After decades of anti-tobacco campaigns, cigarette use is at an all-time low. Despite that, smoking remains the leading preventable cause of death in the United States. Nearly half a million Americans die every year from smoking tobacco—approximately one in five US deaths. Another 16 million Americans live with smoking-related diseases.
Switching from combustible tobacco to vaped nicotine would dramatically reduce those numbers, according to several public health experts and advocates of harm reduction.
Harm reduction is a set of practices that seek to limit the negative consequences of certain behaviors—in this case, the consumption of nicotine products. Vaping could potentially save millions of lives; at the same time, though, it should not be understated that an increasing number of young people are experimenting with e-cigarettes and other vapes, drawing calls nationwide for prohibitionist measures.
The fight over vaping is the latest tension in the long-standing debate about how society should address substance use we consider harmful, particularly among young people.
So far, more than 3 million smokers in the United States have transitioned to exclusively vaping. Many harm reductionists argue that prohibitionist policies on vapes would be an enormous setback for public health.
“Bans are an extremist reaction that people are going to regret,” said David Abrams, a professor of social and behavioral sciences at New York University. “It’s going to take a decade or more to pick up the pieces and see what mistakes we’ve made by this extreme emotional—rather than balanced scientific—approach.”
Research shows that vaping nicotine leads to far safer health outcomes than smoking cigarettes—95 percent safer, according to Public Health England, the United Kingdom’s executive public health agency. For chronic smokers, research has found that heart health rapidly improves upon transitioning to vaping. Yet the American public is largely unaware of the differential harm. (Informing both adults and young people about the different risks of drugs is considered a critical piece of the harm reduction–based approach to education.)
Supporters of harm reduction point out that public ignorance over the dangers of e-cigarettes is deepening. Almost two thirds of American adults disagreed with the notion that vaping nicotine is safer than smoking cigarettes—a 16 percent jump from a similar survey in 2016. Lynn Kozlowski, a professor of community health and health behavior at the University of Buffalo, told me that both adults and young people “have a right to accurate information about products or activities that increase or decrease risks to their health,” adding later that “there is an ethical demand for that approach.”
The backlash against vaping accelerated this summer when mysterious lung injuries emerged. While nearly all the vape-related hospitalizations and deaths (as of December 17, 2,506 and 54, respectively) were linked to contaminated black market THC cartridges, it didn’t stop politicians on both sides of the aisle from going after nicotine vape products.
Eight states have moved to limit vape sales so far, and, under mounting pressure, the monopolist e-cig company Juul pulled all non-tobacco or menthol flavors from the shelves. President Donald Trump even threatened to make all flavored nicotine vape products illegal, though he has since stepped back from a federal ban.
“It’s a classic drug panic,” said Helen Redmond, a licensed clinical social worker and senior editor of the online harm reduction–focused magazine Filter, adding that to foresee the consequences of flavor bans, “we only have to look back to alcohol prohibition. Immediately, underground markets spring up. And people get hurt because invariably these products will contain harmful chemicals. That’s what we’re seeing now [with THC].”
Alex Norcia, who along with others at Vice, has reported extensively on the war on vaping, said Colorado was the only state taking a measured approach to the rise in vape-related injuries and deaths. Rather than banning flavors or nicotine vaping outright, the state proposed banning potentially harmful additives in cannabis vapes, notably the oil-thickening substance vitamin E acetate, which the Centers for Disease Control and Prevention (CDC) recently isolated as the official culprit of the lung injuries.
Now, Pennsylvania might be added to the list of rational states; the crisis prompted lawmakers to pursue legalizing, and therefore more carefully regulating, marijuana. Noting Governor Tom Wolf and Lieutenant Governor John Fetterman’s support for legalization, based in part on the greater control it would bring over cannabis product standards and distribution, Norcia reports, “Pennsylvania seems to be the only state in the nation using the vape crisis as a reason to potentially legalize weed.”
