New York Magazine forgets that smokers exist

The cover story of this week’s issue of New York Magazine is all about vaping. The publication employs smart, talented writers, so despite the alarmism of the cover tease – “The making of a health crisis that’s only just begun” – I was hopeful that the story itself might offer more nuance. Regrettably, it’s a one-sided mess that fails to convey the complexities of the issue and pays virtually no attention to the needs of current and former smokers whose lives are risk.

Mainstream coverage of vaping tends to focus on the latest fears rather than the long-term case for harm reduction. Stephen Hall’s New York article is hardly unique in that respect. It is unique in that it manages to maintain this bias at such length. I’ll say this for his cover story: There certainly is a lot of it. It stretches on for a luxurious 6,000 words, providing copious detail, original reporting on the outbreak of lung illnesses, and quotes from leading figures in tobacco control. Yet despite all this, and regardless of Hall’s presumably good intentions, it essentially amounts to a hit piece.

The article opens, predictably, with scenes from the mysterious lung illness that dominated headlines since last summer. It’s been clear for months that a contaminant in cannabis cartridges is behind the outbreak, with vitamin E acetate recently confirmed by the CDC as the most likely culprit. The story of how this additive entered the THC market has been reported previously, most notably by the cannabis website Leafly, whose coverage has been far superior to that of most national news publications. Rehashing the story in New York serves mostly to provide drama and color. Which is fair: A feature story needs drama and color. But Hall devotes nearly 3,000 of his words to THC and the lung illness, taking up about half the article. For a writer who purports to have something important to say about the potential dangers of nicotine vaping, this is a dubious narrative decision.

The conflation of nicotine and THC vaping by government agencies and the media has caused immense confusion in the debate over e-cigarettes, which many of us who follow the issue have been striving to correct. New York muddies things up again by threading together two ideas that, taken separately, would be unobjectionable, but that combine to mislead the reader. The first is that contaminated THC cartridges have caused a truly frightening pulmonary illness that has tragically sickened and killed people who use them. The second is that the long-term health effects of nicotine vaping are not yet completely known. These are both valid stories, but they don’t have much of anything to do with each other. One is a short-run story about the illicit drug market. The other is a long-run story about the potential risks of vaporizing nicotine. The products vaporize different liquids, rely on different supply chains, are sold in different venues, are regulated (or not regulated) by different agencies, and appeal to different consumers. Mashing these stories together with the implication that fear of one should inform our response to the other generates more confusion than clarity.

Despite acknowledging the role of vitamin E acetate, Hall speculates that since not every case of lung illness has been definitively linked to it, perhaps nicotine e-cigarettes actually are causing some of the cases. While it’s impossible to rule out that someone, somewhere may have ended up with a contaminated e-cigarette, this would be extremely aberrant. E-cigarettes have been used by millions of people for more than a decade in multiple countries, raising the question of how they would trigger lung illnesses that are geographically and temporally clustered. There was clearly something new at work that was not inherent to e-cigarettes, and it would be a major a coincidence if a different contaminant causing the same symptoms just happened to enter the nicotine supply at the same time that vitamin E acetate was contaminating THC carts. The parsimonious explanation is that THC contaminants are the primary and perhaps exclusive cause of the outbreak, and that if any cases ever do get conclusively tied to e-cigarettes, they will be very weird outliers in the nicotine e-cigarette market.

By suggesting that killer e-cigarettes may be lurking behind any corner, suddenly striking down vapers by some unknown causal mechanism, New York Magazine exceeds the alarms of the CDC. The agency’s current guidance is that people should not “use THC-containing e-cigarette, or vaping, products, particularly from informal sources like friends, family, or in-person or online dealers.” It advises further that “[adults] using nicotine-containing e-cigarettes or vaping products as an alternative to cigarettes should not go back to smoking.” Also, “E-cigarette, or vaping, products should never be used by youths, young adults, or women who are pregnant. Adults who do not currently use tobacco products should not start using e-cigarette, or vaping, products.”  The CDC is generally antagonistic to e-cigarettes, and the agency rightly advises that minors and non-smokers shouldn’t go taking them up for fun. But it also recognizes that the alternative for many vapers is not abstinence, but a return to smoking combustible cigarettes. Which brings us to the bigger problem with New York’s coverage: it almost completely disregards the health of smokers.

I was alerted to Hall’s article on Twitter by CBS journalist Tony Dokoupil, who compared its alarmism to “old school pot coverage.” More to the point, he noted that it “shows little regard for [34 million] adult smokers who might benefit from a safer alternative” and “reeks of class judgement.” Tony could have also added that more than 400,000 of those smokers will die in the United States this year, or that 7 million annual deaths worldwide are attributed directly to tobacco use. Hall doesn’t mention these figures in his story, either of which would have helped put the 60 deaths due to lung injury that he does cover into perspective.

