As FDA Commissioner Scott Gottlieb put it:
The FDA is tied in knots over e‐cigarette use. On the one hand, the FDA does not want people to smoke. But, on the other hand, the FDA does not want people to use smoking alternatives that could help them quit, such as e‐cigarettes. To that end, the FDA recently signaled its interest in increasing regulation of e‐cigarettes including Altria’s MarkTen and British American Tobacco’s Vuse, with an eye towards protecting teens from potential health effects.
[Some say] in order to protect kids, [the FDA] is going to encumber adult smokers by putting in place restrictions that make these products less attractive, or harder to purchase by adults. These things may all be true.
But although the commissioner recognizes new regulation could negatively impact adult e‐cigarette consumers, he does not consider that new restrictions may disproportionately affect the poor.
This is likely for three reasons. First, low‐income and low‐skill Americans are more likely to smoke traditional cigarettes, and more likely to smoke traditional cigarettes heavily. For example, the CDC finds the prevalence of smoking is around two times as high for smokers below the U.S. poverty line as for smokers at twice the poverty level. Likewise, adults with less than a high school education are more than 2.5 times as likely to smoke as adults with a college degree.
Second, when it comes to quitting smoking, poor and less‐educated Americans have the hardest time. A CDC report suggests that smokers with less than a high school degree are less than half as likely to report recently quitting smoking as smokers with graduate degrees. And adults at or above the poverty level are more likely to report recently quitting than those below the poverty level.
Third, poor and less‐educated Americans are more likely to use e‐cigarettes. According to a recent study, 10.2 percent of individuals in households with between $0–$20,000 of income have used e‐cigarettes, whereas about half as many individuals in households with $75,000 of annual income or more have used e‐cigarettes. Education levels break the same way: Around twice as many individuals with less than a high school degree have ever used an e‐cigarette, compared to individuals with a college degree or more.
Why does this matter? Low income and less‐educated Americans report lower levels of access to health care and poorer health outcomes along a variety of metrics. E‐cigarettes ostensibly provide an affordable avenue to improve health for smokers that can’t afford professional help quitting or reducing cigarette use.
According to a variety of studies, smokers commonly use e‐cigarettes with an intention of substituting them for tradition al cigarettes or quitting smoking. Indeed, the most common reason cited for using e‐cigarettes is smoking cessation or improving health, and research finds e‐cigarettes are an effective substitute or “quit aid”: Randomized control trials suggest e‐cigarettes are as effective as other methods and some survey research indicates e‐cigarettes are more effective than over‐the‐counter nicotine replacement therapies or trying to quit “cold turkey.”
Smokers who use e‐cigarettes also report improved health. In a 2014 longitudinal study of regular smokers who purchased e‐cigarettes, the majority of participants reported improved health (65.4 percent), reduced smoker’s cough (57.7 percent), improved sense of smell (53.8 percent) and taste (50.0 percent) within 8 weeks’ time of e‐cigarette use.
Of course, e‐cigarettes are neither guaranteed safe nor lacking in health risks of their own. Because e‐cigarettes are relatively new, long‐term effects are still unknown and evidence on outcomes is limited.
Still, most everyone agrees that e‐cigarettes are a safer option than cigarettes and that e‐cigarette vapor is safer than second‐hand smoke. As the National Academy of Sciences mentions in a consensus study, cigarette smoke is estimated to contain “approximately 1,500 times more harmful and potentially harmful constituents” than e‐cigarette vapor and there is “substantial evidence” that “exposure to potentially toxic substances … is significantly lower” with e‐cigarettes. In other words, when used the way most smokers intend, e‐cigarettes constitute improvement over traditional cigarettes.
It also bears mentioning that a non‐trivial portion of Americans report using e‐cigarettes for cost reasons. Taken together, this suggests e‐cigarettes are an affordable and accessible way for poor American smokers to voluntarily improve their health.
The FDA is ostensibly committed to protecting Americans from harmful substances. However, the commissioner should also consider whether the FDA is interested in protecting poor Americans from regressive regulation. Evidence suggests e‐cigarettes are an easy way for poor American smokers to improve their health. Unfortunately, future restrictions may change that.