State Attorney General Acknowledges the Potential of Vaping as a Tool of Harm Reduction
It’s not every day that you get to see a politician or a diplomat, let a lone a state attorney general take an objective approach on a sensitive issue like vaping, especially in today’s generally hostile climate. And that’s exactly what makes this story so special.
Iowa Attorney General, Thomas J. Miller, recently published a very interesting editorial in the American Journal of Public Health, in which he discusses the “quandary” of reducing smoking among the adult population while keeping youths from becoming a new generation of smokers. And, if you haven’t already guessed, Miller sees vaping as key to a harm-reduction approach that could save millions of lives.
While most public health experts, policy makers and politicians in the United States seem focused on protecting youths from the danger of nicotine addiction, Thomas Miller brings into discussion the fate of the 34 million adult smokers who could benefit from the switch to a less dangerous alternative. Does the noble goal of “saving the kids” justify the risk of losing half (statistically) of the adult smoker population to premature death?
“E-cigarettes are helping adult smokers move away from smoking, but they could do so much more if we could fully embrace harm reduction,” the Iowa Attorney General writes. “It is estimated that three million American current users of e-cigarettes have completely switched from cigarettes. As many as six million premature deaths could be averted if most smokers switched to e-cigarettes over the next 10 years.”
Miller goes on to mention the UK’s completely different approach to vaping, compared to the United States. In the European country there is a consensus between academics, scientists, the medical community, and tobacco control groups that vaping is a considerably less dangerous alternative to smoking, and that e-cigarettes should be promoted as quit smoking aids. He also links to the various comprehensive reviews and scientific studies that confirm that there are far fewer carcinogens and toxins, thus posing a much lower health threat.
As for the capacity of electronic cigarettes to help smokers quit, Thomas J. Miller cites verified data that shows a more rapid drop in the number of US smokers – from 19.3% in 2010 to 13.7% in 2018 – since vaping became popular, as well as a recent study that found e-cigarettes to be at least twice as effective nicotine replacement therapy for smoking cessation.
But where does that leave the youths, right? Miller is the first to acknowledge that nobody wants adolescents to become addicted to nicotine, but is taking extreme action that could put smokers’ lives at risk the right way to go? Yes, the use of electronic cigarettes among youths is probably the highest it has ever been, and that isn’t ideal, but it’s also not as bad as the media and certain groups would have us believe. Much of the reported e-cig use among youths is just experimentation – very common in this age group – not regular use, not to mention that the data shows a sharper drop in tobacco cigarette smoking simultaneous with the rise of vaping, which suggests a displacement of smoking among youths.
Coming up with a balanced approach to save as many adult smoker lives as possible, while also keeping minors from 
becoming addicted to nicotine is a challenge, but one way we’re certainly not going to fulfill both goals is by spreading misinformation and half-truths.
“I see one of the biggest barriers to encouraging smokers to switch is the almost unanimous misunderstanding of nicotine and the dramatic harm difference between cigarettes and e-cigarettes,” Miller writes. “One of my greatest priorities as attorney general is consumer protection. In that role, I believe I have learned a lot about deception. In my opinion, deception is all too common in the anti–e-cigarette, anti–harm-reduction campaign.”
“The deceptions take many forms, some of them of the classic consumer protection type,” the Iowa AJ adds. “Sometimes trace amounts of chemicals—believed to not be harmful at that level—are found, and it is promoted that they or nicotine alone cause cancer, or ‘popcorn lung’. Things are said that are literally true but in context and effect strongly imply a falsehood. For example, critics say e-cigarettes are not harmless but do it in a way that strongly implies that they are much more harmful than they are. A journal recently retracted a study that claimed that heart attacks were caused by e-cigarettes among people who had the heart attacks before using e-cigarettes. Those engaged in deception also cherry-pick numbers and omit material facts.”
Unfortunately, biased reporting, even biased research, has become so widespread these days that it is reshaping the public’s perception of vaping. Only a few years ago the vast majority of adults saw e-cigarettes as less harmful than tobacco analogs, but nowadays people see them as just as bad or worse than tobacco cigarettes. There haven’t been any major scientific findings to influence this switch; instead we’ve had the EVALI epidemic and years of anti-vaping campaigning from e-cigarette opponents.
In the closing paragraph of his excellent editorial, Thomas J. Miller notes that there are those who would simply let the adult smokers die in an effort to save the youths from becoming addicted to nicotine, as if the two were mutually exclusive. They are not, we just use the kids as an excuse to fulfill a much darker agenda, and take advantage of the fact that most of the 34 million smokers in the US are disproportionately low to middle income, not college educated, live in the South and Midwest, and struggle in other health and economic ways. It’s not the first time these categories have been ignored, as Miller himself acknowledges.
“Ignoring those people is not my conception of the United States. Ignoring Americans like these and looking down on them is tearing at the fabric of our democracy. And my political party, the Democratic Party, is paying a terrible price for doing or being perceived to be doing this,” the Iowa politician writes.
So what is to be done about this harm reduction quandary? Well, the hard stance isn’t going to work. Liming nicotine concentrations in e-liquid to unsatisfying doses, a total ban on e-liquid flavors or banning electronic cigarettes completely, will discourage both youths and adults from vaping, and potentially push them to other, more dangerous, tobacco products. So why not focus on keeping youths safe by adopting measures that do not impact adult users?
“We have done a great job reducing underage use of cigarettes—we know how to do that,” Miller writes. “The first choice should be implementing all the proven measures that affect youths exclusively: raising the legal age to 21 years at the state and federal levels, stronger enforcement, greater restrictions on marketing to youths, and targeted educational campaigns such as those of the FDA and Truth Initiative.”
Usually, when I see politicians tackling controversial topics like this, I expect the worse. Just last week, I wrote about Raja Krishnamoorthi, a Democrat from Illinois, and his call to the FDA to ban e-cigarettes during the Covid-19 pandemic. But I must say I was impressed by Thomas J. Miller’s editorial, his arguments for a harm-reduction approach to vaping, and all the scientific evidence he cited. He clearly did his research on this subject, and I only wish more of his fellow politicians and policy makers follow his example.
