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Balancing Consideration of the Risks and Benefits of E-Cigarettes David J. K. Balfour, DSc, Neal L. Benowitz, MD, Suzanne M. Colby, PhD, Dorothy K. Hatsukami, PhD, Harry A. Lando, PhD, Scott J. Leischow, PhD, Caryn Lerman, PhD, Robin J. Mermelstein, PhD, Raymond Niaura, PhD, Kenneth A. Perkins, PhD, Ovide F. Pomerleau, PhD, Nancy A. Rigotti, MD, Gary E. Swan, PhD, Kenneth E. Warner, PhD, and Robert West, PhD
See also Samet and Barrington-Trimis, p. 1572.
The topic of e-cigarettes is controversial. Opponents focus on e-cigarettes’ risks for young people, while
supporters emphasize the potential for e-cigarettes to assist smokers in quitting smoking. Most US health
organizations, media coverage, and policymakers have focused primarily on risks to youths. Because of
theirmessaging,much of the public—includingmost smokers—nowconsider e-cigarette use as dangerous
as or more dangerous than smoking. By contrast, the National Academies of Science, Engineering, and
Medicine concluded that e-cigarette use is likely far less hazardous than smoking. Policies intended to
reduce adolescent vaping may also reduce adult smokers’ use of e-cigarettes in quit attempts.
Because evidence indicates that e-cigarette use can increase the odds of quitting smoking, many scientists,
including this essay’s authors, encourage the health community, media, and policymakers tomore carefully
weigh vaping’s potential to reduce adult smoking-attributable mortality.
We review the health risks of e-cigarette use, the likelihood that vaping increases smoking cessation,
concerns about youth vaping, and the need to balance valid concerns about risks to youths with the
potential benefits of increasing adult smoking cessation. (Am J Public Health. 2021;111(9):1661–1672.
https://doi.org/10.2105/AJPH.2021.306416)
The use of nicotine-containing elec-
tronic- or e-cigarettes has divided
the tobacco control community along a
spectrum from fervent opponents to
enthusiastic supporters. Opponents
emphasize that vaping can cause nico-
tine addiction among young people and
could lead some to become dependent
cigarette smokers, possibly
“renormalizing” smoking. They cite
research indicating that nicotine may
harm adolescents’ developing brains.
Some consider vaping’s health risks
substantial, and somequestionwhether
vaping decreases smoking cessation.1
By contrast, proponents present evi-
dence that vaping assists smokers in
quitting smoking and believe that vaping
poses far less risk to users’ health than
does smoking. Smoking among youths,
they observe, has declined rapidly dur-
ing vaping’s ascendancy.2
Many US governmental health agen-
cies3–6 and nongovernmental medical7,8
and health organizations9–12 focus pri-
marily onvaping’s risks for youngpeople.
These organizations’ pronouncements
and their influence on policymakers and
the media have had a profound impact
on the public’s understanding of vaping.
A study of US news articles on
e-cigarettes found that, from 2015 to
2018, 70%ofarticlesmentionedvaping’s
risks for youths, while only 37.3% noted
potential benefits for adult smokers.13
Of respondents to a 2019 national sur-
vey, nearly half considered vaping nico-
tine just as harmful as or more harmful
than cigarette smoking. Only 1 in 8 con-
sidered vaping less harmful. (The rest
responded “I don’t know.”14) By contrast,
the US National Academies of Sciences,
Engineering, and Medicine15 and the
BritishRoyalCollegeofPhysicians16have
concluded that vaping is likely far less
hazardous than smoking cigarettes.
