In a recent letter to the Chicago Sun-Times, Sen. Richard Durbin (D-Ill.) takes issue with my argument that new FDA restrictions on e-cigarettes could deter smokers from switching to vaping, resulting in more tobacco-related deaths than would otherwise occur. "Mr. Sullum needs to check his facts," Durbin says, claiming that e-cigarettes, on balance, lead to more rather than less smoking. That conclusion is based on some highly implausible assumptions.
"[Sullum] claims that vaping helps people quit smoking traditional cigarettes," Durbin writes. "A recent study from Dartmouth found the exact opposite: e-cigarette use leads to 81 times more new smokers than quitters." The study to which Durbin refers, which was published in the online journal PLOS One last March, grossly underestimates the number of smokers who use e-cigarettes to quit while overestimating the number of people who would never have started smoking if e-cigarettes were not available.
To calculate the impact of e-cigarettes on smoking cessation, the researchers relied on a single 2013 study, reported in The Lancet, that compared quit rates among smokers randomly assigned to groups that received nicotine patches or e-cigarettes with or without nicotine. The six-month quit rate for e-cigarette users was 7.3 percent, compared to 5.8 percent for patch users and 4.1 percent for subjects who used nicotine-free e-cigarettes. In other words, e-cigarettes were 26 percent more effective than patches.
By contrast, a 2014 study based on British survey data, reported in the journal Addiction, found that smokers who used e-cigarettes to quit were twice as likely to be successful as smokers who used nicotine replacement therapy (NRT) such as patches. That suggests e-cigarettes are something like 100 percent more effective than NRT. Although randomized studies are usually considered to be stronger evidence of causality than surveys (which don't control for confounding variables), they may underestimate the effectiveness of e-cigarettes if vaping is more appealing to some subgroups of smokers than others. Another issue with the earlier study is that improved e-cigarette design in recent years has resulted in more satisfying nicotine delivery, which probably has increased the effectiveness of e-cigarettes as an aid to quitting.
The PLOS One study assumed that the availability of e-cigarettes increases successful quit attempts by just 2,070 per year in the United States. But as Brad Rodu points out, data from the National Health Interview Survey (NHIS) indicate that 2.6 million former smokers were vapers as of 2016, which would amount to 260,000 successful quit attempts per year, on average, in the decade since e-cigarettes were commercially introduced in the United States. It is not safe to attribute all of those successes to e-cigarettes, since some vapers might have quit smoking through other means. But the 125-fold difference between the NHIS results and the estimate used in the PLOS One analysis suggests the latter number is unrealistically low, to put it mildly.
On the other side of the ledger, the PLOS One study put the number of additional smokers attributable to e-cigarettes at 168,000 a year, or 81 times the number of quitters (hence the number cited by Durbin). The researchers arrived at that figure by comparing smoking initiation rates among people who try vaping and people who don't. But that risk ratio, although "adjusted for demographic, psychosocial, and behavioral risk factors," cannot possibly account for all the pre-existing differences between people who are attracted to vaping and people who aren't. It stands to reason that some of the same factors that predispose people to vaping also predispose them to smoking. The relevant question is how many people who start smoking after vaping would not have used tobacco if e-cigarettes had never been introduced. The answer is unclear, but the number is certainly lower than 168,000 per year.
The predicted net increase in smoking does not seem to be happening in the real world. To the contrary, smoking rates among adolescents and adults continue to fall, and a 2017 BMJ study found that "the substantial increase in e-cigarette use among US adult smokers was associated with a statistically significant increase in the smoking cessation rate at the population level." A 2018 analysis in the journal Tobacco Control projected that switching from smoking to vaping could result in as many as "6.6?million fewer premature deaths with 86.7?million fewer life years lost" over a decade in the United States.
Durbin also dismisses the point that adult vapers happen to like supposedly kid-friendly e-liquid flavors. "Mr. Sullum…claims that these candy-like flavors are aimed at adults, not kids," he writes. "Flavors like blue razz candy, gummy bear, whipped cream, and chocolate cupcake? Come on." That is the full extent of Durbin's argument. Yet it's undeniable that such sweet e-liquid flavors are highly popular among adult e-cigarette users, many of whom report that flavor variety was an important factor in switching from smoking to vaping.
If you think e-cigarettes are a public health disaster, as Durbin insists, such details may not matter to you. But if you acknowledge the harm-reducing potential of e-cigarettes, as the FDA does, you have to recognize the potentially lethal impact of attempts to reduce underage vaping by making these products less appealing.
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