Why are so many anti-tobacco groups attacking electronic cigarettes (and to some degree nicotine pouches) but saying little about the risks of much more dangerous behaviors such as smoking? This is the $64,000 question, although I will only add my 2 cents here. But it is something that I have been thinking about for a long time (specifically, 16 years).

After a decade and a half of thought, I've gone through and discarded a slew of hypotheses and although I think there is some truth to many of them, there is only one that I find can consistently explain the shocking, irrational, unscientific, hysterical, and damaging behavior of so many anti-tobacco organizations.

First, why do I explain the behavior of so many of these groups as shocking, irrational, unscientific, hysterical, and damaging?

Shocking: It is shocking to me that an organization like the American Lung Association (with which I worked closely for several decades as both an employee and volunteer) is telling the public that quitting smoking by switching to vaping is not quitting smoking. That statement doesn't even make sense grammatically. It's false on its very face. You can't say "quitting smoking by doing X isn't quitting smoking." Unless that X is smoking! In this case, the X is not smoking, but vaping. They're not even qualifying the statement by asserting that if you don't switch completely to e-cigarettes, then you haven't quit smoking. They're actually saying - and I believe they actually mean - that if you quit smoking you have not quit smoking (if you did it in a way that they disapprove).

Irrational: It is irrational to discourage people who are addicted to smoking from switching to a much safer form of nicotine intake that has helped millions of people quit completely. Groups like the American Cancer Society are actively discouraging smokers from quitting using e-cigarettes, despite their proven effectiveness.

Unscientific: There is abundant scientific evidence that switching to vaping is the single most effective method for quitting smoking (other than cold turkey quitting for those who are highly motivated or triggered). The smoking cessation rate associated with the use of e-cigarettes is consistently about twice as high as that for nicotine replacement therapy, yet NRT is considered the "gold standard" for smoking cessation treatment.

Hysterical: By hysterical, I don't mean that the claims that many of these groups are making are funny. I mean that they are completely ungrounded in science and greatly exaggerated. In other words, that they are a form of hysteria which is helping to spread false information. For example, the claim that vaping causes popcorn lung is hysteria: there is not a shred of evidence to support that claim. Smoking itself is not associated with popcorn lung. It is, quite frankly, a hysterical claim in its lack of scientific grounding.

Damaging: As a result of all of the above, these organizations are essentially recommending against smoking cessation for smokers who desire to quit using e-cigarettes. They are actually providing medical advice to smokers indicating that they might as well continue to smoke rather than switch to e-cigarettes and some are even suggesting that switching to e-cigarettes is more dangerous than just continuing to smoke, arguing that dual use of smoking and e-cigarettes somehow greatly increases health damage despite dramatically lower tobacco smoke consumption. The campaigns of deception have resulted in demonstrable public health damage, as national surveys confirm that the majority of both youth and adults in the U.S. do not appreciate that smoking is any more hazardous than exclusive e-cigarette use. Undoubtedly, this has discouraged many smokers from quitting and has probably even led some ex-smokers to return to cigarette smoking.

The Rest of the Story

The conclusion I have come to is that the primary reason that so many of these groups are attacking these forms of nicotine use that have few acute risks is precisely because they have so few acute risks. In other words, deep down there is something about the relative lack of health dangers of these behaviors that bothers them and that they cannot accept. Ironically, these products pose such a risk to these groups because they don't pose a tremendous risk to youth and actually help adults who smoke. It finally occurred to me that the reason why these groups are attacking the very nicotine products at the lowest end of the risk continuum is because they are at the lowest end of the risk continuum. This is threatening to the idea that drug use should be harmful.

And more specifically, it is threatening to the idea that people who use a recreational, addictive drug should be punished for that decision rather than rewarded for it. It is difficult for these groups to accept the fact that:

(1) millions of adults are using a recreational drug involving addictive nicotine in a healthy way -- namely, in a way that actually improves their health; and

(2) hundreds of thousands of youth are using a recreational drug involving addictive nicotine without putting themselves at great risk of substantial health harm.

In other words, the huge threats here are that an adult can use nicotine as a recreational drug in a way that improves their health and that a youth can use nicotine as a recreational drug in a way that does not put them at a particularly high risk of suffering severe health damage.

Let's play this argument out a little more.

A devil's advocate argument might be that it can't be the lack of risk that is the cause for alarm because these same anti-tobacco groups are OK with the low risks associated with pharmaceutical nicotine products -- such as nicotine patches or gum or drugs like varenicline or buproprion. If these groups are threatened by the fact that people might be using nicotine in a healthy way, then why wouldn't they also be attacking NRT?

But it's not the use of nicotine in a healthy way that is threatening to these groups -- it is the recreational use of nicotine that bothers them. For decades, we in tobacco control have demonized nicotine. Given its demonic status, how can we possibly condone, or even support and recommend, the recreational use of this drug for any purpose, even one that improves the health of an individual? We're not offended if it's prescribed by a doctor as a medication because then it's not recreational use. It's the recreational use aspect that makes it unacceptable.

It's unfortunate because in some ways, latching on to nicotine as a central evil of cigarettes was what helped greatly reduce cigarette smoking, promote effective regulations, destroy the reputation of the cigarette companies, and achieve major legislative and litigation battles. In many ways, it was former FDA Commissioner David Kessler's pronouncement of nicotine as a drug that ultimately led to passage of the Family Smoking Prevention and Tobacco Control Act of 2009. So recognizing and emphasizing the role of nicotine in smoking addiction played a major role in fighting the tobacco industry and in greatly reducing smoking rates.

The problem is that now, what was previously an appropriate obsession with the problem of nicotine addiction is threatening to destroy a golden opportunity to literally make smoking history, as we had previously indicated was our primary goal (e.g., the slogan of the Massachusetts anti-smoking campaign for many years was "Let's Make Smoking History.")

Ironically, it is the tobacco control movement that is now the greatest threat to making smoking history as the movement's continuing demonization of nicotine--divorced from any consideration of its actual health effects--is leading to misguided public recommendations, physician misinformation, public deception, and ill-conceived regulation and legislation that has combined to achieve the effect of doing everything possible to protect combustible tobacco use from being completely displaced by much safer forms of nicotine use that do not even involve tobacco (although the mainstream tobacco control groups continue to incorrectly call e-cigarettes and nicotine pouches "tobacco products" and "forms of tobacco use").

While the mainstream tobacco control movement has become obsessed with trying to destroy the safest forms of nicotine available, they are at the same time protecting the most dangerous form of nicotine available (cigarette smoking). And while groups like Parents Against Vaping E-Cigarettes would apparently like to see nicotine e-cigarettes banned, they don't utter a word about much more acute and severe threats to youth health like black market THC vapes, drug-spiked cannabis products, and alcohol use. Apparently, while they think that every single flavored e-cigarette product needs to be banned, they are OK with alcohol companies recruiting kids to dangerous drinking by indoctrinating them with flavored alcoholic beverages (which, unlike e-cigarettes, are a gateway to more dangerous forms of drug use). Ultimately, it's not doing any good for our nation's youth to teach them that ripping an occasional cherry vape is the greatest risk to their health.

The rest of the story is that the demonization of nicotine--while it previously played a critical role in the fight against smoking--is now impeding progress in what would otherwise be a golden opportunity to eliminate the use of combustible tobacco. This is largely a result of the inability of the tobacc...

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