Tom Frieden, director of the U.S. Centers for Disease Control and Prevention (CDC), has been agitating against electronic cigarettes for the last year or so, sometimes inventing facts from whole cloth in an effort to portray the product as a grave threat to public health and a menace to "our children." In a recent interview with NPR, Frieden offers a glimpse of the mentality underlying his puzzling hostility to e-cigarettes, which show great promise as a way to reduce smoking-related disease:
There are an enormous number of misconceptions about e-cigarettes. For example, smokers routinely say, "Well, if I want to quit, maybe I should get an e-cigarette," rather than saying, "I'm going to get an FDA-approved medicine that will double or triple my likelihood of quitting." So there are certainly many misconceptions around e-cigarettes
According to Frieden, switching from smoking to vaping is not just a bad idea; it is a "misconception." In other words, the choice itself is scientifically incorrect, on par with declaring the world flat or attributing personality traits to the arrangement of stars in the night sky. That way of framing the issue assumes away individual tastes and preferences, which Frieden evidently considers irrelevant. But those factors matter a lot when it comes to the question of whether e-cigarettes can be a satisfactory replacement for the real thing. Because vaping delivers nicotine in a way that closely mimics the ritual of smoking, it may work better for smokers who have unsuccessfully tried to quit with other methods. Even if the overalll quit rate achieved with e-cigarettes is no higher than the quit rate achieved with "FDA-approved medicine," e-cigarettes might be more effective for some people.
Frieden loads the dice against e-cigarettes by exaggerating the effectiveness of the methods he prefers, which he says "double or triple" the likelihood of quitting. According to a 2008 review by the Cochrance Collaboration, nicotine replacement therapy (including gum, lozenges, patches, inhalers, and nasal sprays) increases quit rates by 50 percent to 70 percent, which is neither doubling nor tripling. Furthermore, the base rate is pretty low. The authors note that "studies of people attempting to quit on their own suggest that success rates after six to 12 months are 3-5%." Nicotine replacement might boost that to somewhere between 4.5 percent and 8.5 percent. Not exactly a magic bullet.
How do e-cigarettes compare? There is not a lot of research on that question, but a randomized study reported in The Lancet last year put the six-month quit rate at 7.3 percent for subjects who used e-cigarettes, compared to 5.8 percent for those who used nicotine patches. The researchers deemed e-cigarettes "modestly effective at helping smokers to quit, with similar achievement of abstinence as with nicotine patches, and few adverse events." Hence the choice that Frieden presents as utterly irrational—indeed, objectively wrong—seems at least as sensible as the course he recommends.
Frieden further illustrates his bias with this maxim:
When it comes to tobacco products, we really have to assume they're dangerous until they're proven safe, rather than the other way around.
This variation on the precautionary principle is questionable for several reasons, but here is the one that leaps out at me: E-cigarettes are not tobacco products. True, the nicotine they contain is derived from tobacco, which is the rationale for letting the Food and Drug Administration regulate them as tobacco products. But by the same logic, the nicotine replacement therapies that Frieden favors are also tobacco products. Like those "FDA-approved medicine[s]," e-cigarettes do not contain any tobacco, and they do not burn anything, which is why they are much less hazardous than conventional cigarettes. That much is beyond serious dispute, a point obscured by Frieden's misleading safe/dangerous dichotomy. Even if they are never "proven safe," whatever that might mean according to Frieden, e-cigarettes are clearly safer than conventional cigarettes, which is the crucial consideration for smokers contemplating a switch.
At one point in the interview Frieden actually acknowledges the harm-reducing potential of e-cigarettes but dismisses it as entirely theoretical, in contrast with the fears that keep him up at night:
I certainly see the theory that they could be helpful, and I've heard some anecdotes about individuals who say they've helped them quit. But much more importantly is the actuality that right now we're getting millions of kids experimenting with or using regularly e-cigarettes. We're getting smokers who are perhaps not using them to quit but to keep smoking regular cigarettes.…We're seeing the reglamorization of smoking…We're also seeing potential exposure of nonsmokers, including pregnant women, to the nicotine in e-cigarette products. So I see theoretical potential benefits but definite harms occurring.
The situation is almost exactly the opposite of what Frieden claims. The "definite harms" he perceives—a "gateway effect" that lures teenagers into smoking by way of vaping, smokers "perhaps" not using e-cigarettes to quit, "the reglamorization of smoking," "potential exposure of nonsmokers" (some of whom might be pregnant!) to atmospheric traces of nicotine—are hypothetical. By contrast, the benefits he dismisses—actual ex-smokers who quit with the help of e-cigarettes—are real. Their experiences should count for something, and so should the choices of people who decide to follow their example despite the best efforts of scaremongers like Frieden.