The public’s inaccurate perception
worsened following a 2019 vaping-
associated acute pulmonary disease
outbreak (named “e-cigarette or vaping
use-associated lung injury” [EVALI]) that
caused 68 fatalities.17 Media coverage
was extensive. Several states and cities
promptly banned retail and online sale
of flavored e-cigarettes.18 In early 2020,
however, research attributed the illness
to vitamin E acetate, an adulterant in
illicit tetrahydrocannabinol (THC) vaping
devices shown to produce pulmonary
injury inanimals.19–21A small percentage
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of patients with EVALI reported vaping
only nicotine, but they were primarily in
states where THC was illegal, and most
had no toxicology testing.22 Once the
potential harm of vitamin E acetate was
publicized and adulterated THC
removed from themarket, the incidence
of new cases fell precipitously.19 Yet,
after the outbreak, two thirds of
respondents to a poll related the lung
disease deaths to use of “e-cigarettes
such as JUUL.” Only 28% related the
deaths to use of “marijuana or THC e-
cigarettes.”23
Scientists differ in their views of the
relative risks and benefits of vaping nic-
otine, and of their implications.1,2,24,25
Many, including this article’s authors,
believe that vaping can benefit public
health, given substantial evidence sup-
porting the potential of vaping to reduce
smoking’s toll. Our objective is to
encourage more balanced consider-
ation of vaping within public health and
in the media and policy circles.
In the following pages we address:
� the health risks of vaping,
� the likelihood that vaping increases
smoking cessation,
� the principal concerns about youth
vaping, and
� balancing concerns about risks to
youths with potential benefits for
adult smokers.
THE HEALTH RISKS OF VAPING
According to the National Academies of
Sciences, Engineering, and Medicine,
“Laboratory tests of e-cigarette ingre-
dients, in vitro toxicological tests, and
short-term human studies suggest that
e-cigarettes are likely to be far less
harmful than combustible tobacco ciga-
rettes.”15(p1) The British Royal College of
Physicians similarly concluded that
“vaping isn’t completely risk-free but is
far less harmful than smoking
tobacco.”16
High-quality clinical and epidemio-
logical data on vaping’s health effects
are relatively sparse. There are no data
on long-term health effects, reflecting
the relative novelty of vaping and the
rapid evolution of vaping products.
Determining even short-term health
effects in adults is difficult because
most adult vapers are former or cur-
rent smokers.
Some studies find that vaping may
worsen asthma, bronchitis, and cough,
including among nonsmoking young
people.26,27 By contrast, a few studies
found that smokers with asthma or
chronic obstructive lung disease see
symptoms improve after switching to e-
cigarettes.28,29 Randomized switching
trials (cigarettes to e-cigarettes) docu-
ment improvements in respiratory
symptoms.30,31
Laboratory studies have reported
potentially adverse effects of
e-cigarette aerosol in cells and ani-
mals.26,32 It is difficult, however, to
extrapolate from exposure conditions
in cells and animals to humans.26
Human experimental studies have
focused on acute effects,33 which may
not predict future disease. For example,
e-cigarettes acutely impair tests of
endothelial function, a common feature
of cardiovascular disease, but when
smokers switch from cigarettes to
e-cigarettes, endothelial function nor-
malizes.34,35 A recent study detected no
difference in biomarkers of inflamma-
tory and oxidative stress in exclusive
e-cigarette users and nonusers of
either cigarettes or e-cigarettes.36
There is little evidence that
e-cigarettes pose significant cancer
risk.15 However, some studies raise
concerns that warrant long-term follow-
up of vapers.37,38
Many scientists have concluded that
vaping is likely substantially less dan-
gerous than smoking because of the
following15,16:
� Thenumberof chemicals in cigarette
smoke, greater than 7000,39
exceeds that of e-cigarette aerosol
by 2 orders of magnitude.40,41
� Among potentially toxic substances
common to both products, ciga-
rette smoke generally contains sub-
stantially larger quantities than
e-cigarette aerosol.42–44 However,
e-cigarette aerosol contains some
substances not found in cigarette
smoke.45
� Biomarkers reflecting exposure to
toxic substances are present at
much higher levels in exclusive ciga-
rette smokers than in exclusive
vapers, and studies of smokers who
switch to e-cigarettes find decreases
in toxicant exposures.31,46–50
� Tests of lung and vascular function
indicate improvement in cigarette
smokers who switch to e-ciga-
rettes.28,29,34 Exclusive users of
e-cigarettes (most being former
smokers) report fewer respiratory
symptoms than do cigarette smok-
ers and dual users.51
However, questions remain.52 Ongo-
ing research will lend further insight into
the products’ absolute and relative
dangers.
