E-cigarettes can't shake their reputation as a menace

WASHINGTON — A decade after electronic cigarettes were introduced in the United States, use has flattened, sales have slowed and, this fall, NJoy, once one of the country's biggest e-cigarette manufacturers, filed for bankruptcy.

It is quite a reversal for an invention once billed as the biggest chance to end smoking as we know it and take aim at the country's largest cause of preventable death. Use of the devices is slumping because they are not as good as cigarettes at giving a hit of nicotine. Dealing another strike against them, the country's top public health authorities have sent an unwavering message: Vaping is dangerous.

The warning is meant to stop people who have never smoked — particularly children — from starting to vape. But a growing number of scientists and policymakers say the relentless portrayal of e-cigarettes as a public health menace, however well intentioned, is a profound disservice to the 40 million U.S. smokers who could benefit from the devices. Smoking kills more than 480,000 Americans a year.

"We may well have missed, or are missing, the greatest opportunity in a century," said David B. Abrams, senior scientist at the Truth Initiative, an anti-smoking group. "The unintended consequence is more lives are going to be lost."

[Alaska among the worst states for smoking-caused cancer deaths]

U.S. public health experts, led by the Centers for Disease Control and Prevention, have long been suspicious of e-cigarettes. The possible risks of vaping are vast, officials warn, including the potential to open a dangerous new door to addiction for youths. Scientists will not know the full effect for years, so for now, they caution, be wary.

But mounting evidence suggests vaping is far less dangerous than smoking, a fact that is rarely pointed out to the U.S. public. Britain, a country with about the same share of smokers, has come to the opposite conclusion from the United States. This year, a prestigious doctors' organization told the public that e-cigarettes were 95 percent less harmful than cigarettes. British health officials are encouraging smokers to switch.

The U.S. approach "is the same as asking, 'What are the relative risks of jumping out a fourth-story window versus taking the stairs?'" said David Sweanor, a lawyer with the Center for Health Law, Policy and Ethics at the University of Ottawa. "These guys are saying: 'Look, these stairs, people could slip, they could get mugged. We just don't know yet.'"

E-cigarettes are much less harmful because they do not have the deadly tar found in regular cigarettes. They instead provide the nicotine fix smokers crave through a liquid that is heated into vapor and inhaled. There is no long-term data yet, but evidence does not show the vapor to be particularly harmful in the short term.

That e-cigarettes are less harmful is a message U.S. smokers rarely hear, partly because U.S. regulation prevents it. Companies are banned from making such claims unless they go through a long process to prove it, and so far, no e-cigarette maker has done so. More states are passing laws that lump e-cigarettes in with traditional cigarettes, levying taxes on them and banning their use as part of local smoke-free rules.

"When they are regulated just like tobacco, people draw the conclusion that they are just as dangerous," said Daniel I. Wikler, an ethicist at the Harvard School of Public Health. "You didn't say it, but you didn't have to. People make that assumption, and you don't try to disabuse them of it."

Last week, Georgia State University published a report finding that the percentage of Americans who thought e-cigarettes were as bad as cigarettes or worse than them had tripled, to 40 percent in 2015 from 13 percent in 2012.

If smokers have tried everything else, and use an e-cigarette to quit completely, "that's a good thing," said Dr. Thomas R. Frieden, the director of the CDC. He has heard anecdotes about that happening, he added.

"But the plural of anecdote is not data," he said. "And counterbalancing that good trend, there are at least three negative things that might be happening," like people who have never smoked using them, children picking them up as a path to smoking, or smokers using them to perpetuate their habit.

[Report: More Alaska teens using e-cigs than cigarettes]

But smoking has been declining. The 2015 adult smoking rate dropped by more than 10 percent from the previous year, the biggest decline since the government began tracking the measure in 1965, said Kenneth E. Warner, a professor of public health at the University of Michigan, citing the government's National Health Interview Survey. Past dips have always been linked to some event, he said, like a tax. But there was no single event to explain this one, and some suspect e-cigarettes may have played a role.

Terry F. Pechacek, a professor of public health at Georgia State University, estimated that in 2015, more than 4 million Americans reported that e-cigarettes had helped them quit smoking over the past five years, up from about 2.4 million in 2014.

Youth cigarette smoking has gone down, too — by about half since 2007, around the time e-cigarettes started to be sold in the United States. In fact, youth smoking had its biggest-ever drop in 2015, Warner said, citing Monitoring the Future, a federally funded survey. The rate is now 7 percent, a historical low. (Frieden noted that hookah use had been rising, as had the share of young people using e-cigarettes.)

Science is filling in the blanks, said Dr. Thomas Glynn, a consulting professor at Stanford University and the former director of cancer science and trends at the American Cancer Society. "We've been wringing our hands for years, saying we don't have enough research, but we're getting to the point where we can't say that anymore," he said.

British policymakers say that they were also skeptical of the devices at first but that they have become more convinced of their benefit as data has accumulated. Success in quitting is up. The smoking rate is down. Surveys by Action on Smoking and Health, a British anti-smoking group, have found that half of Britain's 2.8 million e-cigarette users no longer smoke real cigarettes. Among people who are trying to quit smoking, e-cigarette users are 60 percent more likely to succeed than those who use over-the-counter nicotine therapies like gum and patches, a British study found.

Americans tend to value abstinence above all else, an all-or-nothing approach that British advocates see as rooted in the United States' puritanical culture, said Deborah Arnott, the chief executive of Action on Smoking and Health.

"It's a bit fundamentalist in the U.S.," Arnott said, adding that the intense focus on children missed the potential utility of e-cigarettes for current smokers, often some of the poorest and least educated members of society. "What about the smokers? What about the people who are dying now as a result of this habit?"

[Alaska Airlines flight grounded after e-cig batteries ignite]

Glynn said the U.S. approach was well-meaning and had in the past achieved spectacular success. But it comes with a deep suspicion of the tobacco industry that goes back decades, he added.

"We know there's a big, bad tobacco industry, and that's the enemy," he said. "But e-cigarettes do not fit that narrative. We are fighting a 2016 insurgency with nuclear weapons from the 1980s."

Some researchers think they cannot speak openly, and in many organizations, "advocacy is leading the charge, as opposed to science," Glynn said. "Public health is suffering as a result."

Wikler said, "You want to be married to the science, but in this case, I think there's been a kind of unmooring, and that's a somewhat dangerous game."