The 2019 “Evali” Misinfodemic (Part 3)

Continued from Part Two: The misinfodemic spreads worldwide

The first two parts of this series were based on an independent analysis of 18,000 news stories covering “EVALI” – an outbreak of lung injuries that occurred in the United States in 2019.  The probable cause of that outbreak is now clear:  An adulterant in unregulated illicit THC vaping products. Part One explored how the media blamed legal nicotine vaping for lung injuries that were caused by unregulated illicit THC vaping. Part Two looked at how that misdiagnosis then spread to other countries.

Part Three:  Why misdiagnosing “EVALI” matters

Smoking is the number one cause of all preventable cancers, heart and lung disease.  The death toll from smoking this year will exceed – by far – the number of people projected to die from COVID-19.  The COVID-19 pandemic will eventually end.  It is less clear when the current 100-year-long smoking “epidemic” will end.  Decreasing public misperceptions surrounding alternatives to smoking might help.

Recent surveys show a dramatic increase in the number of people who believe that nicotine vaping is as harmful as, or more harmful than, smoking (see Parts One and Two, and the Foundation’s Global State of Smoking Polls from 2017 and 2019).  Misperception of relative risks worsened in many countries as the US official misdiagnosis of the “EVALI” outbreak filtered through the media to the public.

Public misunderstanding may cause substantial harm if it convinces people who use safer nicotine products to return to smoking, discourages smokers from quitting, and encourages policy makers to embrace taxes and bans that favor cigarette sales.  Which begs the question:  Are “safer nicotine products” truly safer?

In the case of a smokeless tobacco product called snus, the answer is clearly “yes” based on decades of epidemiological data.  In October 2019, the US Food and Drug Administration (FDA) authorized a snus manufacturer to advertise its products as safer than cigarettes.  So yes, safer.

We do not have long-term epidemiological data on nicotine vaping.  These products have only been used by millions of people for 14 years.  But we do know that smoking shortens the lives of half of all long-term smokers by 10 years.  And we now have a substantial (and growing) body of evidence on the constituents of nicotine vapor, as well as the short- and medium-term health effects in humans.

It took years to develop a scientific consensus that smoking kills.  The first major confirmation came from the British Doctors Study, launched in 1951.  Findings from that study played a central role in the pivotal 1962 Royal College of Physicians report on Smoking and Health, which heralded the early beginnings of tobacco control (two years before the first US Surgeon General report on smoking).

Thankfully, science works faster today.  Some claim it would take a modern toxicologist less than a week to prove that cigarette smoke is toxic.  A growing list of scientific and public health organizations have reviewed all the available evidence from thousands of scientific studies on safer nicotine products including snus and nicotine vaping products (see list below and here).

These organizations all say “safer.”  To take one key example, the official position of the Royal College of Physicians is:  “…available data suggest that [the long-term health risks of e-cigarettes] are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure… [and] E-cigarettes appear to be effective when used by smokers as an aid to quitting smoking.

The “EVALI” misinfodemic widened the gap between this growing scientific consensus and public beliefs.  Tobacco control experts and the media must now work together to correct these public misperceptions.  The alternative is more preventable deaths from smoking.

All statements are hyperlinked to the original documents.

World Health Organization Euro Office:

“There is conclusive evidence that:  Completely substituting electronic nicotine and non-nicotine delivery systems for combustible tobacco cigarettes reduces users’ exposure to numerous toxicants and carcinogens present in combustible tobacco cigarettes.”

Public Health England:

“Our new review reinforces the finding that vaping is a fraction of the risk of smoking, at least 95% less harmful, and of negligible risk to bystanders.  Yet over half of smokers either falsely believe that vaping is as harmful as smoking or just don’t know.”

Royal College of Physicians:

“Although it is not possible to precisely quantify the long-term health risks associated with e-cigarettes, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure… E-cigarettes are effective in helping people to stop smoking.”

British Medical Association:

“Significant numbers of smokers are using e-cigarettes (electronic cigarettes), with many reporting that they are helpful in quitting or cutting down cigarette use.  There are clear potential benefits to their use in reducing the substantial harms associated with smoking, and a growing consensus that they are significantly less harmful than tobacco use.”

Cancer Research UK:

“While the long-term health consequences of e-cigarette use are uncertain, the evidence so far suggests that e-cigarettes are far less harmful than smoking.  …There is also growing evidence to suggest that e-cigarettes can work successfully as an aid to cessation.  …There is insufficient evidence to support a blanket indoor ban on e-cigarette use, either on the basis of renormalisation of smoking or harm to bystanders from second-hand vapour.”

British Lung Foundation:

“Experts have reviewed all the research done on e-cigarettes over the past few years, and found no significant risks for people using e-cigarettes.  …Swapping cigarettes for an e-cig can improve your symptoms of lung conditions like asthma and COPD.”

Royal College of General Practitioners:

“The evidence so far shows that e-cigarettes have significantly reduced levels of key toxicants compared to cigarettes, with average levels of exposure falling well below the thresholds for concern.”