THE LIKELIHOOD THAT VAPING INCREASES SMOKING CESSATION
A growing body of evidence indicates
that vaping can foster smoking cessa-
tion, although the evidence is not
definitive.53,54
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Randomized Trials
In an English smoking cessation ran-
domized controlled trial,55 smokers
assigned to e-cigarettes achieved nearly
twice the rate of biochemically con-
firmedsmoking cessationat1 year (18%)
than smokers assigned to nicotine
replacement therapy (9.9%); all received
identical behavioral counseling. While
80% of those who quit with e-cigarettes
were still vaping, they were no longer
exposed to smoking’s substantially
higher risk.
A New Zealand trial found that at 6
months, nicotine patch with nicotine
e-cigarettes outperformed patch with
nicotine-free e-cigarettes and patch
alone. Thus, in addition to aiding quitting
when used alone, nicotine e-cigarettes
may increase the effectiveness of exist-
ing cessation aids.56
Examining 26 randomized controlled
trials, a recent Cochrane Review con-
cluded that “There ismoderate-certainty
evidence that ECs [electronic cigarettes]
with nicotine increase quit rates com-
pared to ECs without nicotine and com-
pared to nicotine replacement
therapy.”53 Another meta-analysis drew
similar conclusions, albeit with less cer-
tainty.57 However, the US Preventive
Services Task Force’s smoking cessation
practice guideline did not find the evi-
dence convincing.58 As such, and for
reasons theCochrane Reviewdescribes,
more well-designed clinical trials are
needed.
Noteworthy is the lack of trials by
e-cigarette manufacturers in pursuit
of regulatory agency approval to use
e-cigarettes for smoking cessation,
likely reflecting the profitability of
selling e-cigarettes as consumer
products, rather than medicinal
devices.
Population Studies
Collectively, population studies’ findings
are consistent with a near doubling of
quit attempt success, found in the ran-
domized controlled trials, and the fact
that e-cigarettesare smokers’mostused
aid in quit attempts.59 Four studies60–63
found significant increases in smoking
cessation (10%–15%) that the authors
associated with vaping. A Centers for
Disease Control and Prevention study
reported that, in 2018, 15.1%of smokers
had quit smoking for 6months or longer
using e-cigarettes, compared with 3.3%
using other noncigarette tobacco prod-
ucts and 6.6% using no tobacco prod-
ucts.64 Another study identified a near
doubling of self-reported cessation
among users of e-cigarettes or vareni-
cline compared with smokers not using
these products.65 Consistent with these
population studies, simulation analyses
have generally found that vaping
increases smoking cessation, avoiding
large numbers of premature
deaths.66–69
Other researchers have found regular
and frequent e-cigarette use to be
associated with increased smoking ces-
sation, while infrequent usewasnot.70–75
This could reflect self-selection, with
frequent vapers possibly liking vaping
more and being more motivated to quit
smoking. Infrequent vapers might use
vaping as a temporary nicotine source
where smoking is prohibited.73,76
Other researchers have reported
reduced cessation rates among smok-
ers who vape.77,78 However, many failed
to distinguish frequency of vaping,
introducing the risk of the selection
biases just noted. Other studies
included only current vapers who also
smoke, systematically excluding vapers
who had successfully quit smoking.53,78
An often-cited meta-analysis found
vapers’ odds of quitting smoking 28%
lower than for nonvaping smokers.77
This analysis combined clinical trials,
cohort studies, and cross-sectional
analyses, an inappropriate practice for
meta-analyses.79 Furthermore, the indi-
vidual studies’ sources of bias could be
compounded in a meta-analysis, possi-
bly producing an incorrect result.76
Cigarette Sales
For years, US cigarette sales declined 2%
to 3% annually. More recently, as vaping
product sales increased, cigarette sales
decreased much more rapidly. Con-
versely, following the EVALI outbreak
and e-cigarette sales restrictions, sales
of e-cigarettes fell and sales of cigarettes
resumed their prevaping pattern.80
Studies finding a positive cross-price
elasticity of demand between cigarettes
and e-cigarettes support the conclusion
that the products are substitutes.81,82
Support for the plausibility of an
inverse causal relationship between
vaping and smoking comes from coun-
tries in which startling decreases in cig-
arette sales have accompanied rising
sales of another novel nicotine product,
heated tobacco products (HTPs). Like
e-cigarettes, HTPs exposeusers to lower
levels of toxicants than do cigarettes.83
In Japan, HTP adoption from 2015 to
2019 was accompanied by cigarette
sales declining by a third.84 In both
cases—HTPs in Japan ande-cigarettes in
the United States—as sales of reduced-
risk products rose, cigarette sales fell.
