Around 8% of American adults now vape, and just 11% smoke, according to a recent Gallup poll. This puts the U.S. smoking rate at its lowest level in 80 years. But, while American nicotine use has evolved dramatically over the decades, public guidance on the relative risks of nicotine products remains stuck in the past.
The last U.S. surgeon general’s report on nicotine was issued in 1988 when cigarettes were one of the only options for nicotine consumers, and around 32% of adults smoked.
Today, consumers have access to a broader range of products, including many that the scientific evidence indicates pose significantly lower risks compared to smoking, such as e-cigarettes, snus, heated tobacco, and modern oral tobacco. A fresh review from the surgeon general could cut through growing public confusion surrounding these products, ensuring that public health messaging keeps pace with scientific advancements.
E-cigarettes, in particular, have risen in popularity, and nearly two decades of evidence shows that smokers who switch to vaping drastically reduce their health risks. Despite these advancements in science and technology, public misperceptions about nicotine and confusion over e-cigarettes have only grown.
Nicotine has been vilified due to its association with combustible tobacco products. Cigarettes are undeniably harmful and are a leading cause of lung cancer, heart disease, and other serious conditions. However, while nicotine plays a role in smoking’s habit-forming nature, researchers have long been aware that the health risks associated with smoking are due not to nicotine but rather the nicotine delivery method cigarettes employ: combustion. Without the smoke and tar created by lighting tobacco and paper on fire, nicotine use is not linked to the diseases associated with smoking. For example, nicotine replacement therapies, like the nicotine patch or gums, are generally regarded as safe for most users, for long-term use, and even for pregnant smokers who cannot otherwise quit.
Nearly two decades of research on e-cigarettes has repeatedly vindicated e-cigarettes as a lower-risk alternative to combustible smoking. E-cigarettes have also been tacitly endorsed as a method of tobacco harm reduction by various representatives of the Food and Drug Administration (FDA)—the agency responsible for regulating tobacco products and communicating the relevant health information about such products to the public. Brian King, the current director of the FDA’s Center for Tobacco Products (CTP), has noted that adults who switch completely from smoking to vaping can improve their health, a view echoed by other FDA representatives, including former FDA Commissioner Scott Gottlieb and former CTP Director Mitch Zeller. King, however, cautions that while vaping is generally safer than smoking, some vaping products are “more risky” than others.
Despite the acknowledgment that there is a spectrum of risk when it comes to tobacco products and e-cigarettes, neither King nor anyone else at the FDA has clearly specified which products or types of e-cigarettes might be on the safer or riskier side of that spectrum. Nor has the FDA meaningfully updated its public messaging strategies to reflect this shift in understanding. As a result of the FDA’s failure, public knowledge about nicotine and the lower risks associated with e-cigarettes has only grown more muddled, even as the science on these issues has become clearer.
In 2012, when the science of e-cigarettes was still developing, only about 13% of adults incorrectly believed that e-cigarettes were as harmful as or more harmful than smoking. Yet, as research increasingly demonstrated that e-cigarettes are a lower-risk alternative, this public misperception grew. By 2020, nearly 65% of adults held this mistaken belief.
Alarmingly, the falsehood is even more prevalent among smokers—the very people who could benefit most from accurate information about nicotine products—with 88% of adult smokers believing as of 2023 that e-cigarettes are no safer than smoking. Physicians might be able to correct these myths, but even they are confused about nicotine. A 2021 study revealed that a shocking 80% of U.S. physicians mistakenly believe that nicotine is the cause of tobacco-related cancers. On the contrary, there is a broad scientific consensus that while smoking exposes smokers to numerous carcinogens, nicotine is not one of them. Without the knowledge that e-cigarettes offer a safer alternative to smoking, fewer smokers will switch, more will continue to smoke, and more will die as a result.
The FDA has been aware of the growing public misinformation since at least 2017, when then-Commissioner Scott Gottlieb unveiled the agency’s new approach to tackling tobacco-related harm. The ambitious plan centered on taking a more sober and scientific perspective on the role nicotine plays in addiction and disease, with a key component aimed at educating the public about the relative risks of different nicotine-consumption methods. However, apart from informal acknowledgments from staff and a single page on its website, the FDA has done little to correct public confusion. The FDA’s failure to address a problem it has acknowledged—and, in some ways, contributed to—underscores the need for other health authorities to intervene.
The surgeon general should initiate a comprehensive review of the evidence on nicotine e-cigarettes, summarizing what the evidence says about their risks and benefits and comparing those risks to other forms of nicotine use. Such a report could provide much-needed clarity on e-cigarettes, cutting through sensationalistic news reporting and FDA rigidity to provide the public, providers, and policymakers with the clear and actionable information they need to make science-based health decisions.
Recent statements from the FDA suggest a willingness to embrace harm reduction more fully. However, this shift must be accompanied by robust public education efforts, which must be grounded in evidence. An updated surgeon general’s report could serve as a cornerstone of those efforts, helping to reshape public understanding and policy in a way that truly promotes health. Such a report could correct longstanding myths, correct misperceptions, and support regulatory strategies that differentiate between the harms of smoking and the far lesser risks associated with noncombustible nicotine products like e-cigarettes.
With an updated report from the surgeon general, we can better align public health policy with scientific evidence about e-cigarettes and provide individuals with the information they need to make better health choices.