The Surgeon General just released a comprehensive report on smoking cessation in the United States. At a mammoth 700 pages, the report covers everything from tobacco use patterns to nicotine replacement therapies to menthol cigarette bans to tax increases.
But there’s one area that will no doubt draw more interest than most, and that’s its assessment of the role of e-cigarettes can play in smoking cessation. E-cigarette policy is one of the most fraught in public health, with fierce divisions between those advocating a prohibition model and those advocating harm reduction and consumer choice.
The Surgeon General’s report will leave those arguing for harm reduction far from satisfied with its inconclusive position on the net benefit of e-cigarettes.
“The evidence is inadequate to infer that e-cigarettes, in general, increase smoking cessation,” says the report. “However, the evidence is suggestive but not sufficient to infer that the use of e-cigarettes containing nicotine is associated with increased smoking cessation compared with the use of e-cigarettes not containing nicotine, and the evidence is suggestive but not sufficient to infer that more frequent use of e-cigarettes is associated with increased smoking cessation compared with less frequent use of e-cigarettes.”
Many will wonder how much more evidence is needed to conclude that e-cigarettes play a role in reducing smoking. After all, millions of American smokers and tens of millions of smokers worldwide have already switched from traditional cigarettes to vaping,
The Surgeon General’s report falls well short of the advice that has been given by public health bodies in the United Kingdom, which actively promote e-cigarettes as a form of smoking cessation.
The report also fails to come to any relevant policy conclusion on whether e-cigarettes should be taxed differently from regular cigarettes or whether the regulatory process should be eased to ensure they remain on the market. All that is said is that there needs to be more research on the possible benefits and that more must be done to combat youth vaping.
What’s striking, however, is not the hairsplitting on the benefits of vaping but rather the difference between the stance on e-cigarettes and the advice given with regards to a possible ban on menthol cigarettes. After reviewing the available evidence, the authors conclude: “The evidence is suggestive but not sufficient to infer that restricting the sale of certain types of tobacco products, such as menthol and other flavored products, increases smoking cessation, especially among certain populations.”
This is the exact same wording and level of confidence that the report shows towards e-cigarettes. But instead of advocating further research and greater efforts to combat youth menthol smoking, as the Surgeon General does for e-cigarettes, the report finds that the restrictions are a necessary but an insufficient means to end the tobacco epidemic:
To that end, several end-game strategies could help to increase cessation and reduce the disease and premature death caused by tobacco use. Strategies that have been proposed include:
• Implementing a tobacco product standard to lower the level of nicotine in cigarettes to minimally addictive or nonaddictive levels, and
• Restricting the sale of tobacco products, such as prohibitions on entire categories of flavored tobacco products, including menthol.
Such actions have the potential to accelerate increases in smoking cessation and declines in the prevalence of smoking in the United States, thus hastening the end of the tobacco epidemic. However, these actions and the extensive body of evidence-based clinical, health system, and population-based tobacco prevention, control, and cessation strategies that are outlined in this report are a necessary but insufficient means to end the tobacco epidemic.
With the exact same level of confidence in the evidence, the Surgeon General is unable to say if e-cigarettes should be taxed less than combustible cigarettes or whether smokers should consider switching to vaping.
Yet, the Surgeon General is confident that a prohibition of menthol cigarettes is needed to aid smoking cessation.
There’s a clear double standard with how evidence is being used in the report.
According to the report, if the evidence is suggestive that banning menthol cigarettes may increase smoking cessation, it should become government policy.
But if the evidence is suggestive that nicotine e-cigarettes help smokers quit, the government should hold off on making any policy recommendations until further research proves this is the case.
Nationwide menthol prohibition would be an extreme experiment on several levels, including posing questions over creating a new class of illicit products and potentially disproportionate criminal justice measures.
E-cigarettes, on the other hand, have proven, beyond any reasonable doubt, to be safer than cigarettes and assisted millions in quitting smoking for good.
The Surgeon General’s report suggests not a commitment to evidence-based policy but policy-based evidence.
Whenever the evidence suggests that menthol prohibition may have a beneficial effect, it is taken as fact.
Whenever the evidence suggests e-cigarettes may benefit public health, it is treated with extreme skepticism, it requires further research, and it is never quite good enough to merit a word of recommendation from the Surgeon General.