Unintended Consequences of Policies Restricting Vaping
Studies have found that policies
intended to restrict e-cigarette use may
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have unintentionally increased cigarette
smoking. One study associated a Min-
nesota e-cigarette tax with increased
adult smoking and reduced cessation,
estimating that taxing e-cigarettes at the
same rate as cigarettes nationwide
could deter 2.75 million smokers from
quitting smoking over a decade.85 Two
other studies found state restrictions on
minors’ access to e-cigarettes associ-
ated with higher adolescent cigarette
smoking.86,87
Implications
Although not the final word, the totality
of the evidence indicates that frequent
vaping increases adult smoking cessa-
tion. Smokers unable to quit smoking
with evidence-based cessation meth-
ods88 should bewell informed about the
relative risks of vaping and smoking and
vaping’s potential to help them quit
smoking. They should understand that,
while the long-term health consequen-
ces are unknown, completely substitut-
ing vaping for smoking likely reduces
health risks, possibly substantially.15
Dual use of cigarettes and e-cigarettes
will not have a comparable beneficial
effect.88 However, a period of dual use
may be necessary for some smokers to
transition from smoking. Because vap-
ing itself poses some risk, thebest advice
is to eventually stop vaping as well.
THE PRINCIPAL CONCERNS ABOUT YOUTH VAPING
Theprincipalobjections to vaping regard
3 potential effects on youths:
� Vaping can cause nicotine addiction
among young people who never
would have tried smoking.
� Vaping by never-smoking youths
may cause some to try smoking,
risking “renormalizing” smoking
among young people.
� Nicotine can harm developing
brains, and vaping nicotinemay have
other adverse health effects.
Vaping as a Cause of Nicotine Addiction
Vaping likely addicts some young people
to nicotine. However, the evidence does
not suggest it is addicting very large
numbers.89 Jarvis et al. concluded that
“Data . . . do not provide support for
claims of a new epidemic of nicotine
addiction stemming from use of
e-cigarettes.”90 Jackson et al. recently
reported that the e-cigarette–driven
increase in nicotine product use among
high-school students is not associated
with an increase in population-level
dependence.89 Among tobacco-naïve
youths, in addition to low vaping preva-
lence (9.1% in the past 30 days in 2020)
and frequency (2.3% vaping$20 days in
the past 30 days),91 small percentages
exhibited signs of nicotine
dependence.90
Frequent use is much more common
among current or former smoking
youths than among never-smokers.90
Many former smokers were already
addicted to nicotine before initiating
vaping. With high-school students’
smoking declining at an increasing
rate since youths began using
e-cigarettes,92,93 some may vape to
reduce or quit smoking.
Nonetheless, to the extent that vaping
creates nicotine addiction among oth-
erwise tobacco-naïve youths, concerted
efforts are needed to reduce youth
vaping. The new minimum age of 21
years for purchasing tobacco products
should help.94 Governmental agen-
cies3,95 and voluntary organizations12,96
disseminate vaping’s risks to youths
through Web sites, social media, and
television campaigns. Voluntary organi-
zations lobby Congress and state gov-
ernments to adopt policies restricting
youth access to e-cigarettes.
