Today, it seems so obvious. Cigarettes and tobacco cause lung cancer. It is remarkable however, that this relationship wasn’t always so clearly defined. In fact, during the initial rise in individual cigarette use, the possibility that they contributed to lung cancer was laughable to some, derided by others.

Dr Evarts Graham, a pioneer of lung cancer surgery, openly scolded one of his colleagues and former trainees, Dr Alton Oschner, for suggesting in 1939 that smoking cigarettes was a “responsible factor” for the rise in lung cancer he was seeing in his own clinic. Graham reportedly responded to this suggestion by stating, “Yes, there is a parallel between the sale of cigarettes and the incidence of cancer of the lung, but there is also a parallel between the sale of nylon stockings and the incidence of lung cancer.” In other words, social trends may come and go, but their link to the changing incidence of any medical diagnosis is likely only circumstantial.

Physicians and the public continued to be skeptical of the relationship between cigarettes and lung cancer as per capita cigarette consumption rose at a staggering rate in the 1930’s and 1940’s. This, of course, led to the tragic rise in lung cancer rates that lagged behind by approximately a 20- to 30-year period. Described in 1912 as among the rarest of all cancers, lung cancer rose from the ashes of cigarettes to become the most common cancer killer of men by 1955 and of women by about 1990.

Classic case control studies in 1950 by Richard Doll and A Bradford Hill and ironically by Evarts Graham himself and a medical student, Ernst Wynder, subsequently provided strong evidence linking cigarettes to lung cancer. Graham, after seeing Wynder’s initial figures outlining the clear correlation between cigarette use and lung cancer, is reported to have remarked, “It is possible that I may have to eat humble pie.” This unfortunately didn’t save Graham, himself a heavy smoker, from succumbing to lung cancer in 1957. It would be seven more years until the seminal Surgeon General’s report in 1964 alerted the nation to the risk of cigarettes and definitively declared a causative link between cigarettes and lung cancer.

Why should we relive such a story today? Surely in the rapidly moving world of modern science and research and of widespread dissemination of knowledge, such a debacle would never happen and we could easily get ahead of a social trend with any potential for staggering public health consequences. Unfortunately, that is not the case.

We are already well behind on the burgeoning epidemic of e-cigarettes and vaping. Recent articles from the New England Journal of Medicine and from Lancet Respiratory Medicine confirmed that vaping, essentially a non-existent habit in 2011, has continued to increase dramatically in teenagers. In 2018, according to survey data, 16% of 10th graders and 21% of 12th graders had vaped nicotine within the past 30 days. In what is perhaps the best indicator that we are not doing enough to address this crisis, those rates had increased 8% and 10% respectively from 2017, rates which, when applied nationally, translated to a staggering 1.3 million new adolescent vapers in just one year. Personally, I have already heard enough when my eighth-grade son explicitly details the vaping habits of some of his classmates along with their distribution network.

This increased incidence of vaping in adolescents comes despite a general lack of knowledge about the long-term effects of e-cigarettes and vaping on lung heath and lung cancer. Certainly, some researchers are trying. Recent reports have demonstrated that e-cigarette vapors can have booster effects on carcinogen-bioactivating enzymes and that DNA damage occurs after long term inhalation, both precursor events to cancer.

Recent reports have demonstrated that e-cigarette vapors can have effects that are precursors to cancer

The high temperature reached by e-cigarette solutions can also generate numerous toxic substances which get inhaled directly into the lungs. These substances cause lung inflammation, another well-known precursor to cancer and other lung diseases. E-cigarette vapor may disable protective immune cells in the lung, cells which are vital to the clearance of harmful particles from the lungs and which may have a role in surveillance against precancerous cells. All of these effects are magnified with the addition of nicotine to the vapor.

Although many teenagers may vape with just “flavoring”, a high proportion of vaping teens are also using e-cigarettes for the nicotine, which should justifiably raise fears that vaping will become a gateway for long-term addiction and potentially for transition to regular cigarette use. Shockingly, a single JUUL cartridge may contain as much nicotine as a whole pack of regular cigarettes. A real public health concern over the risk of nicotine addiction should therefore be front and center in the e-cigarette debate.

Fortunately, policy makers are beginning to rise to the task. Scott Gotlieb, the Food and Drug Administration Commissioner, has begun to target flavoring and marketing practices that appeal to adolescents and has warned that further regulatory restrictions are forthcoming. Such actions should be applauded. As a society, we have to get ahead of this issue. The e-cigarette industry is clearly not going to regulate itself, much like big tobacco before it. E-cigarettes should be treated as medications to aid smoking cessation (where they likely have a real role and potential benefit) and subjected to the same rigorous regulations that govern development, approval, and prescribing practices of other medications.

We remain shockingly ignorant about what the combustible liquids within e-cigarettes actually contain. We already made that mistake with tobacco and cigarettes. Without a doubt turning a blind eye and minimizing the risks of tobacco hurt people – our family members, our friends, and our colleagues – and helped to inflict an enormous cancer burden on them and upon our society. There are few things as heartbreaking as seeing the regret and self-blame of a former smoker newly diagnosed with lung cancer long after he or she got wise and gave up their cigarettes. Let’s not repeat those mistakes and regrets with e-cigarettes and vaping.