Why it’s so hard to talk about e-cigarette risks

A growing proportion of American adults consider vapes just as or even more dangerous than cigarettes, according to a study out today. The findings illustrate just how hard it is to accurately convey the risks of e-cigarettes, especially when public health researchers are still working out what some of those risks actually are.

Part of the challenge is that the risk-benefit calculation for e-cigarettes depends on who’s using them. For adult smokers, completely switching to e-cigarettes may actually be less dangerous than smoking combustible cigarettes. But that doesn’t mean they’re completely safe: vapes haven’t been around long enough for us to know what their long-term harms might be, and at the moment, there’s little regulatory oversight of their ingredients, or their batteries — which sometimes, but rarely, explode. As for non-smoking adults and minors under the age of 18, they certainly shouldn’t be vaping because of the potential risks for heart and lung problems, as well as nicotine addiction that might eventually lead to cigarette smoking.

It’s a complicated public health message to digest — and today’s study, published in the journal JAMA Network Open, suggests that some of it is getting lost in translation. It’s understandable that the public doesn’t know what to think, because the science is still evolving, according to Gideon St. Helen, a tobacco researcher at the University of California, San Francisco, who was not involved in the study. “It’s not like the tobacco control community is united in terms of their opinion of electronic cigarettes,” he says. “Some people believe electronic cigarettes are bad, and some people believe they’re like the second coming of Christ.”

Jidong Huang, an associate professor of health management and policy at Georgia State University, wanted to know what that means for the public’s perception of vapes. “We don’t know what Americans now think about e-cigarettes,” he says. “Do they believe e-cigarettes are safe, or do they believe that e-cigarettes are more harmful?” So for this study, he and a team of researchers analyzed the results from two different surveys: one was an online survey conducted by Georgia State University, and the other was conducted by the National Cancer Institute. Starting in 2012, both surveys asked thousands of adults how risky they thought e-cigarettes were compared to regular cigarettes.

The team found that by 2017, more adults developed feelings about e-cigarettes. And in both surveys, the proportion of people who thought e-cigarettes were less harmful than regular cigarettes dropped between 2012 and 2017, with the biggest drop between 2012 and 2015. At the same time, the percentage of people who thought e-cigarettes were just as bad as cigarettes climbed. And while few adults thought e-cigarettes were more harmful than cigarettes in 2017 — 4.3 percent in one study and 9.9 percent in the other — that’s still a big increase from the 1.3 percent and 2.8 percent who thought that in 2012.

What those results mean, according to Huang, is that people have an imperfect understanding of the risks of e-cigarettes — especially compared to cigarettes (which, according to the CDC, “are extraordinarily dangerous, killing half of all people who smoke long-term.”) “What we were trying to say is actually it is very difficult to accurately communicate to the public,” he says.

Robert Jackler, a professor of otorhinolaryngology at Stanford, thinks that some of the confusion is because the public is becoming better, but unevenly, informed about e-cigarettes through the media. The dangerous risks of cigarettes are old news. But the health risks of e-cigarettes are newsworthy — so when scientists discover chemicals in them that can cause lung irritation or heart problems, or when vapes explode and vape juice poisons children, we report it.

“Most of us would like to see adult smokers leave their combustibles behind and move to vapor,” he says. Raising concerns about e-cigarettes is appropriate, he says, but can also lead to confusion about their relative risks compared to cigarettes. “All you see as a reader of news online is one report after another revealing the newsworthy fact that vaping is not perfectly safe. And people misunderstand the concept of safety versus safer.” He compares cigarettes to speeding down the highway at 90 miles per hour, and e-cigarettes to a more reasonable — but still fast — 75 miles per hour. “Both increase your risk of death, but speeding at 75 is nowhere near as risky of death or injury as speeding at 90.”

Getting the messaging wrong could be risky for public health, Huang says. On the one hand, overblowing the risks of e-cigarettes demonizes what may be a potentially less dangerous (albeit still risky) alternative to cigarettes for adult smokers; on the other hand, underselling the risks could wind up increasing teen vaping, he says. That means it’s key to tailor messaging to specific groups, in specific channels, Huang says. So campaigns on social media, which may reach a young audience, shouldn’t focus on the fact that e-cigarettes may be less risky than the regular kind. But that message might be appropriate for AARP magazine, which is more likely to reach adult smokers.

The study authors point out a big limitation with their own study: the data stop at 2017, which is before the massive spike in teen e-cigarette use that prompted the US Surgeon General to call teen vaping an “epidemic.” It’s also before big tobacco company Altria paid $12.8 billion to buy a chunk of e-cigarette giant Juul. So it’s possible that risk perception has changed since then. Another problem is that one of the surveys waffled on what to call vapes — switching from e-cigarettes early on to electronic vapor products in the latter years of the survey. That could make it hard to compare from year to year. And Michael Ong, a professor of medicine and public health at UCLA, says the surveys didn’t get into how people perceive different kinds of risks — like heart problems, cancer, or exploding devices.

Still, the results from both surveys back each other up. And for public health experts like St. Helen, the findings mean we need to get better at communicating risk — although striking the right balance is tricky. “I don’t think it’s okay to scare people into believing that something is risky that is potentially not as risky as you say. Because then it makes people question the scientific community,” he says. “The public can see through that anyway.”