Recentpolicyattentionhas focusedon
restricting the availability of e-cigarettes
with flavors,97 a principal attraction for
youths.98–101While flavor bans could
reduce youth interest in e-cigarettes,
they could also reduce adult smokers’
vaping to quit smoking.102–104 Like
youths, adults prefer nontobacco fla-
vors,105 both groups favoring fruit and
sweet flavors.106,107
Policies regarding flavors reflect the
more general issue considered in this
article: the need to create a balance
between the sometimes-conflicting
goals of preventing youth vaping and
supporting adults’ smoking cessation
attempts, particularly for smokers
unable or unwilling to quit otherwise.108
Vaping Causing Smoking Initiation
Prospective studies have found that
young people who had vaped but never
smoked cigarettes were more likely to
have tried cigarettes severalmonths to2
years later than contemporaries who
had neither smoked nor vaped.15,109–113
Some commentators thus consider
vaping a “gateway” into smoking.114,115
Other observers believe the relation-
ship reflects a “common liability”116:
young people who vape are generally
more prone to risky behavior117; hence,
they might be more likely to try smoking
evenwithout vaping.118–121Three recent
studieshave concluded that vaping likely
diverts more young people from smok-
ing than encourages them to
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smoke.122–124 Conversely, some pro-
spective studies have found the
vaping–smoking relationship strongest
in youths at low risk of smoking.125–127
Obvious plausible correlates are often
not considered, however.128 Impor-
tantly, few studies include youths’ use of
other psychoactive substances, includ-
ing marijuana and alcohol. In 1 study,
inclusion of marijuana and 3 other vari-
ables eliminated the otherwise statisti-
cally significant link between vaping and
subsequent smoking.126,127Most stud-
ies do not even consider previous use of
tobacco products other than cigarettes.
Adjustment for confounders substan-
tially reduces the relationship between
vaping and subsequently trying
cigarettes.129
Numbers of cigarettes smoked at
follow-up are frequently very low, only 1
or 2 in the past 12 months in one
study.130 Furthermore, the prospective
studies generally have not examined
progression to regular dependent
smoking, with 1 recent exception.131
Only a small proportion of youths who
experiment with smoking become reg-
ular smokers. Kim and Selya found that
while e-cigarette use was associated
with ever trying smoking, it was not
associated with current continued
smoking.119 Pierce et al. recently con-
cluded the opposite.131 Shahab et al.
reported that less than 1% of US stu-
dents who initiated nicotine or tobacco
use with e-cigarettes were established
cigarette smokers.132
If vaping causes someyoungpeople to
try cigarettes, the aggregate impact
must be small. A recent study68 esti-
mated that if vaping increases non-
smoking youths’oddsof tryingcigarettes
by 3.5 (as reported by Soneji et al.109),
smoking initiation among young adults
would increase less than 1 percentage
point. Furthermore, US survey data
demonstrate that smoking among
young people has declined at its fastest
rate ever during vaping’s ascen-
dancy.92,93,133 If vaping increases smok-
ing initiation, other unknown factors
more than compensate.
Nicotine Harming Developing Brains
Animal model studies have found that
nicotine can affect maturation of brain
parts associated with executive function
and decision-making, potentially leading
to more impulsive behavior, cognitive
deficits, and greater likelihood to self-
administer other drugs.134,135 In addi-
tion, there is evidence in humans of
neurological changes attributed to nic-
otine in the brains of adolescent smok-
ers, interpreted by some as reflecting
similar harmful effects to those in the
animal models.136,137
These studies lead some researchers
to suspect that adolescent nicotine use
in any form may lead to long-term
structural and functional brain changes
with associated negative implications for
cognition or impulse control.138 How-
ever, given species differences and
questions about the relevance of
experimental animal nicotine dosing
paradigms to human use patterns, the
validity of extrapolation to humans is
speculative. Whether impaired brain
development with behavioral conse-
quences occurs in young nicotine con-
sumers is difficult to determine because
of potential confounding of genetic and
socioeconomic factors, the influence of
other substance abuse, and the role of
preexisting neuropsychiatric problems
associated with youth smoking.
Research has yet to isolate nicotine use
in the adolescent years and then exam-
ine later sequelae. Still, concerns about
brain function effects of nicotine
exposure through vaping deserve seri-
ous examination.98
Concerns About Youth Vaping in Context
Several considerations raise the ques-
tion of whether, for youth as a whole,
vaping creates dangerous levels of nic-
otine exposure that would not have
occurred in the absence of vaping.
