults who already smoke. “It’s too bad, because I take care of smokers that aren’t able to quit any other way and I’m tired of watching people die of cigarette-related disease,” she says. “If I can reduce that by getting them on e-cigarettes, I think I’m helping them. I wish we had better data to prove that.”
The problem, some researchers say, is that in the absence of good data, the vape debate has become extremely contentious. While some researchers see them as a useful way to reduce harm to existing smokers and even help them quit, others argue that vaping is simply too dangerous and will lead an entirely new generation of kids to start smoking. “This is the most fraught, controversial issue in my 45 years in tobacco control,” says Warner. “It has torn the field asunder.”
Rigotti points out that many are rightfully wary of tobacco companies making claims about safer products. “Everyone in tobacco control has so much PTSD, because the tobacco industry has historically been so evil,” she says. She points to shams like low tar cigarettes that were advertised as less harmful, but were in fact just as dangerous as their predecessors. She also criticizes vape companies that have aggressively targeted their advertisements to kids. “There’s no excuse for that,” she says.
Pierce’s study shows that vaping currently isn’t acting as a stopgap to prevent young people from moving on to cigarettes. So for harm reduction proponents, the next question is whether e-cigarettes’ net benefit to society—exposing fewer adults to harmful chemicals and helping them give up regular cigarettes—outweighs the risk that kids who try them won’t be deterred from smoking. Pierce says that he’s still not sure we have enough data to come to a conclusion. New types of e-cigarettes come out faster than researchers can study them, so it’s possible that recent models, which deliver nicotine more efficiently and may be more satisfying to smoke than earlier brands, may be better at helping people quit. “I’m on the fence,” says Pierce.
Overall, he worries that the conversation has become dominated by dogma, rather than data. “We’ve got to do proper science on this and follow the data, not our biases,” he says.
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