In my syndicated column last week, I noted that politicians who favor new taxes and restrictions on nicotine vaping products tend to ignore the lifesaving potential of this harm-reducing alternative to conventional cigarettes. One of those politicians, Rep. Raja Krishnamoorthi (D–Ill.), responded with a letter to the Chicago Sun-Times that proves my point. Krishnamoorthi exaggerates the threat posed by underage vaping, conflates vaping with tobacco use, and insists "there's simply no evidence" that e-cigarettes help smokers quit.
Krishnamoorthi, who last year spuriously urged the Food and Drug Administration (FDA) to ban e-cigarettes as a COVID-19 hazard, thinks "vapes are a huge health threat to millions of America's young people." To back up that claim, he cites data from the National Youth Tobacco Survey (NYTS), which show that vaping by high school students fell by 29 percent in 2020 after rising substantially the two previous years. Ignoring that drop, Krishnamoorthi instead emphasizes that "20% of high schoolers [are] currently using this highly addictive product," meaning they reported vaping in the previous month. That figure is down from about 28 percent in 2019.
Krishnamoorthi also does not mention that cigarette smoking by teenagers, a far more dangerous habit, has been falling since the late 1990s, reaching record lows in recent years. In the 2020 NYTS, 4.6 percent of high school students reported smoking cigarettes in the previous month, down from 5.8 percent in 2019 and 15.1 percent in 2011—a 70 percent drop. In the Youth Risk Behavior Survey, that rate fell from 27.5 percent in 1991 to 6 percent in 2019—a 78 percent drop. According to the Monitoring the Future Study, which covers a longer period, the prevalence of past-month cigarette smoking among high school seniors fell from 36.5 percent in 1997 to 7.1 percent in 2020—a drop of more than 80 percent.
This downward trend accelerated as vaping became more popular among teenagers, which suggests that e-cigarettes are replacing combustible tobacco products in this age group. That is unambiguously good news from a "public health" perspective, since e-cigarettes are a much less hazardous source of nicotine—another point that Krishnamoorthi conspicuously ignores in his statements about vaping.
Most high school students who vape (61 percent in 2020) are occasional users. An analysis of NYTS data from 2017 through 2019 found that frequent use (on 20 or more of the previous 30 days) was concentrated among current or former smokers, which is consistent with the hypothesis that teenagers increasingly are vaping rather than smoking. "Frequent use and signs of e-cigarette dependence remained rare in students who had only ever used e-cigarettes and never any other tobacco product," the researchers reported.
"Vaping likely addicts some young people to nicotine," David J.K. Balfour and 14 other leading tobacco researchers say in an American Journal of Public Health article published last month. "However, the evidence does not suggest it is addicting very large numbers."
And contrary to the fears frequently voiced by critics of vaping products, there is little evidence that vaping products are encouraging smoking among teenagers who otherwise never would have tried nicotine. "With high-school students' smoking declining at an increasing rate since youths began using e-cigarettes, some may vape to reduce or quit smoking," Balfour et al. note. "If vaping causes some young people to try cigarettes, the aggregate impact must be small. A recent study estimated that if vaping increases nonsmoking youths' odds of trying cigarettes by 3.5…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 ascendancy. If vaping increases smoking initiation, other unknown factors more than compensate."
Krishnamoorthi glosses over these considerations by misleadingly equating vaping with "tobacco use." In September 15 press release, he says federal excise taxes on vaping products "can reduce tobacco use in America and prevent a generation of kids from getting hooked on smoking and vaping." Yet e-cigarettes do not contain tobacco and do not burn anything—crucial differences that explain why Public Health England estimated that switching from smoking to vaping reduces health risks by at least 95 percent.
"Laboratory tests of e-cigarette ingredients, in vitro toxicological tests, and short-term human studies suggest that e-cigarettes are likely to be far less harmful than combustible tobacco cigarettes," the National Academies of Sciences, Engineering and Medicine reported in 2018. The British Royal College of Physicians likewise concluded that "vaping isn't completely risk-free but is far less harmful than smoking tobacco." A 2017 study in the journal Tobacco Control estimated that, depending on how many smokers make the switch, the availability of vaping products could prevent as many as 6.6 million premature deaths in the United States alone.
Krishnamoorthi avers that "there's simply no evidence that vapes help [smokers] to quit." Yet as Balfour et al. note, "a growing body of evidence indicates that vaping can foster smoking cessation, although the evidence is not definitive."
A 2020 meta-analysis of 26 randomized controlled trials concluded "there is moderate-certainty evidence that [e-cigarettes] with nicotine increase quit rates compared to [e-cigarettes] without nicotine and compared to nicotine replacement therapy." The results of population studies, Balfour et al. say, "are consistent with a near doubling of quit attempt success, found in the randomized controlled trials, and the fact that e-cigarettes are smokers' most used aid in quit attempts." They also note that declines in U.S. cigarette sales accelerated sharply as sales of vaping products took off, which reinforces the impression that more vaping means less smoking.
While denying that any of this evidence exists, Krishnamoorthi says he thinks "adults can do what they want." But that is not true either.
Krishnamoorthi supports federal excise taxes that would double or triple the cost of nicotine liquids, discouraging smokers from quitting and driving vapers back to a far deadlier habit. He wants to ban the e-liquid flavors that former smokers overwhelmingly prefer, which likewise would make these products less appealing as an alternative to conventional cigarettes. And he wants to mandate reductions in e-liquid nicotine content, which would have a similar effect, while authorizing the FDA to order further reductions.
Krishnamoorthi says the FDA should have the power to make nicotine concentrations so low that they are "minimally addictive or non-addictive," which would make vaping products an unsatisfactory substitute for cigarettes, effectively nullifying this potentially lifesaving option. Even the FDA, despite its foot dragging on approval of the products it calls "electronic nicotine delivery systems" (ENDS), recognizes that they promise to reduce smoking-related disease and death. Krishnamoorthi's attitude, by contrast, is crystallized in the name he chose for his nicotine reduction bill: the END ENDS Act.
Krishnamoorthi says FDA regulation is aimed at making sure that vaping products "have a net positive public health benefit," because "the unregulated, untaxed marketplace now requires no such proof." Krishnamoorthi's admission that e-cigarettes could "have a net positive public health benefit" is rather puzzling given his position that there is no reason to think they help smokers quit. And it's a mystery how imposing new taxes on e-cigarettes provides information about the relative hazards of vaping and smoking—unless it's misinformation, since Krishnamoorthi says he wants to treat both types of products the same.
In any case, tobacco cigarettes remain on the market despite their well-established hazards. Krishnamoorthi, who wants to "END ENDS," seems to have concluded that it is better for public health to eliminate competing nicotine products that dramatically reduce the dangers that smokers face. He reaches that implausible conclusion by pretending that the millions of Americans who have chosen vaping as a risk-reducing alternative to smoking don't exist.