番茄社区

In this exclusive video interview, 番茄社区's editor-in-chief Jeremy Faust, MD, sits down with U.S. Surgeon General Vivek Murthy, MD, MBA, to discuss several health issues: e-cigarettes for smoking cessation, medical misinformation, and masking.

Watch the first part of this interview here, which examines social media and teen mental health.

The following is a transcript of their remarks:

Faust: Way back in 2016, that taught me a lot on vaping. When I read that, I took away two things. One, nicotine exposure in young people could be really harmful, and that's a very big area. But I also took a surprise, which was that the connection with these products and cancer is not there. And so this could be a major form of harm reduction for adults.

Has your thinking on vaping changed in terms of a harm reduction strategy for adults?

Murthy: Well, my belief back then in 2016 when we issued the first federal report on e-cigarettes and youth was that there very much is a possibility that e-cigarettes could be a useful cessation aid for adults if they were used entirely as a substitute for cigarettes and not as an addition to cigarettes.

While I still believe that, I also still believe that we continue to have a problem with youth access to e-cigarettes. Thankfully, we are in some ways in a better place than we were at the time I issued that report back in 2016, but we still know that there is no safe amount of e-cigarette use among kids, and we know that nicotine itself is highly addictive.

So while I continue to believe that there's a possibility that it may help adult smokers in specific circumstances, I'm still worried about youth exposure to e-cigarettes.

Faust: Yeah, me too.

And I also know that an area where you're passionate is in health information and misinformation -- you've written and spoken a great deal on this. I've heard colleagues that you and I both admire and respect say things like, "Don't let anybody tell you that these ENDS devices -- these electronic nicotine delivery systems -- are any safer than traditional tobacco and cigarette products." And that makes my head spin because as you say, there's no safe level, but I think by definition, they're safer. Would you agree?

Murthy: Well, I think harm reduction is based on that notion, right? That there are degrees of risk associated with products and with practices. And here too, I do think that there's a degree of risk.

I think one of the challenges that we were having with saying across the board that all e-cigarettes are definitively safer, especially in 2016, had to do with the fact that we didn't even know what was in a lot of these e-cigarettes because they weren't, at that time, well-regulated and the ingredients were often not fully disclosed.

But by and large, because you're not combusting tobacco and other products in the way you are with traditional cigarettes, one would believe that the risk of e-cigarettes, by and large, would be lower than what you would see with combustible cigarettes. Again, not zero risk. There's certainly risk associated with it. But if you had a patient who was able to completely substitute their use of combustible cigarettes with e-cigarettes, in certain circumstances that could be safer.

That's part of where we need additional study and evidence. Because thinking about this as a clinician, many clinicians have patients who are struggling with smoking, and in some cases we do have FDA-approved products that people can use to aid with smoking cessation. In circumstances where people have tried those, though, and maybe they haven't had success -- which is true for some portion of the population -- the possibility they may be an additional cessation tool is potentially attractive.

And that's why I actually continue to believe that that's something that we should be aggressively studying and then making available to people in safe circumstances.

Faust: Thank you so much.

Let's talk about health misinformation briefly. How can the government do this? The example I always put in front of people is that if in February of 2020, someone had said on Twitter -- now X -- "COVID is airborne," if there had been a rigorous misinformation platform in place, that kind of messaging would've been suppressed, and it in fact ends up being true or at least true enough.

How do we do misinformation when science is always a moving target?

Murthy: Gosh, one place where we've had to deal with this, Jeremy, has been in the field of nutrition, right? How much in our own lifetimes and careers have we seen nutritional science and information evolve and the recommendations change. It leaves people exhausted, sometimes. They're like, "Well, how do I really know what to eat anymore?"

We know that science evolves. And I think that's why, when it comes to the communication that we do as clinicians in particular and as public health more broadly, we have to approach that with some humility, being clear with people about what we know now, what we don't know, and about what may change.

And look, I know that that's hard to do en mass, but that's something that clinicians actually have to do every day in the exam room, right? When we're with patients, a lot of times we have to tell them what we know and what we don't know. We may tell them, "Look, we're going to recommend this treatment to you today, but we're going to see how you do. We may have to change course. If you don't respond to this treatment, it may not end up being the right one for you."

Those are easier to have one-on-one, especially when you have a well of trust that you have built with a patient over time. And that's, I think, what a lot of this comes back to is, yes, in addition to approaching these topics with humility as we communicate about them publicly, one of the challenges we've encountered, Jeremy, is that there has been a real erosion of trust, in public health, and even in medicine, I would say, especially during the COVID pandemic, but even preceding the COVID pandemic.

There are a whole bunch of reasons for that. But I do think that any effort to ultimately better communicate about health needs to include a building of trust, a rebuilding of trust, and that starts locally. You don't put up better ads -- that's not what gets you more trust in institutions and in the profession. You rebuild that trust locally, not just through doctors and nurses with their patients, but that means what are we doing in our schools, in our communities, in our faith organizations, in our neighborhoods to bring clinicians together with the patients and communities they're serving so they can put a face to a name. So they can understand the people who are looking out for them.

And in the middle of a crisis then, it then becomes easier for them to take in the information, uncertain as it may be, versus just hearing from a stranger with a piece of advice, which then changes, and they're led to believe that that person wasn't trustworthy, whereas that may not be the case.

Faust: Speaking of messaging, your predecessor, Dr. Jerome Adams, will sometimes post pictures of himself traveling wearing a mask. I'm wondering how you comport with that messaging.

I don't think I've seen you wear a mask in quite some time, and obviously it's a different day than it was 4 years ago, but a lot of my readers are very COVID conscious and they want me to ask you: Do you mask ever? And if not, aren't you worried about the message that sends about regard for the most vulnerable?

Murthy: That's a good question. You're right, a lot has changed and evolved in our masking practices.

Dr. Adams -- who was my predecessor in this iteration, he was the 20th Surgeon General of the United States; he's a good friend of mine. We talk from time to time, and I also know -- and I'm not revealing anything that's private because he has said this publicly -- that one of the reasons Dr. Adams masks is in part because his wife is living with cancer and is undergoing treatment. And he wants to make sure, because he has a family member who's immunocompromised potentially because of a treatment, that he's protecting her.

That absolutely makes sense. That's a very reasonable thing to do.

In my case, there are circumstances where I do mask, certainly when I'm in a clinical setting where masking is recommended, I will certainly do that. If I'm around people who are immunocompromised, I will certainly mask. If I am myself feeling like I may be getting sick, I will mask to protect people around me. So, there are circumstances where I mask as well.

I know we're all navigating this in our own way to try to keep ourselves as well as the people around us safe. But I appreciate what Dr. Adams has done, in not only setting an example, but explaining his rationale for masking and recognizing that the exact practices each person takes depends on their circumstances.

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