In 2020, an academic paper suggested that more than 80% of U.S. physicians mistakenly thought that nicotine was a carcinogen. The implication of this finding was that perhaps physicians thought vaping (and even nicotine-replacement therapy) to be almost as dangerous as smoking. But physicians are busy people and I suggest that 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. Additionally, the UK government is more supportive of vaping and other nontraditional nicotine-replacement therapies than U.S. government, so a comparison of UK and U.S. physicians was undertaken to see if government policy and advice affects physician knowledge and opinion.
I find that most physicians correctly recognize that nicotine does not cause cancer, but that far more U.S. physicians than UK physicians still believe that it is carcinogenic. Additionally, vaping is viewed far more positively as a smoking-cessation tool by the surveyed UK physicians than surveyed U.S. physicians, and this is partly caused by the mistaken stance by U.S. health authorities.
Smoking: The Real Threat
Smoking substantially increases a person’s risk of lung cancer, heart disease, and many other major health problems. Burning tobacco releases myriad carcinogens and the U.S. Centers for Disease Control and Prevention (CDC) associates smoking with more than 480,000 premature deaths a year. In the United Kingdom, the death rate is similar: there are 74,600 deaths attributable to smoking in a population of about 67 million.
Nicotine is the main substance in cigarettes that tends to create physiological dependence. Nicotine-replacement therapy (NRT) was developed to provide nicotine without the dangers of tobacco combustion. It has proved effective in assisting smoking cessation for some smokers, but for many it has not worked.
Smoking is not just about addiction. It is a ritual and a social habit and, for many smokers, a pleasure. Smokers often miss these aspects when nicotine is just supplied with gum and patches. Additionally, pharmacokinetic studies show a greater “hit” from cigarette smoking than from NRT, which both may make smoking more pleasurable and may be a reason why many smokers using patches and gum relapse back to smoking.
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.
There is considerable evidence that vaping products aid smoking cessation. A systematic review of clinical trials using nicotine replacement to stop smoking identified 61 trials, most of which took place in the United States (26 studies), the United Kingdom (11), and Italy (7). The review found that, for every 100 people using nicotine e?cigarettes to stop smoking, nine to 14 might successfully stop, compared with only six of 100 people using NRT, seven of 100 using nicotine?free e?cigarettes, or four of 100 people having either no support or only behavioral support.
The conclusions are that vaping is slightly 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 are substantially safer than smoking. The UK government suggests they are 95% safer, based on the available (albeit limited) evidence.
UK health authorities are sufficiently convinced of the relative safety of vaping that they encourage it as an alternative to traditional NRT. Hospitals hand 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 20% of identified smokers. The stated aim of UK health officials is for United Kingdom to be a smoke-free society (under 5% regular smokers) by 2030.
U.S. government policy is equivocal about the relative benefits and smoking cessation role of vaping. The U.S. Food and Drug Administration (FDA) has approved some nontraditional nicotine/tobacco products as “appropriate for the protection of public health” through the pre-market tobacco product application (PMTA) process, since they pose “significantly lower risk” than cigarettes. This means that, under the modified risk tobacco product (MRTP) review process, companies can explain to the public the relative safety of these products.
While the FDA allows manufacturers of these products to explain to the public that they are relatively safer than cigarettes, FDA communications still focus more on the potential risks of vaping, especially to youth, rather than its role in smoking cessation for adults. The CDC also does not promote the use of vaping as a significant part of harm reduction. Nor is vaping’s role in smoking cessation an active policy position for it or other government agencies.
What US and UK Physicians Think About Nicotine
This research evaluates physician knowledge and opinion about nicotine in United States and United Kingdom and re-tests the finding that more than 80% of U.S. physicians think nicotine is carcinogenic. Using hand-compiled lists of primary-care physicians in the city and suburbs of Philadelphia, Pennsylvania and Cambridge, England, physicians were interviewed for their knowledge and opinions about smoking, nicotine, and vaping. This is a convenience sample with no evaluation of whether it is representative of the cities and regions, let alone nations, from which it is taken.
The physicians were asked simple questions that could be answered with a yes, no, or maybe response. In total, 312 physicians answered these questions (154 in Philadelphia and 158 in Cambridge).