Anti-prohibitionists also highlight the discriminatory policing that would likely follow a flavor ban. “We know that bans are not enforced in a race- or class-neutral way,” Redmond said. “Where will the NYPD go to enforce the flavor ban? They will go to neighborhoods where people of color live, where working people, poor people live.”
Michigan’s proposed flavor prohibition bars all sales, but as GQ writer Jay Willis points out, anyone with “four or more flavored tobacco products” is “rebuttably presumed” to be intending to sell and can be fined a maximum of $200 fine and/or be sentenced to six months in jail.
A federal prohibition of flavored vapes would also threaten the vape shop industry, which makes much of its profits from flavor sales. Dr. Michael Siegel, a professor of community health sciences at Boston University, doesn’t think it would be a loss only for small-business owners; it would be a loss for the 34 million adult cigarette smokers in the United States.
“I call them ‘smoking cessation clinics,’” Siegel said. Evidence is mounting that vape shops are instrumental in transitioning people from cigarettes to healthier vaped nicotine. Owners are often former smokers themselves and act as guides for those seeking to switch. Additionally, according to Siegel, vape shops provide something that’s crucial in overcoming cigarette addiction: community.
“The smoking addiction is not purely a pharmacological addiction,” he explained. Quitting cigarettes, Siegel said, is an incredibly difficult task in part because it involves shedding the social, cultural, and behavioral elements of the habit. Vaping fills in that gap with a healthier alternative. “This is more than a nicotine replacement device. This is an entire culture.”
While non-tobacco flavored vapes, like mango or cotton candy, appeal to children and teens, the CDC found that 55 percent of them used e-cigs out of curiosity, 31 percent because friends or family used them, yet only 22 percent for the availability of such flavors. What’s more, the focus on youth flavor affinities might obscure flavors’ importance for helping adults move off of cigarettes.
Amelia Howard, a PhD candidate in sociology at the University of Waterloo, told me, “What happened with e-cigarettes” in the 2000s before the youth vaping panic “is the market proliferated with consumers [trying to quit cigarettes] really keen on being able to try different things. In the value package that vaping offers to consumers, flavors are really fundamental.”
According to Abrams, flavors are key to why vaping might be twice as effective for smoking cessation as other nicotine replacement therapies like patches or gum. “From a behavioral psychology point of view,” Abrams said, “it makes perfect sense that to prevent relapse or to reduce the likelihood that you’re going to dual use both deadly cigarettes and e-cigarettes, you want to forget about the flavor of cigarettes.”
Research demonstrates that most people who successfully transition to only vaping may start off using menthol or tobacco flavors, but nearly everyone quickly switches to other flavors. Flavors bans are “ludicrous,” Abrams said. “Any smokers at any age,” he argued, “are going to be far bigger losers in the unintended consequences of removing a much more appealing flavored nicotine product from the market in every mom-and-pop store, while ironically leaving the most lethal products, which are flavored little cigars and cigarillos and mentholated cigarettes, on the market in every corner store in the country.”
Abrams advocates shifting from the abstinence model for nicotine addiction to one of harm minimization. His own research estimates that in the best-case scenario, if cigarettes were mostly replaced by e-cigarettes over a 10-year period in the United States, even accounting for a potential increase in people who don’t smoke picking up vaping, 6.6 million people would be saved from premature death.
Redmond said that while smoking rates have dropped in the last couple of decades, they remain high among marginalized populations: people who use drugs, people who are homeless, and people with mental illnesses. She also said that many decades-long smokers may not want to quit nicotine, and e-cigarettes provide them a “revolutionary” maintenance tool.
If we are to take the principles of harm reduction seriously, Redmond said, “the most stigmatized, hated, and hounded groups of people in our society” are the ones “we would be having a national conversation about. Not teenagers. That’s not where the problem is.”