� The large majority of nontobacco
product–using young people do not
vape and, thus, have no nicotine
exposure.90
� Among those who vape, most do so
infrequently; many are short-term
experimenters.90
� Frequent vaping is most common
among current or former smokers,
individuals already exposed to
nicotine.91
� The most dangerous form of youth
exposure to nicotine, cigarette
smoking, has declined at an
unprecedented rate during the era
of youth vaping.92,93,133 Use of other
tobacco products has declined as
well.139
Still, concerns emanating from sub-
stantial increases in youth vaping in
2018 and 2019 are readily understand-
able and important to address. A sizable
decline in 2020 is encouraging.139 We
must continuemonitoring youth vaping,
learning more about potential harms
and identifying effective prevention
strategies. However, as public health
groups, the media, policymakers, and
the general public focus on youth vap-
ing, vaping’s potential to help adults quit
smoking too often gets lost. That may
come at a significant public health cost.
Fourteen percent of US adults smoke;
smoking annually causes nearly half a
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million deaths. Anything that can reduce
that toll deserves serious attention.
With the focus on youths creating an
environment in which smokers believe
that vaping is as dangerous as or more
dangerous than smoking,14 many
smokers struggling to quit may be
unwilling to try vaping as an alternative.
This likely translates into less smoking
cessation than if smokers correctly
understood the relative risks of vaping
and smoking.
BALANCING CONCERNS ABOUT RISKS AND POTENTIAL BENEFITS
Research comparing vaping’s risks for
youths with potential benefits for adult
smokers has found the latter to
dominate,66 potentially avoiding the
smoking-produced loss of tens of mil-
lions of life-years.67,68 Vaping cannot
end cigarette smoking. But vaping can
complement tried-and-true methods of
reducing smoking, including taxes on
combustible tobacco products, smoke-
free workplace laws, marketing restric-
tions, plain packaging with graphic
warning labels, antismoking media
campaigns, tobacco-21 laws,94 and
evidence-based smoking cessation
treatment.88
We believe the potential lifesaving
benefits of e-cigarettes for adult smok-
ers deserve attention equal to the risks
to youths.140 Millions of middle-aged
and older smokers are at high risk of
near-future disease and death. Quitting
reduces risk.88 Young people will not
experience smoking-related (and con-
ceivably vaping-related) chronic dis-
eases for 3 decades, and likely not at all
if they quit within a decade or 2. Social
pressures to quit smoking will probably
remain strong, and quitting aids may
improve. Furthermore, as noted
previously, the rate of smoking among
young people has declined while vaping
has increased.92,93,133 Vaping may
addict some youths to nicotine, but
many fewer than popularly
believed.89,90
Seeking a Sensible Mix of Policies
To date, the singular focus of US poli-
cies on decreasing youth vaping may
well have reduced vaping’s potential
contribution to reducing adult smok-
ing. Those policies include taxing
e-cigarettes at rates comparable to
cigarette taxes,141 decreasing adult
access to flavored e-cigarettes thatmay
facilitate smoking cessation,103 and
convincing the public—including
smokers—that vaping is as dangerous
as smoking.14
The public health objective should be
to develop policies and interventions
that both reduce youth vaping and
increase adult smoking cessa-
tion.97,120,140,142 While an in-depth dis-
cussion of an optimal policy mix
exceeds the scope of this article, we
here present illustrative policies that
would serve this objective. These are all
in addition to conventional evidence-
based prevention and cessation
measures.
� Tax cigarettes and other combusti-
ble tobacco products heavily;
impose a more modest tax on
e-cigarettes. Taxes should be pro-
portionate to risk. A much higher
tax on combustibles will encourage
adult smokers to quit smoking or to
switch to less expensive
e-cigarettes. By raising the price of
e-cigarettes, a modest tax will dis-
courage their use by price-sensitive
youths.141
� Because both youth and adult smok-
ers find e-cigarette flavors
attractive,98–107 banning all (or most)
flavors risks reducing smokers’ use
of e-cigarettes to quit smoking102–104
at the same time that it reduces
youth vaping.99,101 An alternative
would be to limit the retail sale of
flavored e-cigarettes to adult-only
outlets such as vape shops. An
imperfect policy for either goal, this
approach could benefit both.
