Electronic cigarettes have been in the marketplace for almost 20 years and current estimates are that worldwide users number close to 70 million. Many former cigarette smokers have benefitted from switching to electronic nicotine delivery systems. Nevertheless, during my short time working to help persons with behavioral health conditions reduce their smoking (see www.smokingandrecoverytoolkit.com) I have experienced tobacco control activists who assert that tobacco harm reduction (THR) was invented by big tobacco, that THR advocates are dupes, and that our efforts are a “sham”. Having worked in the alcohol and drug field for four decades I am well aware of the damage wrought by drug war zealotry and the need for courage to speak out against these kinds of moral panics. In the United States, harm reduction advocates have been engaged in a David versus Goliath battle for the attention of the public. Our voices are fragmented and regularly drowned out by big tobacco control’s fetish with cessation-only orthodoxy.

The authors state their belief that “…vaping can benefit public health, given the substantial evidence supporting the potential of vaping to reduce smoking’s toll.” The fifteen co-authors, all former presidents of the Society for Research on Nicotine and Tobacco, have decided that now is the time to call for a “balanced consideration” of the pros and cons of electronic nicotine delivery systems. Unfortunately, this seems a bit late in the game as misinformation about tobacco harm reduction approaches has proliferated and hardened.

The report states that the topic of e-cigarettes is controversial. This understatement fails to acknowledge the sources of what others might call the purposeful vilification of e-cigarettes and tobacco harm reduction approaches. How else to explain the fact that, today, the majority of Americans believe that e-cigarettes are more harmful than combustible cigarettes and are responsible for the e-cigarette or vaping use-associated lung injury (EVALI) outbreak of 2018.

Another aspect of this systematic demonization of THR approaches is a 2020 survey finding that 80% of physicians surveyed believe erroneously that nicotine causes cancer, cardiovascular disease, and chronic obstructive pulmonary disease. As was the case with America’s drug war, the foundations for such warped views are a lopsided research industry, and a public health community that should have known better and also had the courage to speak out.

A question for the 15 eminences is: how do you create balance when research funding priorities largely benefit studies that confirm negative views of electronic nicotine delivery systems, or when the stigma that has been attached to tobacco harm reduction approaches causes institutions to avoid any association? This orthodoxy and the anti-THR megaphone wielded by big tobacco control will not disappear, as this article only amounts to a drop in the bucket.

Tobacco harm reduction advocates in the United States need to organize and coordinate a robust response to the opportunity suggested by the AJPH piece. It took decades for the alcohol and drug field to eventually survive the imbalances of the Drug War and the vilification of drug harm reduction approaches. My hope is that the “balancing consideration of the risks and benefits” called for in this article will take much less time.


John de Miranda is a Knowledge-Action-Change Tobacco Harm Reduction Scholarship recipient. He has developed a THR toolkit for treatment programs and persons with substance use disorder. More information about his work is available at www.peninsulahealthconcepts.com. His e-mail address is [email protected]