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September 22, 2023
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Q&A: Education can improve public understanding of e-cigarette risks, use for cessation

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Key takeaways:

  • A recent survey revealed that adult smokers are uninformed about risks associated with cigarettes vs. e-cigarettes.
  • Pulmonologists have the power to help patients quit smoking and educate adult smokers.

Many U.S. adults appeared to believe that e-cigarettes contain a larger amount of dangerous chemicals than cigarettes, according to survey results published in Addiction.

Further, results of the online survey — which was conducted in 2021 and included 1,018 adults who smoked cigarettes and 1,051 young adult nonsmokers — showed 35.6% of the adults and 24.9% of the young adults expressed a lack of knowledge on which product contains more harmful chemicals, signaling the need for education on the risk differences between cigarettes and e-cigarettes among adults who smoke.

Quote from Tracy Smith

In an accompanying editorial, Benjamin Toll, PhD, director of the Medical University of South Carolina Health Tobacco Treatment Program, and Brian King, PhD, MPH, director of the FDA’s Center for Tobacco Products, wrote that it’s important for this education among adult smokers to be data-driven.

“It breaks my heart that I’ve met with a lot of well-intentioned physicians who say to me, ‘Vaping is worse than smoking.’ And I say, ‘No, that’s not true,’” Toll said in a press release.

“I want to be crystal clear that I am very opposed to vaping by minors,” Toll added. “Youth use of any tobacco product is unsafe, and outreach strategies must not inadvertently make it seem like e-cigarettes are OK for youth to use.”

Healio spoke with Tracy Smith, PhD, associate professor in the addiction sciences division at Medical University of South Carolina, and the FDA to learn more about how e-cigarettes developed their bad reputation, what the FDA is doing to regulate e-cigarettes and how pulmonologists can change this misperception.

Healio: When did e-cigarettes develop their bad reputation in the public eye? What sparked the change from being a low-risk cigarette alternative to a harmful product?

Smith: When e-cigarettes first came on the market, the risks were entirely unknown. Public health professionals were hesitant to view them as a lower-risk alternative without data, and rightfully so. There have been other tobacco products that were embraced or touted as lower-risk alternatives that turned out to be as harmful or more harmful than regular cigarettes. When “light” cigarettes were first introduced, they were initially sold as a way to reduce nicotine and toxicant exposure, but it turned out that when people smoked light cigarettes, they inhaled them more deeply, and they were more harmful to human health than full-flavor cigarettes. People were hesitant to view e-cigarettes as lower risk without data demonstrating their risks, and that perception has persisted in the U.S.

Healio: Why is it dangerous for adult smokers to think that vaping is worse than cigarettes? How could this interpretation negatively impact their health?

Smith: We know that people who view e-cigarettes/vaping as more harmful than cigarettes are less likely to try to switch to e-cigarettes. In the meantime, cigarettes are the most harmful tobacco product available and kill one-third to one-half of long-term users. People who cannot quit smoking would reduce their exposure to deadly carcinogens by using a lower-risk product instead of smoking. It’s important that people stop smoking completely if they use e-cigarettes and do not continue to use both products.

FDA: We know based on the available science that e-cigarettes are generally less harmful than cigarettes. As such, if an adult smoker were to transition completely from cigarettes to e-cigarettes it could benefit their health; but to best protect their health, it’s important that they transition completely, with the goal of eventually quitting the use of all tobacco products, including e-cigarettes. It’s also important to note that lower risk does not mean no risk. E-cigarette aerosol has been shown to contain harmful and potentially harmful ingredients, and the long-term health risks of using e-cigarettes are unknown. Therefore, youth should not be using any tobacco product, including e-cigarettes, and adults who don’t currently use tobacco products shouldn’t start.

Healio: How can the FDA help the public understand that different tobacco products pose different risks?

FDA: We want to ensure that any educational efforts on the relative risks of tobacco products are evidence-based. In particular, it is important to assess the benefits among the intended population (ie, adults who smoke) and risks among unintended populations (eg, youth). Currently, FDA is in the early stages of a research effort to assess messaging about the continuum of risk of tobacco products among adults who smoke. This is in addition to FDA’s continued work to prevent youth tobacco product initiation, including through “The Real Cost” cigarette prevention and e-cigarette prevention public education campaigns, which use a variety of marketing tactics and creative advertising to educate youth about the dangers of tobacco product use.