Royal Society for Public Health:

“RSPH has welcomed a new comprehensive evidence review on e-cigarettes published by Public Health England (PHE).  The report reflects an up-to-date evidence base that is increasingly pointing in the same direction:  not only that vaping is at least 95% less harmful than smoking, but also that it is helping increasing numbers of smokers to quit.”

Action on Smoking and Health UK:

“It has been estimated that e-cigarettes are 95% less harmful than ordinary cigarettes.  There is negligible risk to others from second-hand e-cigarette vapour.  …The lifetime cancer risk of vaping has been assessed to be under 0.5% of the risk of smoking.  [But] Public understanding of the relative harms of e-cigarettes [vs smoking cigarettes] have worsened over time and are less accurate today than they were in 2014.”

National Health Service Scotland consensus statement on e-cigarettes:

“Smoking kills.  Helping people to stop smoking completely is our priority.  …There is now agreement based on the current evidence that vaping e-cigarettes is definitely less harmful than smoking tobacco.” 

This statement was created and endorsed by:  Action on Smoking & Health Scotland • Cancer Research UK • Chest Heart & Stroke Scotland • Chief Medical Officer for Scotland • NHS Ayrshire and Arran • NHS Greater Glasgow and Clyde • NHS Lothian • NHS Tayside • Roy Castle Lung Cancer Foundation • Royal College of General Practitioners • Royal College of Physicians of Edinburgh • Royal College of Physicians and Surgeons of Glasgow • Royal Environmental Health Institute of Scotland • Scottish Collaboration for Public Health Research and Policy • Scottish Consultants in Dental Health • Scottish Thoracic Society • UK Centre for Tobacco & Alcohol Studies • University of Edinburgh • University of Stirling

New Zealand Ministry of Health:

“The regulatory controls in the Smoke-free Environments Act 1990 were designed primarily for tobacco products that are smoked.  They are inadequate for vaping and smokeless tobacco products, which are less harmful to users.  There is an opportunity, through better regulation (and public information), to support smokers to switch to significantly less harmful alternatives, substantially reducing the risks to their health and those around them.”

US National Academies of Sciences, Engineering and Medicine:

“While e-cigarettes are not without health risks, they are likely to be far less harmful than combustible tobacco cigarettes.”

US Food & Drug Administration:

“Make no mistake. We see the possibility for ENDS products like e-cigarettes to provide a potentially less harmful alternative for currently addicted individual adult smokers who still want to get access to satisfying levels of nicotine without many of the harmful effects that come with the combustion of tobacco.”

US Centers for Disease Control:

“E-cigarettes have the potential to benefit adult smokers who are not pregnant if used as a complete substitute for regular cigarettes and other smoked tobacco products.”

American Cancer Society:

“Based on currently available evidence, using current generation e-cigarettes is less harmful than smoking cigarettes.” 

NOTE:  This was the official statement from 2018-2019.  As of November 2019, ACS no longer recommends e-cigarettes as a smoking cessation tool.  Their stated reason for this change was “e-cigarette use by young people.”  Illegal under-age use is undesirable, but does not change the original finding that nicotine vaping is less harmful than smoking.

American Association of Public Health Physicians:

“Smoke-free tobacco/nicotine products, as available on the American market, while not risk-free, carry substantially less risk of death and may be easier to quit than cigarettes.  …Smokers who have tried, but failed to quit using medical guidance and pharmaceutical products, and smokers unable or uninterested in quitting, should consider switching to a less hazardous smoke-free tobacco/nicotine product for as long as they feel the need.  Such products include pharmaceutical Nicotine Replacement Therapy (NRT) products used, off-label, on a long term basis, electronic “e” cigarettes, dissolvables (sticks, strips and orbs), snus, other forms of moist snuff, and chewing tobacco.”

Royal Australian & New Zealand College of Psychiatrists:

“Research shows that 70% of people with schizophrenia and 61% of people with bipolar disorder smoke compared to 16% of those without mental illness.  …E-cigarettes and vaporizers provide a safer way to deliver nicotine to those who are unable to stop smoking, thereby minimizing the harms associated with smoking tobacco and reducing some of the health disparities experienced by people with mental illness.”

Royal Australian College of Physicians:

“The RACP acknowledges that e-cigarettes may have a potential role in tobacco harm reduction and smoking cessation for smokers unable or unwilling to quit.”

Government of Canada:

“Vaping is less harmful than smoking.  Completely replacing cigarette smoking with vaping will reduce your exposure to harmful chemicals.  There are short-term general health improvements if you completely switch from smoking cigarettes to vaping products.”

French National Academy of Pharmacy:

“The World Health Organization’s [anti-e-cigarette] position is incomprehensible.  Tobacco is responsible for 73,000 deaths in France.  The e-cigarette helps people quit smoking.  Its components are obviously less harmful than tobacco.” 

NOTE:  This is a Tweet from the Académie Nationale de Pharmacie.  Not an official statement.

Cochrane Tobacco Addiction Group:

“No serious side effects were associated with [the use of e-cigarettes] (up to two years).”