The Cleveland Clinic's very bad advice

They're not lying about smoking and vaping. They're not telling the truth either.

In a carefully worded article on its website headlined Vaping vs. Smoking: Both Are Dangerous, the world-renowned Cleveland Clinic says:

Both vaping and smoking are bad for you. But is vaping better than smoking cigarettes, as you may have heard?

The honest answer is: We don’t know yet.

But we do know, for sure, that both behaviors are risky.

This is literally true but far from an “honest answer.” It may be well intended but its effect is to mislead. It’s the kind of thing that leads people to mistrust public-health experts. Worst of all, it could discourage some people who smoke cigarettes to quit by switching to vapes to get their nicotine.

Let me explain, beginning with the claim that “we don’t know yet” whether vaping is better than smoking. We may not know with absolute certainty.

But all the evidence points that way.

A 2018 report from National Academies of Sciences, Engineering, and Medicine (NASEM) says that

…there is conclusive evidence that completely substituting e-cigarettes for combustible tobacco cigarettes reduces users’ exposure to numerous toxicants and carcinogens present in combustible tobacco cigarettes” and “would be expected to result in reduced adverse health outcomes.

Public Health England says:

An expert review of the latest evidence concludes that e-cigarettes are around 95% safer than smoked tobacco and they can help smokers to quit.

Health New Zealand says:

Nicotine vaping is less harmful than smoking. It is one of the most effective tools available for helping people quit. However, it is not completely risk-free, and the long-term health effects are still not fully understood. For that reason, vaping is not recommended for children or for people who do not already smoke.

That is a model of clear, accurate and helpful public-health communication.

Especially in comparison to the message from the Cleveland Clinic, which says that both smoking and vaping “are risky.”

Yes, smoking and vaping are risky.

So is swimming. About 4,000 Americans die from drowning in a typical year, according to the CDC.

Smoking and secondhand smoke exposure cause over 480,000 deaths in the U.S. each year, the CDC says.

As for vaping, there have been zero—yes, zero— definitive cases of people dying from using e-cigarettes to obtain nicotine.

To be sure, vaping’s long-term effects are not fully known. E-cigarettes pose risks. The vehemently anti-vaping American Lung Association warns that “children and adults have been poisoned by swallowing, breathing, or absorbing e-cigarette liquid through their skin or eyes.” That sounds awful. Dying of lung cancer or heart disease is worse.

Only because vaping is safer than smoking has the FDA authorized the sale of a small number of vaping products — 45 devices, from five brands — as "appropriate for the protection of the public health." FDA has judged that the potential benefits of those products to people who smoke outweigh the risks that they will attracts new users, especially underage ones. This is meaningful because FDA has been hostile to e-cigarettes since the spike in youth vaping in the late 2010s.

Truth or consequences

The misinformation from the Cleveland Clinic and others (see below) has potentially deadly consequences. Surveys show that growing numbers of US adults wrongly believe that e-cigarettes are as harmful or more harmful than combustible cigarettes, according to researchers at the UT Southwestern Medical Center.

In a press release, David Gerber, a professor at UT Southwestern, says:

The perception that e-cigarettes are more harmful than cigarettes has been linked to both a decreased willingness to use e-cigarettes for smoking cessation and an increased likelihood of switching from vaping to smoking.

Neither the government nor the Cleveland Clinic tell people who smoke what they need to hear, in plain terms: That vaping is safer than smoking and that e-cigarettes can help them give up lethal, combustible cigarettes.

Instead, as Brad Rodu, a professor of medicine at the University of Louisville, notes on his Tobacco Truth blog:

The Cleveland Clinic offers this shocking advice for smokers: “You may have also heard that vaping is a good way to kick a smoking habit, but experts discourage it.

Again, all the evidence indicates that vaping is a good way to kick a smoking habit. The New England Journal of Medicine published results of a clinical trial in 2019 that concluded: “E-cigarettes were more effective for smoking cessation than nicotine-replacement therapy.” The respected Cochrane Collaborative reviewed 104 studies including 30,366 adults who smoked and found that e-cigarettes worked better than FDA-approved smoking cessation methods at helping people to quit. Between 2017 and 2023, about 6.8 million people stopped smoking and 7.2 million began to exclusively use e-cigarettes, the CDC says. Coincidence? I think not.

I emailed and called the Cleveland Clinic several times, pointing out their mistakes. No response. The article attributes the advice to Dr. Peter Mazzone, a pulmonologist who has been on advisory panels for the American Lung Association. Could that explain his aversion to vaping? The lung association, along with the American Heart Association and the American Cancer Society, get funding from Bloomberg Philanthropies, which has spent a fortune crusading against vaping. I asked the Cleveland Clinic if they were paid to publish anti-vaping messages. Again, no reply.

By email, Cliff Douglas, a lawyer and lifelong anti-smoking activist who now favors tobacco harm reduction, described the misinformation from health authorities as “a problem of epidemic proportions.” He said:

The responsible parties include speakers like this fellow [Dr. Mazzone] who assumed he knows what is going on and, doubtless with good intent, has consequently misled a lot of people, including his and the Cleveland Clinic’s own patients.

Sadly, such uninformed public messaging from people in positions of medical and public health influence, [who] absolutely should know better, constitutes a form of public health malpractice.

Lest I be accused of singling out the Cleveland Clinic, here, briefly, are a few more examples of misleading information about vaping coming from respected sources.

University of Iowa Health Care: “You may start vaping because you think it’s safer than smoking cigarettes — but is it? As of now, researchers don’t have a clear answer to that question.” But, of course, they do.

Jason Semprini, an economist and public health expert at Des Moines University, did a great job annotating UIHealth’s message on LinkedIn. “Multiple claims in the communication were incomplete and some, in my view, were factually incorrect,” he wrote.

Harvard Medical School: “The rising popularity of vaping has been dramatic, especially among teenagers.” Not true—the percentage of teenagers who vape has fallen by about 75 percent since it peaked in 2019.

Also: “You may have seen news reports of sudden and severe lung problems, including deaths, linked to vaping. This condition is called e-cigarette, or vaping, product use-associated lung injury, or EVALI.” Yes, it is called EVALI, wrongly. The deaths have been tied to illicit THC vapes, and not to nicotine e-cigarettes.

WebMD “Researchers are divided on whether e-cigarettes are as effective in smoking cessation as other nicotine replacement therapies like gums and lozenges.” Not really. Authoritative sources like the Cochrane Collaborative have concluded that vapes are more effective than FDA-approved NRTs.

Mayo Clinic: Not a word about e-cigarettes in a long article about smoking cessation.

The government and my industry, the media, have done no better at explaining the relative risk profiles of smoking and vaping.

Cliff Douglas put it well: This is public health malpractice.

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Thanks to Brad Rodu and Skip Murray for calling out the Cleveland Clinic’s errors.