FDA Largely to Blame for Physicians' Misperceptions on Nicotine
Back in 2020, an academic paper suggested that over 80% of US physicians mistakenly thought that nicotine was a carcinogen. The implication of this finding was that perhaps physicians considered vaping (and even nicotine replacement therapy) almost as dangerous as smoking. But physicians are busy people, and I wondered if some, maybe most, might have misunderstood the question in the survey and assumed the researchers were asking about smoking.
To test this hypothesis, I surveyed physicians to learn more about their actual knowledge and opinion. As part of this survey, I reached out to both US and UK physicians. The UK government is more supportive of vaping and other non-traditional nicotine replacement therapies than the US Government, so I wanted to see if government policy and guidance affects physician knowledge and opinion.
In my research, published this week, I found that roughly two thirds of the US physicians surveyed correctly recognize that nicotine does not cause cancer, but far more US physicians than UK physicians still believe that it is carcinogenic. Additionally, vaping is viewed far more positively as a smoking cessation tool by UK physicians than US physicians, and this is partly caused by the misguided US public health campaign against vaping.
Smoking is the real threat. Burning tobacco releases carcinogens that cause more than 480,000 premature deaths a year in the US. Nicotine is the main substance in cigarettes that creates physiological dependence, but it is not dangerous in normal doses. Nicotine patches and gum were developed to provide nicotine without the dangers of tobacco combustion. While helping some smokers to quit, patches fail to feed the ritual and social habit of smokers.
Cigarette companies and other corporations understood this and developed alternatives to combustible products, notably “heat not burn” tobacco products and vaping with flavored nicotine (traditional tobacco flavor as well as strawberry, pineapple, bubble gum and many others). These products satisfy some of the ritual and social aspects that many smokers enjoy, while lowering the risks for the user.
A systematic review of clinical trials showed that vaping is more successful at driving smoking cessation than other methods, with no significant evidence that it is a gateway into smoking.
Vaping products are not riskless, but they are substantially safer than smoking; the UK government suggests they are 95% safer, based on the available evidence.
UK health authorities are convinced enough of the relative safety of vaping that they encourage it as an alternative to patches and gum. Hospitals are handing out free vaping starter kits to recruit smokers into a cessation program. And in April 2023, the UK government decided to send vaping kits to roughly one million people - 20% of identified smokers. The aim of UK health officials is for UK to be a smoke free society (under 5% regular smokers) by 2030.
US government policy is equivocal about the relative benefits of vaping. The Food and Drug Administration has approved a few products, but FDA communications (along with all other US agencies) focus more on the potential risks of vaping, especially to youth, rather than its role in smoking cessation in adults.
As a result of US policy, US physicians are confused. While none of the physicians interviewed in my research thought that patches or gum could cause cancer, illogically a third thought vaping could. In addition, more than half of US physicians were unaware that the FDA had approved any non-traditional nicotine products. Although the sample size is too small to provide meaningful statistical analysis, at least nine US physicians (6%) were convinced that nicotine vaping is so dangerous that vaping products should be banned, or available only under prescription for smokers.
The vast majority of US physicians (85%) think the FDA has the responsibility to correct misperceptions about the relative risk of nicotine health products. Yet US agencies are failing to do so.
Vaping is not entirely risk free, and we might learn that it is far more dangerous than currently understood, but most physicians sampled seem to want policy based on available data, not a possible but unproven risk. It is the duty of the FDA to actively inform society that vaping is far safer than smoking.
US agencies should learn from their UK counterparts and encourage vaping as part of a smoking cessation effort.
Dr. Roger Bate is a Senior Scholar at the International Center for Law and Economics where he researches health policy in UK and USA.
