What would we know about cigarettes and health if they were as new as e-cigarettes?

by Carl V Phillips

The question in the title (h/t to Rolygate for posing it to me) is intriguing.  If cigarettes had been used for less than a decade, and had seen the rate of uptake that e-cigarettes have seen, how much would we know about their health effects right now, and how does that compare to what we know about e-cigarettes?

For purposes of this exercise, assume that we have current general epidemiology knowledge and methods (ex knowledge about cigarettes per se, of course).  That is more complicated a counterfactual than you might realize because of how entangled the early history of epidemiology was with research on cigarettes.  However, even if semi-modern methods got a later start, epidemiology has evolved so ridiculously slowly that it is not unreasonable to assume we could have about the same level of development.  We would have to assume that there would not be a tobacco control industry and the associated enormous pools of money from taxes on smokers.  This would improve the accuracy of what information we did have, but would mean that there were not billions of dollars looking for something to do, so there would be a lot less research (perhaps even compared to what has been done on e-cigarettes in reality, in spite of the obvious difference in its value).  I will also make the absurd assumption that despite how easy and appealing it is to smoke tobacco in some form (it has been happening since before recorded history in the Americas, after all), that there is no history of chain-smoking pipes or anything similar that would have provided a lot of the same data we have about cigarettes.

So what would we know?  It is safe to assume we would know that smoking causes acute negative effects for the lungs and cardiovascular system.  These are easy to observe and many would have been noticed by smokers.  There would probably have been some formal studies in addition to the general observations.  We would probably have a pretty good catalog of these effects already, though would not know all of them.  For example, the vascular tissue damage caused by circulating smoke particles might not have been detected, given that it is only now starting to be understood.

This contrasts with what we know about the acute negative effects of e-cigarettes in several ways.  First, e-cigarettes cause no easily observed, relatively common serious consequences.  There has been ample opportunity to observe these so we can safely conclude they do not exist.  (And this is obviously not changed by the fact that the ANTZ have tried to trump up such claims — e.g., the lies about there being lung effects similar to cigarettes, but that are really just similar to breathing in very humid air.)  On the other hand, in the cigarette scenario we would probably have the (scientific) advantage of observing people transitioning from abstinence to smoking, whereas for e-cigarettes we only observe the transition from smoking to vaping.  Thus, it might be that some of the acute effects from smoking still exist when someone switches to e-cigarettes but are hidden because switching still dramatically reduces them.

If cigarettes were less than a decade old, we would know very little about the cancer risk.  Very few already-detectable cancers would have been caused.  We would probably guess that they cause cancer based on chemistry and analogy to other smoke exposures.  On the other hand, so much of what we know about those analogies exists because of research on smoking, so the opportunity to learn from analogy would probably be greatly reduced.   Similarly, the epidemiology does not tell us anything about the cancer risk from e-cigarettes.  The assessment that there is very little, if any, cancer risk from them is based on the chemistry of the exposure and how that compares to other known exposures.

The picture for long-term lung effects is similar.  There would be too few cases of smoking-caused COPD to detect in the epidemiology, though there might be a few suggestive case studies.  However, even in a world without much smoking, we would by now probably know enough to predict that there would be such risks from smoking.   Similarly, what we believe about e-cigarettes is based on no useful epidemiology, but our knowledge that there is no reason to believe they could cause much risk for lung damage.  (This is not to say we can be sure there is none — inhaling anything other than clean air, whether that is common indoor air pollution or using drug delivery devices, should not be assumed to be completely risk-free for the lungs until we have good epidemiology.)

The picture for non-acute cardiovascular effects is rather more complicated.  Some of the risk pathways for smoking have rapid enough impacts that it is possible they could have been detected in the epidemiology already if researchers had really moved fast to gather data.  Some of the risk pathways are more like cancer, taking so long to have an impact that we would not have seen them yet.  But some are as short as harvesting effects (smoking immediately triggering heart attacks or strokes in people who were on the verge of having them within months), and so have even been measured if the right research was done.[*]  Also, without a tobacco control industry, there is a much better chance that any such research would have been done honestly.

[*Note that this observation does not change the fact that the “smoking ban miracle” “studies” are lies.  There would be very few acute cardiac events, so they might be detected using methods that really drill down to them, but they clearly would not be enough to show up in short-term population statistics as the ANTZ claim in their junk science.]

For e-cigarettes we have no such data and have little chance of getting anything useful for a very long time, if ever.  Once again, our knowledge of the exposure and analogy tell us that any such risk from e-cigarettes is going to be small.  Even if we had epidemiologic data on vapers right now (which we do not) it would be impossible to detect any effect from e-cigarettes given the larger effect that the years of smoking before using e-cigarettes had.  When the day comes that there are a lot of e-cigarette users who were never smokers, we could theoretically detect long-term cardiovascular risk, if it exists.  But realistically, any such risk is probably small enough that it would be below the limit of detection; the confounding would swamp it.  We have observed this in the experience of smokeless tobacco, where any cardiovascular risks is too small to detect given the confounding, and since these risks are probably basically the same for e-cigarettes or smokeless tobacco we have pretty good evidence they are below the threshold of detection.

In sum, if cigarettes were as new as e-cigarettes are, we would already have some observations about them being quite bad for you.  We would probably have enough knowledge from all source to make estimates of the total risk, and if done realistically the range of uncertainty would cover the true value (perhaps better than the current claims do!).  Still, we might well underestimate the cancer risk since we never would have seen an everyday exposure that caused quite so much cancer.

Still, concluding that frequently inhaling a concentrated smoke is quite bad for you would not require an appeal to ignorance.

This contrasts sharply with what we know about e-cigarettes or what we would know about smokeless tobacco if somehow it had recently appeared (an even more difficult scenario to imagine).  In the real world, we know that the acute negative effects are trivial and have no affirmative reason to believe there is any substantial risk.  Thus, anti-e-cigarette activism leaps immediately to an appeal to ignorance — “we do not know for sure…” — the logic of which is that we should never allow people to do anything that they have not already been doing for decades.

As an aside, it is interesting extend this counterfactual analysis to analyze one of the many thought-free mantras of the tobacco control industry:  “if cigarettes were invented today, they would be banned.”  This actually seems quite unlikely to be true.  If a rapid ban did happen in the hypothetical world, it would would not be because of the true risks, but rather would be driven by a Drug War mentality — the inclination to ban any drug people like because people should not be allowed to use drugs.  After all, absent the tobacco control industry, who else other than the drug warriors would be calling for a ban?

The perversion of public health (an effort to help people) into “public health” (an effort to control people) was caused by the tobacco control industry.  Indeed, absent the tobacco control industry, it is not clear that the Drug War would have much traction on “soft” drugs at all.  Even within the counterfactual, it is difficult to imagine that smokeless tobacco not being widely used when cigarettes were “invented” in the 2000s, just as similar everyday drugs are used in almost every culture.  Though switching to smoking from it would be an unfortunate choice, it is not clear it would trigger a Drug War type reaction.