FDA’s Mixed Messaging on E-Cigarettes Undermines Public Health

Lindsey Stroud

The Food and Drug Administration is failing to deliver a clear and important message about e-cigarettes, particularly to adults who smoke and the physicians treating them. Recent efforts by the Center for Tobacco Products fall short of informing the public about the potential of e-cigarettes as a harm-reduction tool.

In April, a commentary by Brian King, the director of CTP, was published in the journal Nature Medicine. It offered limited guidance to healthcare providers on the “considerations” of nicotine-containing e-cigarettes. In “conjunction” with the commentary, CTP launched a “new webpage aimed at educating the public about the relative risks of tobacco products.”

The commentary acknowledges that non-combustible tobacco products (including e-cigarettes) generally carry “lower health risks” compared to cigarettes. The correspondence also notes the need to address misperceptions about e-cigarettes among healthcare professionals. In fact, as stated in the commentary, these misperceptions are hindering successful switch attempts. Yet, the paper prioritizes FDA-approved nicotine replacement therapies as the “first line of treatment” for quitting despite acknowledging their limitations for some individuals.

The commentary acknowledges that while nicotine replacement therapies may not work for all and that medical providers may need to inform their patients of e-cigarettes, it states specifically that “exclusive use of e-cigarettes instead of cigarettes would reduce exposure to known toxicants and carcinogens.” Yet, the commentary offers no clear guidance for healthcare providers to discuss e-cigarettes as a potentially lower-risk option.

The webpage is also not clear-cut. It contains a straightforward question: “Are e-cigarettes a lower-risk alternative to cigarettes?” However, the answer from CTP is far from clear. It downplays the potential benefits, noting e-cigarettes “can generally be a lower-risk alternative” while emphasizing the need for further research despite existing evidence.

This mixed messaging undermines the supposed purpose of educating the public. While the agency is acknowledging the potential of tobacco harm-reduction products for the tens of millions of adults who smoke, its communication lacks clarity.

In comparison, Canada’s agency regulating tobacco products offers a more transparent approach. Health Canada hosts a section on its website dedicated to vaping. When comparing cigarettes to vaping products, that website clearly states that “switching completely to vaping nicotine is less harmful than continuing to smoke.” It also notes that adults “may be more likely to quit smoking than those who use (nicotine replacement therapies).”

Health Canada’s public communication on e-cigarettes is in direct contrast to the FDA. In fact, the FDA’s continued push for nicotine replacement products as a first line of treatment ignores scientific evidence finding e-cigarettes to be more effective in helping adults transition.

Many (if not most) adult e-cigarette users have tried (and failed) to quit smoking using FDA-approved nicotine replacement therapies. Since 2019, peer-reviewed evidence has suggested that e-cigarettes are more effective than nicotine replacement therapies in smoking cessation. Most recently, in January, in an analysis of 88 studies in the Cochrane Database of Systematic Reviews concluded that there “is high certainty” that nicotine-containing e-cigarettes “increase quit rates compared to (nicotine replacement therapies).”

While, technically, the FDA has authorized more e-cigarette products than nicotine replacement medicines (27 to seven), the agency has denied millions of e-cigarette products despite understanding that it is these products that have been proven to show efficacy in helping adults transition to safer products.

The FDA’s resistance to authorizing non-tobacco flavored e-cigarettes, which are popular among adult users and linked to declines in cigarette sales, further undermines tobacco harm reduction efforts. Additionally, its focus on a youth vaping “epidemic” — despite data that less than 10 percent of youth were vaping in 2023 — detracts from addressing the needs of adults who smoke.

As noted earlier this year by Konstantinos Farsalinos, a prominent tobacco harm-reduction researcher, nicotine replacement therapies have been a failure. As a lead author of a study examining 70,000 adult e-cigarette users, of which most were using non-tobacco-flavored vapes, Farsalinos understands the importance of flavors and the potential of e-cigarettes in eradicating smoking.

With the latest commentary and webpage, it is apparent CPT is refusing to accept the evidence about e-cigarettes.

The FDA and CTP have a critical opportunity to improve public health. With clearer communication and a shift in priorities, millions of lives could be saved by treating e-cigarettes not as a new danger but as a lifesaving tool.

Originally published in DC Journal.