Roughly a third of the U.S. physicians sampled believe nicotine in any form except NRT to be carcinogenic, which supports the notion that the previous estimate of more than 80% was based on many participants misreading the question. Roughly 60% of these U.S. physicians, however, think that products approved by the FDA to assist in smoking cessation are not significantly safer than cigarettes. Only the traditional NRT of patches, gum, and lozenges are considered by the majority (64%) of U.S. physicians to be far safer than smoking.
Also, more than half of the U.S. physicians sampled (57%) were unaware that the FDA had approved noncombustible nicotine products as being significantly safer than smoking. The largest discrepancy with the United Kingdom is with physician knowledge about government approval of such alternative technologies. In contrast, 92% of UK physicians sampled were aware that their government had approved alternative technologies (indeed, one voiced the opinion that he had been “bombarded with literature and vaping packs”).
Perhaps as a result, more than half (59%) of UK physicians think nicotine vaping should be used as part of smoking cessation and 54% said they had personally advised patients who smoke to switch to vaping, if traditional NRT was not working.
What seems unequivocal is that in both nations, the vast majority of physicians (85% in the United States and 88% in the United Kingdom) think the relevant health authority has the responsibility to correct misperceptions about the relative risk of nicotine health products.
The majority of physicians in both nations (59% U.S. and 84% UK) support the notion that the health regulator should prevent youth uptake of nicotine products as an equal priority to smoking cessation in adults, but when asked whether the former should take priority over the latter, far more U.S. physicians (41%) thought it should, as compared with UK physicians (16%).
Not reflected in the numbers was the vehement response among some physicians—especially of those U.S. physicians—who thought that preventing youth access to nicotine products was far more important than assisting smoking cessation among smokers. Although the sample size is too small to provide meaningful statistical analysis, at least nine U.S. physicians were convinced that nicotine vaping is very dangerous and that vaping products should be banned, or available only under prescription for smokers (Australia, which only allows vaping on prescription, was mentioned by several as an example to follow).
Many US Physicians Mistakenly Think Nicotine Is Lethal
While the U.S. physicians sampled are better informed than was implicit in a prior paper, it does appear that there is considerable confusion about the different risk profiles of the various nicotine products, with significant numbers of U.S. physicians thinking of nicotine as being carcinogenic. A recent study found that more than 60% of U.S.-based physicians believed all tobacco products—from traditional cigarettes to vaping pens—to be equally harmful.
That finding is echoed in this study. There is a misunderstanding that nicotine is carcinogenic and that vaping products are as dangerous as smoking, which is simply not supported by available scientific data. But to a considerable extent, this is the fault of FDA and CDC, due to their equivocal stance on the value of vaping as a smoking-cessation tool. Most physicians sampled in both nations want their health authority to correct misperceptions and U.S. authorities are not doing so.
While vaping and heat-not-burn products are not entirely safe, and while we might learn that they are far more dangerous than currently understood, most physicians sampled seem to want policy based on available data, not a possible but unproven risk.
What seems undoubted across the data is that physician opinion and advice reflects the underlying advice given by the respective health authority. UK authorities are far more supportive of nontraditional NRT, especially vaping (sending vaping kits to smokers, establishing vaping shops in hospitals) and, probably as a result, UK physicians reflect this positive position on vaping.
FDA Failing to Inform US Physicians Leads to Mistaken Opinions About Nicotine
A previous paper finding that more than 80% of U.S. physicians think nicotine is carcinogenic was re-tested, with the result that far fewer in this sample believe this to be the case. But more than a quarter of U.S. physicians surveyed think nicotine to be carcinogenic (except in NRT form), whereas in United Kingdom, it is fewer than one in 10.
The UK government is more supportive of vaping than the U.S. government, allowing far more vaping and heat-not-burn products to be sold, and distributing these products to smokers. This difference in approach is reflected in the opinion of the nations’ respective physicians, with UK physicians being far more aware about approved products and seeing a far greater role for vaping in smoking cessation than U.S. physicians. While all UK and U.S. physicians support efforts to prevent access of these products to youth, far more physicians in the United Kingdom want to encourage adult smokers to switch to vaping as their method of smoking cessation.