Many parents, public health officials, researchers, and politicians are not convinced. Bonnie Halpern-Felsher, a professor of pediatrics and adolescent medicine at Stanford and the founder and director of the youth education resource Tobacco Prevention Toolkit is a firm advocate of flavor bans. She argues that we haven’t yet seen strong enough evidence that vaped nicotine is more effective at smoking cessation than other products. She also said that youth vaping is an especially urgent cause for alarm because of the adverse effects of nicotine on the developing brain. (Some harm reduction experts say that the evidence for such harms on the adolescent brain is inconclusive because the studies have been limited to rodents.)
But Halper-Felsher believes the problem is likely worse than is normally reported. The vaping rates reported in the National Youth Tobacco Survey, she said, likely understate the problem: “Talking to students, teachers, and parents on a very regular basis, we’re hearing that [the national survey’s figures are] a dramatic underestimate. Really the rates are like 50 percent, if not more, of youth who are using e-cigarettes at some level.” And, she added, “a significant number of youth—how many, we don’t know—are addicted.”
Siegel also considers youth vaping an epidemic. Both he and Halpern-Felsher blame Juul and other products popular among young people for its use of nicotine salts, which mimic the nicotine “rush” that cigarettes deliver and are considered more addictive than the freebase nicotine used in many other e-liquids. Because of this, Siegel identifies limiting nicotine concentration as a possible regulatory alternative to prohibition. (NYU’s Abrams and University of Waterloo’s Howard both oppose such regulation, because it would hinder a vape transitioner’s ability to find the highly individualized sweet spot of flavor, nicotine content, and device preference.)
Some researchers, including Sheila Vakharia, the deputy director of the Department of Research and Academic Engagement at the Drug Policy Alliance, disagree with the premise that there is a youth “epidemic” at all. While Vakharia acknowledges that the national survey rates do seem high, she said it’s unclear how many young people are using daily, which would be a clearer sign of addiction.
Vakharia, Siegel, and Abrams all stressed that the vast majority of adolescent e-cig use is experimental. And significantly, they see little evidence that vaping is acting as a gateway for young people to combustible tobacco. (Halper-Felsher points out that young people who vape are more likely to smoke cigarettes; in response, several harm reductionists told me that doesn’t necessarily indicate that people who would otherwise never smoke are being initiated into cigarettes.)
Taking issue with the gateway theory in general, Vakharia said, “People seek out substances for a variety of reasons,” adding, “When we say one drug is a gateway to the other, we minimize [the role] that a human plays in their decisions to use a substance.”
In an e-mail, Dr. Kimberley Sue, the medical director of the Harm Reduction Coalition, wrote, “A harm reduction approach would likely entail deeper dives into why people use substances at that age.” While noting her concern with e-cig companies’ profiting off of young people, Sue urged a look into the societal and psychological factors of drug use: “social pressure, untreated anxiety or depression, problems at home.”
Many harm reductionists do support regulations such as curbing advertising aimed at young people, enacting and enforcing age restrictions, and modest product standards like those seen in the United Kingdom, where the government encourages smokers to switch from cigarettes to vaping products.
Getting an honest and complete education about the differential harms of nicotine products—and all risky behaviors—is considered an essential component of harm reduction. In the “Just Say No” era of the war on drugs in the 1980s and ’90s, the infamously ineffective Drug Abuse Resistance Education curriculum dominated American schools. Even today few schools provide holistic drug education to students, many of whom are going to engage in behaviors considered undesirable whether parents and politicians like it or not.
In response, this year the Drug Policy Alliance released “Safety First: Real Drug Education for Teens,” what they call “the nation’s first harm reduction-based drug education curriculum for high school teachers.” In 15 lessons, students are introduced to harm reduction and drug policy. They learn what drugs are and how they work, with specific lessons on different classes of drugs, from vaping to psychedelics; engage with the relationship between drugs and mental health; and learn to locate resources to learn about and act on the health risks of drug use.
Abrams explained that abstinence-only programs “completely fail. More kids got STDs, were pregnant, and started using drugs than in full sex education.” Multiple people brought up modern sex education, in which young people are informed about relative risks and harms. It has been proven to be more effective than “withholding half the truth” and exaggerating risks.
Abrams added, “To me, telling the truth is harm reduction.”