What the New Surgeon General Should Do About E-Cigarettes

This article originally appeared on Forbes.

In early September, Dr. Jerome Adams, former Indiana State Health Commissioner, was sworn in as the nation’s 20th Surgeon General.

As Commissioner, Adams was celebrated for establishing a needle exchange program, Indiana’s first, in response to an outbreak of HIV caused by needle sharing among abusers of a prescription opioid called Opana.

Having established his bona fides in harm reduction in the context of opioids, Adams must now apply them to nicotine.

He can start by setting the evidentiary record straight on youth and e-cigarettes, devices that deliver a heated nicotine solution with none of the tar and toxins that come from combusting tobacco.

This means undoing the damage inflicted on public understanding of the issue by his predecessor’s report on youth vaping, E-cigarette Use among Youth and Young Adults, issued in December 2016.

That report was, in short, a fiasco. Upon its release numerous critics protested its findings and now a new paper in the Harm Reduction Journal, entitled “A Critique of the US Surgeon General’s Conclusions Regarding E-Cigarette Use Among Youth and Young Adults in the United States of America,” enumerates the problems with the Surgeon Generals’ conclusions.

Most harmful was the report’s breathless hyperbole that “E-cigarette use among U.S. youth and young adults is now a major public health concern.”

The data, summarized by the critique’s authors Riccardo Polosa MD, PhD of the University of Catania and his colleagues, simply don’t support this.

For one thing, the majority of e-cigarette use by youth is infrequent, experimental, and negligible among those who do not already smoke.

A small fraction, 0.7 per cent, of these youth reported using e-cigarettes on a regular basis (defined as 20 out of the last 30 days) in 2015, according to the Monitoring the Future Survey. Another government survey showed that approximately 65 per cent of all youth who had ever vaped used nicotine-free e-liquids.

Second, youth smoking has been declining impressively for the past ten years. In fact, the sharpest declines have occurred as the availability of e-cigarettes increased, suggesting that vaping might have been an exit ramp for teen smokers.

Polosa and his team identified other notable distortions contained in the 2016 report, among them an exaggerated risk surrounding the effect of nicotine on the developing teen brain. The data do not align here either: to date there is no compelling evidence of a negative impact of nicotine on adolescent cognitive performance.

And it gets worse. Some evidence never made it into the report at all.

In a brief but powerful letter to the editor of Nicotine and Tobacco Research, Annie Kleykamp, a research scientist at Pinney Associates in Bethesda, MD, exposed a stunning instance of confirmation bias.

Confirmation bias exists when evidence is selectively sought or interpreted in a manner partial to pre-existing beliefs or expectations. And there it is, right in Chapter One, “The Scientific Basis of the Report,” where the report says “selected studies from 2016 have been added during the review process that provide further support for the conclusions in this report.”

Selected studies -- the other term for this is cherry-picking -- to support existing conclusions?

Omitted were articles showing that raising age of purchase on e-cigarettes was associated with increased use of conventional cigarettes by teens. One of those articles was published in 2015 –culled even before readers were on notice that evidence might have been left out. Given the report’s recommendation to discourage vaping via taxation, these articles are highly relevant.

The 2016 report also neglected to cite a major 2010 review of nicotine’s positive effect on cognitive performance, including on participants that were in the late teens and early twenties.

Between the critique appearing in the Harm Reduction Journal and Kleykamp’s smoking gun on confirmation bias, the 2016 Surgeon General report on youth vaping is a blot on a decades-long record of quality documents issued by the Surgeon General.

What can Surgeon General Adams do?

First, he must bring his pragmatic harm reduction vision to bear upon any announcements or reports on vaping. This means amending and updating the 2016 report on youth smoking.

If there is to be a subsequent report on adult vaping during Dr. Adams’ tenure, it should contain a chapter revisiting youth vaping. That chapter must include evidence omitted from the 2016 youth report and new analyses published after 2016 (such as these, here and here, that appeared just this month). Essential as well is a thoughtful evidence-driven discussion of youth vaping, which will inevitably douse any alarmism prompted earlier by the youth vaping report, plus a consideration of youth vaping within the larger context of anti-smoking efforts for all.

It is also imperative that new Surgeon General revisit the policy recommendations in the 2016 report. This is because the restrictive regulatory regime promoted in the report would fall most heavily upon adult smokers – the very individuals in need of reduced-risk options -- and upon current vapers who benefit from continued innovation.

If the only way to issue a correction is as a stand-alone document – and this would surely be a radical move for the Surgeon General’s office – then so be it. Scientific integrity of such caliber would go a long way to restore confidence in the Office of the Surgeon General.

Second, if there is to be a report on adult vaping – or an independent revision of the 2016 report –there is a solid literature to consult and a roster of first rate researchers in the U.S. and abroad who can serve as reviewers. They must be enlisted.

And they must be retained.

Some reviewers of the 2016 report were so disaffected by the final report, that they took their names off the final product. One was Professor Kenneth Michael Cummings of the Medical University of South Carolina who co-leads the center’s Tobacco Research Program. As Cummings told me, “The 2016 report went well beyond any evidence base for making policy recommendations…it avoided the larger question of whether population health might be enhanced overall by the availability and marketing of products such as e-cigarettes that could potentially displace cigarettes.”

Cummings emphasized to me that he had been “honored and privileged” to have served as a reviewer of previous Surgeon General Reports. In the past, he submitted requested feedback and the editor [as a CDC staffer] had incorporated it in one form or another. “This was the only time I suggested to the editor that I felt the report as written was so seriously flawed it should not be published in its current form,” he said.

Third, and regrettably, Adams will have to be very cautious when collaborating with the Centers for Disease Control and Prevention, CDC, on the issue of smoking and reduced-risk products. The agency, having played a critical role in preparing the 2016 report, has proven itself an unreliable analyst on this topic.

Until the new CDC director indicates a break from her predecessor’s famously biased views on e-cigarettes, participation by the agency in future Surgeon General Reports on vaping and other reduced risk approaches will need serious oversight.

The Surgeon General has a long record of excellent work on smoking, barring the 2016 treatment of electronic cigarettes, which seems to be an aberration.

The good news, Dr. Adams, is that this serious misstep can be reversed in the name of public health and science, and toward the well-being of the nation’s 37 million smokers, who need the truth to set them smoke-free.

Sally Satel is a resident scholars at the American Enterprise Institute.

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