� Government agencies and health
organizations should develop
nuanced, targeted communications
that emphasize the realistic con-
cerns about youth vaping and, sep-
arately, the potential benefits of
e-cigarettes as less-risky (but not
risk-free) alternatives for adult
smokers otherwise unable or
unwilling to quit smoking.
� The US Food and Drug Administra-
tion (FDA) should strictly regulate
e-cigarette advertising and market-
ing, prohibiting all marketing
directed at, or attractive to, youths
and young adults, including all
“lifestyle” advertising. They should
limit advertising to a “switch” theme
directed clearly, and exclusively, to
adult smokers otherwise unable to
quit smoking.
� FDA should implement its thought-
ful comprehensive 2017 plan,143
mandating reduction of nicotine in
cigarettes to levels incapable of
sustaining addiction, while ensuring
the availability of consumer-
acceptable reduced-risk nicotine
products. To achieve the latter, the
agency should develop product
standards for products like
e-cigarettes, ensuring minimization
of risk associated with the product
class while maintaining consumer
acceptability.
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The Role of Nicotine in Tobacco-Produced Disease
FDA predicated its comprehensive
plan on recognition of the continuum
of risk in nicotine products.143 Nico-
tine is the chemical in tobacco that
fosters addiction. However, toxic
constituents other than nicotine, pre-
dominantly in smoked tobacco, pro-
duce the disease resulting from
chronic tobacco use.143,144 Nicotine-
yielding products vary in risk from
FDA-approved nicotine replacement
therapy products at the lowest end of
the risk continuum to combustible
cigarettes at the highest.
Unfortunately, the public has a dis-
torted view of the dangers associated
with nicotine per se. In a recent survey,
57% of respondents incorrectly
agreed that “nicotine in cigarettes is
the substance that causes most of the
cancer caused by smoking.” Only
18.9% disagreed. (The rest answered
“Don’t know.”)14 In a recent survey of
physicians, 80% strongly, but incor-
rectly, agreed that nicotine causes
cancer, cardiovascular disease, and
chronic obstructive pulmonary
disease.145
CONCLUSIONS
We share the very legitimate concerns
about youth vaping with the entire field
of public health. Our goal is to put those
concerns in perspective. We agree with
former SurgeonGeneral C. Everett Koop
who, in 1998, urged that “[A]s we take
every action to save our children from
the ravages of tobacco, we should dem-
onstrate that our commitment to those
who are already addicted . . . will never
expire.”146 The latter appears at risk
today.
While evidence suggests that vaping is
currently increasing smoking cessation,
the impact could be much larger if the
public health community paid serious
attention to vaping’s potential to help
adult smokers, smokers received accu-
rate information about the relative risks
of vapingandsmoking, andpolicieswere
designed with the potential effects on
smokers in mind. That is not happening.
The need to pay attention to adult
smokers is particularly important from a
social justice perspective. African Amer-
icans suffer disproportionately from
smoking-related deaths, a disparity that,
a new clinical trial shows, vaping could
reduce.31 Today’s smokers come dis-
proportionately from lower education
and income groups, the LGBTQ (lesbian,
gay, bisexual, transgender, and queer or
questioning) community,147 and popu-
lations suffering frommental health
conditions148 and from other drug
addictions.149 Smoking accounts for a
significant proportion of the large life
expectancy difference between affluent
and poorer Americans.150,151 For smok-
ers with serious psychological distress,
two thirds of their 15-year loss of life
expectancy comparedwith nonsmokers
without serious psychological distress
may be attributable to their smoking.152
Vaping might assist more of these
smokers to quit.148,153
To the more privileged members of
society, today’s smokers may be nearly
invisible. Indeed, many affluent, edu-
cated US persons may believe the
problem of smoking has been largely
“solved.” They do not smoke. Their
friends and colleagues do not smoke.
There is no smoking in their workplaces,
nor in the restaurants and bars they
frequent. Yet 1 of every 7 US adults
remains a smoker today.
Smoking will claim the lives of 480000
ofour fellowcitizens this year alone.
