A study published in the new issue of the journal Tobacco Control tested a series of new potential warning labels for electronic cigarettes. Currently, the FDA requires that e-cigarettes carry a single warning about the addiction potential of these products. The investigators in this study tested additional types of warnings on 1,629 adult vapers and smokers. The themes of these warnings included: metals exposure, DNA mutation, cardiovascular problems, chemical exposure, lung damage, impaired immunity, and addiction, in addition to the current FDA warning.
The study findings were as follows: "Regarding intended effects, new warning themes all discouraged vaping more than the current FDA-required warning (all p<.001), led to greater negative affect (all p<.001), and led to more anticipated social interactions (all p<.001). The most discouraging warnings were about toxic metals exposure. Regarding unintended effects, the new themes led to more stigma against people who vape (6 of 7 themes, p<.001) and led to a greater likelihood of thinking vaping is more harmful than smoking (all 7 themes, p<.001), though unintended effects were smaller than intended effects. Images of harms (internal or people experiencing) discouraged vaping more than images of hazards (all p<.001)."
The study concluded that: "Vaping warning policies should communicate a broader range of hazards and harms, beyond addiction, to potentially increase awareness of health harms. ... novel warnings should contain text-based information about harms and hazards, including metals exposure, DNA mutation, cardiovascular problems, chemical exposure, lung damage, impaired immunity, and life disruptions from addiction. Pairing text warnings with images showing internal harms (e.g., diseased organs) or someone experiencing harms (e.g., suffering symptoms) will likely discourage vaping more than showing the hazards (e.g., chemicals)."
The Rest of the Story
I have two major problems with this paper. For both, keep in mind that this paper is focused on adults, not youth.
First, I question the very basis (i.e., goal) of the paper. The conceptual basis for the paper, expressed in the Conclusion section, is: "E-cigarette warnings can be an important tool to discourage vaping among people who currently vape, smoke, or use both products."
That may sound rationale on its face, but let's think about it. Let's start with warnings to smokers. Why would we want to warn smokers about the harmful potential effects of e-cigarettes in order to discourage them from vaping? Shouldn't we be encouraging smokers to switch to e-cigarettes as a way to quit smoking, especially if they have tried medications and failed. Discouraging smokers from quitting is essentially the same as encouraging smokers to continue smoking. This doesn't make sense to me.
Now what about discouraging dual users from vaping? That seems even more problematic because if you have someone who is vaping and smoking, the message should be to quit smoking and move to vaping only. Discouraging these people from vaping by warning about it causing DNA mutations seems irresponsible when the likely outcome is that they will return to just smoking. Shouldn't we be trying to tip them in the other direction?
Even among people who are currently vaping, it isn't straightforward that our message should be to scare them about how dangerous vaping is. Suppose that they are a former smoker who quit by switching to vaping. Do we really want to scare them away from vaping so that they return to smoking? Certainly, among young adults other vapers who never smoked, it is reasonable to encourage them to stop vaping. But this is a relatively small audience when you consider all adults who either smoke, vape, or both.
Second, I question the recommendation to proceed with these "more effective" warnings when they have the demonstrated "unintended" consequence of misleading people into believing that smoking is less harmful than vaping. And remember, once you implement such warnings, the "unintended" consequences now become "intended" consequences since they are a known result of your intervention. Misleading the public into believing that smoking is less harmful than vaping is bound to have negative consequences for public health. It will almost certainly encourage many ex-smokers to return to smoking (those who vape) and discourage many smokers from switching to vaping. After all, why should I quit smoking and switch to vaping if vaping is actually more hazardous?
Third, there is the ethical question of whether it is acceptable to knowingly create a massive deception of your target audience about a critical public health principle (that smoking is more hazardous than vaping) even if the intended result (discouraging people from vaping) may be a good one.
The rest of the story is that our analysis need not proceed that far. The recommendations in this paper are problematic and if implemented, would likely cause more harm than good.
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