Smith: This research by the FDA can help develop communications and education campaigns related to the continuum of risk, with the goal of educating adults who smoke without increasing intentions to vape among young people.

Healio: The press release mentions that e-cigarettes are not an FDA-approved smoking cessation device. Are any applying to become so?

FDA: For an e-cigarette product to be marketed for cessation purposes, FDA’s Center for Drug Evaluation and Research would need to approve it as being “safe and effective.” To date, no e-cigarette has been approved as a smoking cessation device.

Smith: I am not aware of any e-cigarette companies that have applied for approval as a smoking cessation device, but I am aware of at least one company, Qnovia, that is pursuing this pathway. This company does not call the device an e-cigarette, but the product description sounds functionally the same.

Healio: What smoking cessation products are approved by the FDA and available for those who want to quit? Besides medication, what other resources exist to help individuals with the goal of quitting cigarettes?

FDA: FDA-approved therapies for smoking cessation include nicotine replacement therapy (available over the counter for adults as skin patches, gum and lozenges, or with a prescription as a spray or inhaler) and prescription medications that do not contain nicotine. In addition, the FDA recently gave marketing clearance to a device using transcranial magnetic stimulation as a short-term cessation aid. For adults who both smoke and choose to use e-cigarettes, the FDA has granted marketing authorization for 23 tobacco-flavored e-cigarette products and devices. Importantly, FDA does not “approve” tobacco products, including e-cigarettes; however, by authorizing them, the agency has found that the applicant provided sufficient information that the potential benefits of the products outweigh the risks to the population as a whole. The FDA seeks to reinforce the importance of completely transitioning to e-cigarettes. Because no tobacco product is safe, the eventual goal should be quitting all tobacco product use, including e-cigarettes. Those interested in quitting today should visit smokefree.gov or call 1-800-QUIT-NOW to learn about cigarette and e-cigarette cessation services available in their state.

Smith: Behavioral counseling also can improve the odds of successfully quitting smoking. The best method is combining counseling with medication. We know that many people must try multiple times to quit smoking, and people should continue trying even if they don’t succeed the first time.

Healio: How should clinicians properly educate themselves on e-cigarettes?

Smith: Government resources including the FDA and CDC’s websites contain useful information about the current health risks, including risks to adults and youth, for e-cigarettes and other tobacco products.

FDA: The FDA provides a range of free resources that can help healthcare providers talk to patients about tobacco product use and cessation. The Tobacco Education Resource Library provides educational materials and resources on youth tobacco prevention and adult cessation that can be printed/downloaded, embedded on websites or shared through social media. Additionally, the Vaping Prevention and Education Resource Center provides resources for teachers, students and parents to learn more about the dangers of vaping nicotine.

Healio: How can pulmonologists balance changing the public’s perception of e-cigarettes while educating minors on the dangers of vaping?

Smith: Pulmonologists should stress that there are no safe tobacco products. They all carry risks, and the long-term risks of vaping are unknown. The most harmful tobacco products are cigarettes. Anyone who does not use tobacco should not start. For people who currently smoke and want to switch to an e-cigarette, the FDA has authorized 23 tobacco flavored e-cigarette products for commercial sale. This authorization means that the FDA has found marketing of these products appropriate for the protection of public health and switching completely from cigarettes to these products reduces exposure to toxicants and harmful ingredients. The list of authorized products can be found here. E-cigarettes not on this list have not been found to meet this standard.

FDA: Opportunities exist to educate adults who smoke about the relative risks of tobacco products, including e-cigarettes. However, these efforts should be accompanied by efforts to prevent youth tobacco product use, and among adults who smoke, encourage first-line use of FDA-approved cessation therapies and devices.

The FDA encourages health care providers to ask all patients about all tobacco product use, including e-cigarettes, to discuss the harms of all tobacco products with youths to prevent initiation and to help any patients who currently use tobacco products to quit.

References:

For more information:

Tracy Smith, PhD, can be reached at smithtra@musc.edu.

The FDA can be reached at AskCTP@fda.hhs.gov.