ABOUT THE AUTHORS David J. K. Balfour is professor emeritus with the Division of Systems Medicine, School of Medicine, University of Dundee, Dundee, UK. Neal L. Beno- witz is with the Department of Medicine, School of Medicine, University of California San Francisco. Suzanne M. Colby is with the Department of Psy- chiatry and Human Behavior, Alpert Medical School, Brown University, Providence, RI. Dorothy K. Hatsukami is with the Department of Psychiatry and Behavioral Sciences, Medical School, Univer- sity of Minnesota, Minneapolis. Harry A. Lando is with the Division of Epidemiology and Community Health, School of Public Health, University of Min- nesota. Scott J. Leischow is with the College of Health Solutions, Arizona State University, Phoenix. Caryn Lerman is with the Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles. Robin J. Mer- melstein is with the Department of Psychology, University of Illinois–Chicago. Raymond Niaura is with the Department of Epidemiology, School of Global Public Health, New York University, New York, NY. Kenneth A. Perkins is with the Depart- ment of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA. Ovide F. Pomerleau is professor emeritus with the Department of Psy- chiatry, Medical School, University of Michigan, Ann Arbor. Nancy A. Rigotti is with the Department of Medicine, Massachusetts General Hospital, Har- vard Medical School, Boston. Gary E. Swan is with the Stanford Prevention Research Center, Depart- ment of Medicine, Stanford University School of Medicine, Palo Alto, CA. Kenneth E. Warner is with the Department of Health Management and Policy, School of Public Health, University of Michigan. Robert West is with the Department of Behavioural Science and Health, University College London, London, UK.
CORRESPONDENCE Correspondence should be sent to Kenneth E. Warner, PhD, Department of Health Management and Policy, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109-2029 (e-mail: kwarner@umich.edu). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.
PUBLICATION INFORMATION Full Citation: Balfour DJK, Benowitz NL, Colby SM, et al. Balancing consideration of the risks and benefits of e-cigarettes. Am J Public Health. 2021; 111(9):1661–1672.
Acceptance Date: May 15, 2021.
DOI: https://doi.org/10.2105/AJPH.2021.306416
CONTRIBUTORS K. E. Warner wrote much of the original draft of the article and supervised revisions. N. L. Benowitz, S.M. Colby, D. K. Hatsukami, R. Niaura, N. A. Rigotti, and R. West drafted specific sections of the article or played lead roles in reviewing and revising article drafts. All authors reviewed all drafts critically, contributed significantly to revisions, and approved the final version of the article.
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ACKNOWLEDGMENTS The paper was presented by K. E. Warner at the E-Cigarette Summit: Science, Regulation & Public Health, USA Virtual Summit, May 25, 2021.
The authors are former presidents of the Society for Research on Nicotine and Tobacco (SRNT), the world’s leading professional organiza- tion dedicated to the subject. They are listed in alphabetical order. All 26 of the then–past presi- dents were invited to participate as co-authors of this article. (A 27th past president was the active president at the time of preparation of the article.) We were unable to reach one of them. Three were not included because of institutional commitments that they felt might be interpreted as conflicts of interest. The remaining 7 declined to co-author. Note. The opinions expressed in this article are
solely those of the authors. They do not represent those of SRNT, which has taken no organizational position on the issues discussed in this article and had no involvement in the preparation of this article.
CONFLICTS OF INTEREST N. L. Benowitz is a consultant to Pfizer and Achieve Life Sciences, companies that market or are developing smoking cessation medications, and has been an expert witness in litigation against tobacco companies. S. J. Leischow is conducting a clinical trial supported by Achieve Life Sciences, which is developing a nonnicotine medication for smoking cessation, and has consulted with them. He also consulted more than 1 year ago for GSK, which is working to bring a new nicotine- replacement product to market, and he receives medication for a National Institutes of Health– funded smoking-cessation study from Pfizer. N. A. Rigotti receives royalties from UpToDate Inc for writing about smoking cessation and e-cigarettes and is a consultant for Achieve Life Sciences for an investigational smoking-cessation medication. R. West has undertaken research and consultancy for Pfizer and GSK, companies that manufacture smoking-cessation medications.
HUMAN PARTICIPANT PROTECTION There were no human participants involved.
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