Hall wants readers to fear the long-term effects of vaping, which he describes as a potential epidemic in the making. What these risks may turn out to be is of course a vital concern, but the stakes are wildly different for smokers and non-smokers. A non-smoker who takes up vaping is increasing their risk; a smoker (or potential smoker) who takes up vaping is reducing it. At the population level, the degree to which these effects offset each other depends on the relative risks of smoking and vaping. If the latter is vastly lower-risk than the former, then vaping can be a net good for public health even if a substantial number of non-smokers become vapers and even if vaping is not “safe” in an absolute sense. This simple relationship (the “risk/use equilibrium”) is one of the main things that has convinced many health researchers that tobacco harm reduction holds promise.

The concept of harm reduction gets short shrift in Hall’s reporting. When he does mention it, it’s only to discredit it shortly after. He notes the influence of estimates from Public Health England and the Royal College of Physicians that the harms of vaping are unlikely to exceed 5% of those caused by smoking cigarettes, then immediately quotes Jeffrey Gotts of the University of California, San Francisco denouncing them as “ludicrous.” Similarly, the founders of Juul make an appearance in secondhand reporting about their goal of replacing smoking, only to have theirs aims immediately dismissed by Stanton Glantz, also of UCSF. Readers of New York Magazine wouldn’t even finish the piece with a clear idea of whether e-cigarettes are safer than smoking; “Now I think they’re about as dangerous as a cigarette,” says Glantz in one of the few paragraphs that addresses the question.

That Gotts and Glantz are both affiliated with UCSF is no coincidence. You’d be hard-pressed to find a research center more institutionally opposed to nicotine or tobacco use in any form. Glantz in particular wears his ideology on his sleeve. His career has long combined research and activism, aiming in his own words to define “smoking as an antisocial act,” and he has a demonstrated willingness to make ludicrous claims of his own when they suit political ends. (See, for example, his infamous Helena heart miracle study.) The other expert Hall cites repeatedly is Matthew Myers of the Campaign for Tobacco-Free Kids, who is an effective lawyer and activist, but far from a neutral source.

Quoting Gotts, Glantz, and Myers is a defensible editorial decision; they’re all significant figures in the field. What’s not defensible is to do so while ignoring the substantial scientific literature making the case for tobacco harm reduction. I’ve covered much of this elsewhere – at greatest length in chapter seven of The Rediscovery of Tobacco – but suffice to say that there’s a great deal that New York omits, from projections that widespread switching to e-cigarettes could prevent more than 6 million premature deaths in the United States to a large randomized control trial finding that smokers given e-cigarettes successfully abstained from smoking at nearly twice the rate of smokers provided with traditional nicotine replacement therapies. There are impeccably credentialed advocates of harm reduction in the United States, Scandinavia, Europe, and around the world whom Hall could have cited to present a more balanced view of the debate.

Similarly, If Hall bothered to interview smokers, vapers, vape shop owners, or vaping advocates, there’s scant evidence of that in the final product. There are more than 3 million ex-smokers who currently vape in the United States and millions of current smokers who struggle to quit. I’ve come to know many of them in person or online, and they beg to make their voices heard and to preserve access to products that have helped them quit smoking. Why are their stories overlooked while teenage drug dealers in Wisconsin take up thousands of words of coverage? This narrative decision reflects poorly on New York Magazine. As rates of cigarette smoking have declined, the practice has become concentrated among the financially worse off and less educated, which has made it all too easy for other Americans to dismiss their interests. Persuading smokers to change their behavior and providing them with tools to do so is among the most vital needs in public health. Yet notably absent from New York’s coverage is any suggestion for how to help them. The magazine hypes speculative fears about dangers of vaping that might appear decades from now, while neglecting the completely unspeculative deaths of more than 1,000 Americans every single day.

To be clear, worries about the long-term effects of vaping are absolutely a valid concern. I’m not suggesting that vaping is perfectly safe, that reasonable steps shouldn’t be taken to curb youth uptake, or that journalists shouldn’t explore the potential risks. As a physician friend of mine likes to say, “If you want lungs that outlast your hair, don’t inhale things that are not air.” Sound advice. But we also know that many people will inhale things that are not air, as they have done throughout human history. Taking their interests seriously requires contemplating trade-offs. Throughout his article, Hall instead maximizes every possible harm while minimizing every possible benefit. (One example: He cites the scariest figures about youth vaping but doesn’t mention that these refer mostly to occasional use or that youth smoking rates have fallen to the lowest levels ever recorded.) Regardless of what one thinks of the Royal College of Physicians’ estimate of the risks of vaping, one should heed their reminder that excessive risk aversion can itself be harmful: “If this approach also makes e-cigarettes less easily accessible, less palatable or acceptable, more expensive, less consumer friendly or pharmacologically less effective, or inhibits innovation and development of new and improved products, then it causes harm by perpetuating smoking.” New York evaluates vaping as if smokers did not exist.

Journalists, academics, and policymakers too often fail to treat nicotine consumers with dignity, respect, and genuine concern for their well-being. By choosing fear over nuance, absolutism over trade-offs, and ideologically-driven sources over balanced reporting, New York Magazine botched its opportunity to publish an informative feature that could improve the debate over vaping. The 34 million smokers and 10 million vapers in the United States deserve better.