Evidence, not fear, should guide the FDA’s vaping policies

In a recent appearance on Politico’s The Conversation podcast, Food and Drug Administration (FDA) Commissioner Marty Makary stressed the importance of building stakeholder consensus and incorporating broad input on policy issues, while grounding decisions in evidence. Yet, in the same discussion, he described a “child vaping epidemic” and signaled plans for increased supply controls. 

The latest National Youth Tobacco Survey found that 5.9 percent of middle and high school students were using e-cigarettes in 2024, down from 7.7 percent in 2023 and the lowest level of youth use recorded in a decade, and nothing close to what could reasonably be described as an epidemic. Rather than using the notion of a “child vaping epidemic” to justify tighter restrictions, Makary should focus on the 28.8 million adult smokers who face the most significant health risks and expand the number of FDA-authorized alternatives that can help them transition from combustible cigarettes to far less harmful products. 

Why weren’t the needs of adult smokers mentioned in this interview? Makary’s one-sided treatment of the issue contrasts sharply with Health and Human Services Secretary Robert F. Kennedy Jr., who, speaking only days before Makary, made clear that while shrinking the illicit vape market and protecting youth is a top priority, nicotine itself is not a carcinogen and products like e-cigarettes and nicotine pouches are “infinitely preferable to smoking.” 

As Makary’s own agency acknowledges, nicotine products exist on a continuum of risk, and not all carry the same level of harm. Combustible cigarettes remain the most dangerous form of nicotine use, while other products present far fewer health risks and can play a valuable role in helping adults quit smoking. Alternatives such as e-cigarettes are not risk-free, but they are significantly less harmful than smoking and help those who are not able to quit with nicotine replacement therapies like gums, lozenges, or patches. Supporting these options is a step toward better health outcomes, especially when the alternative is continuing a behavior that causes severe and preventable disease.

Many adult smokers remain unaware that switching completely to e-cigarettes can substantially reduce their exposure to harmful chemicals. A recent survey found that only about one in five U.S. smokers believes e-cigarettes contain fewer toxic chemicals than cigarettes, and even fewer recognize them as less dangerous. This knowledge gap persists despite endorsements from respected medical journals and conclusive evidence that complete substitution lowers toxicant exposure. If Makary is serious about reducing smoking-related deaths, part of his focus should be on correcting these misperceptions through targeted, evidence-based public education for adult smokers. 

The National Institutes of Health and Cochrane Review have found ample evidence through systematic reviews of randomized controlled trials illustrating that those who use e-cigarettes are more likely to stop smoking for at least six months when compared to those who use traditional nicotine replacement therapies. Despite strong evidence and endorsements from some of the most respected medical journals, U.S. policy continues to heavily restrict e-cigarettes through product bans, flavor prohibitions, and limited market authorizations. This stubbornness on e-cigarettes often ends up causing an uptick in tobacco sales. 

On The Conversation, Makary focused particularly on the problem of illicit disposable products imported from China and framed the issue primarily around youth use, which, as noted, is at an all-time low. The problem with focusing on the illicit market is that this problem itself stems from federal policy choices that limit the legal market. When FDA authorizations exclude the products that adult users prefer, such as certain flavors, device types, and nicotine strengths, consumers are more likely to turn to the unregulated market.

Economic and policy research shows that restrictive measures often fail to reduce use as intended. A Yale School of Public Health study found that local flavor bans reduced e-cigarette sales but increased cigarette purchases, calculating that for each 0.7 ml of e-liquid sales suppressed, an additional 15 cigarettes were sold. In areas with flavor restrictions for more than a year, adult-preferred cigarette brand sales rose 10 percent, and brands popular with underage users rose 20 percent.

The policy takeaway is clear: To reduce the spread of illicit products and improve public health outcomes, the FDA should authorize a broader range of regulated, appealing alternatives. When adult smokers have access to legal options that match their preferences, the economic incentives for illicit trade diminish. 

Efforts that focus only on cracking down on illegal supply while limiting lawful access will continue to drive consumers toward unregulated products, undermining both safety and public health goals. Mackary’s call for collaboration and evidence-based regulation should fully extend to vaping policy, replacing fear-driven narratives with strategies grounded in public health evidence and economic insight.

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