To vape or not to vape?
That is the question sparking a heated debate this week in Geneva where over 1,400 delegates have gathered to discuss the World Health Organization's Tobacco Control Treaty and what they call "the tobacco epidemic."
For years, there have been stories warning about the dangers of vapes, also known as e-cigarettes, and other non-cigarette products like heated tobacco and nicotine pouches.
Many scientists and public health experts point out that the tobacco industry promotes and profits from these newer products and that many young non-smokers are using e-cigarettes and becoming addicted to nicotine.
However, a number of doctors, scientists and public health experts argue that, while these products are dangerous, they may not be as dangerous as traditional cigarettes, which kill up to half of long-term users. As the lesser of two evils, their argument goes, e-cigarettes could be useful in helping people quit smoking.
This matters because even though smoking rates have been dropping, 1.2 billion people worldwide continue to use tobacco. About 80% of them live in low- and middle-income countries.
Accusations of industry influence and scientific censorship are flying.
WHO staked out its stance on the issue this month in a strongly worded position paper, slamming the idea of using e-cigarettes as a tool in smoking cessation. And at the anti-tobacco gathering in Geneva, leaders are calling for tough new restrictions on products like vapes.
Both sides agree that getting this question right now is key to addressing the tobacco epidemic.
"Mea culpa!"
Twenty years ago, Dr. Derek Yach was well regarded in the public health world.
The South African physician played a leading role in drafting and launching WHO's landmark tobacco treaty. And the treaty has played a critical role in reducing tobacco use, which has dropped by a third largely due to strategies like health warnings, taxation and bans on advertising.
But now? Yach acknowledges he's a pariah to many former colleagues. "I'm excommunicated," he says.
That's because of his stance on e-cigarettes, heated tobacco and the like.
Yach has come to believe that the traditional approach to smoking cessation is insufficient. "There was only one message allowed and still is today: The only way to get rid of smoking is to get everybody to quit," he says, arguing that this approach doesn't "recognize the toughness that people go through with a complex addiction, which is driven by nicotine."
In many other areas of medicine, the idea of "harm reduction" is well established. For example, public health programs provide sterile needles to drug users so they don't spread HIV and hepatitis. It reduces the harm, even if it doesn't solve the addiction. Yach sees e-cigarettes as a method of harm reduction.
While products like e-cigarettes still have nicotine, it is not burned. Instead, a heating element converts a nicotine liquid into a vapor that is inhaled.
"It's in the process of burning that you create the cancer-causing agents and many of the other toxins that eventually cause the death and disease," he says.
Yach wants to see these products promoted by doctors and health programs as a way to help current smokers cut back on smoking or quit altogether. He remembers thinking to himself: "Mea culpa! I've missed what is probably the greatest opportunity to save lives."
Yach eventually founded the Foundation for a Smoke-Free World, to advocate for this approach. It's since been renamed Global Action to End Smoking and is under new leadership.
There's an important point to note about this group. It's funded by the tobacco industry. That connection has cemented his self-described excommunication.
But Yach is not a lone voice. The U.K.'s National Health Service, for example, has embraced e-cigarettes as a way to help people stop smoking. And a number of academics — independent of the tobacco industry — have come to agree with him. Mike Cummings, a professor and researcher at the Medical University of South Carolina, is one of them.
Cummings does not want non-smokers to use e-cigarettes or the other products — but he also stresses that "for somebody who is already addicted to nicotine in cigarettes, having an alternative that would be safer, like an e-cigarette, is something that's worth considering."
Because of his call for a debate, Cummings says, he's been shunned by many in the world of tobacco control. He says the fact that he's testified against tobacco companies in court more than 200 times hasn't saved him from being on the outs.
"One of the ways they have attacked us is to claim that we're shills for the cigarette companies, which is absurd. We're not," Cummings says. "Many of us are legitimate scientists."
He says an open debate hasn't happened yet — and that it can be hard to get funding for research into smoking harm reduction strategies. "That's not science. That's anti-science. It's censorship," he says.
One of the largest tobacco companies, Phillip Morris International, declined an interview request from NPR but said in a statement that WHO shouldn't fear dialogue and is out of step with governments that are embracing smoke-free products in order to end smoking.
"Mass marketing harmful products"
When it comes to the idea of harm reduction, WHO is adamant in its opposition. Its position paper says the tobacco industry is "misappropriating" the medical term harm reduction and "mass marketing harmful products" while "cloaking" it in medical language.
"Let's be clear, the companies that make these products are not motivated by harm reduction or health, they are motivated by one thing and one thing only: generating profit," says WHO Director-General Tedros Adhanom Ghebreyesus. "There is no evidence of their net benefit for public health, but mounting evidence of their harm."
One major concern in this debate is that the products are often used by non-smokers — especially young ones who are attracted by the flavors and packaging.
"We see use rates [of e-cigarettes] among children nine times higher than among adults," says Benn McGrady. He heads Public Health Law and Policies at WHO, which helps governments develop and defend tobacco laws. "The latest data that we have shows there are 15 million children worldwide using e-cigarettes."
McGrady worries that, without proper regulations, there could be a generation of people newly addicted to nicotine. WHO argues that countries need to regulate the products at least as strictly as cigarettes.
Last month, the International Pediatric Association also came out forcefully against e-cigarettes, warning in the medical journal Pediatrics that "e-cigarette use is associated with cardiovascular, metabolic, respiratory, oral diseases and cancer, with dual users facing greater health risks than cigarette smokers alone." The stakes, their position paper says, are high: "E-cigarettes threaten to reverse decades of progress in tobacco control."
"That's the opposite of harm reduction, right? That's really harm-causing," says Stella Bialous, the associate director for Global Tobacco Control Initiatives at the University of California, San Francisco's Center for Tobacco Control Research and Education.
One concern that's surfaced has been exposure to metals — like lead — in the heating element of the e-cigarette. However, studies have pointed in both directions.
When it comes to exactly how risky these new products are, McGrady says, there's huge variation between the various products and it's "not responsible" to generalize. These products are relatively new and WHO's report acknowledges their risks will only become clear over time.
"An unutterable scam"
For some, this debate feels like déjà vu — and a classic example of the tobacco industry interfering in public health efforts and sowing division.
Bialous says many researchers believe that this debate is "actually one of the strategies that a tobacco company developed to divide and conquer — like 'let's talk about harm reduction and get all the people fighting among themselves while we continue to sell the products.'"
Dr. Tim McAfee is the former head of the Center for Disease Control and Prevention's Office on Smoking and Health — which has now been eliminated by President Trump. He says this current battle reminds him of when the industry promoted filtered cigarettes as safer in the 1950s and when they pushed low-tar cigarettes in the '60s and '70s.
"Every single one of those things they've done over the last 100 years has turned out to be an unutterable scam," he says. He calls the effort to promote e-cigarettes and similar products a smokescreen.
Cummings, the professor at Medical University of South Carolina, counters that just because these newer products are backed by the tobacco industry doesn't automatically mean they can't play a role in smoking reduction.
"We ought to get the evidence and weigh it and debate it — and help guide the policies based on evidence, not on ideology," he adds.
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