Voices: US Surgeon General on vaping, social media, and Covid-19 misinformation.

Today, I’m sharing the entirety of my 21-minute interview (video and transcript) with Dr. Vivek Murthy, the 19th and 21st Surgeon-General of the United States, serving under President Obama and now again under President Biden. (Highlights of this interview can be found in two shorter segments on MedPage Today here and here.)

We covered some of the major areas where Dr. Murthy has focused attention, including the perils around social media, vaping, and Covid-19 masking and misinformation.

My goal here was to draw Dr. Murthy out on the reality of confronting these challenges. It’s one thing to describe the problem. But how is social media content moderation for young people supposed to work? After all, there are possible benefits to social media for some teens—for example, LGBTQ+ teens who need a place to find community before they have come out to their parents. So, surveillance is not always the answer. But there are obvious dangers as well. Figuring out what action to take won’t be easy.

We also discussed vaping—often lambasted as “all bad”—as a potentially important tool for people who want to quit smoking by choosing it as a safer alternative. (I’ve long been confused by experts who don’t understand that vaping is indeed an important tool for adults who want to quit smoking or other tobacco use—albeit, it should be said that vaping is something that no young person should ever start, as it might be an “on ramp” to worse habits.)

We also discussed how governments can deal with misinformation, especially when science itself is often in flux—which was certainly the case early in the Covid-19 pandemic.

Speaking of Covid, I asked Dr. Murthy a question many of you posed prior to my interview which is why he seems (at least in public) to wear a mask less frequently than his predecessor, former US Surgeon General under President Trump, Dr. Jerome Adams.

Overall, I found Dr. Murthy’s answers nuanced and thoughtful—in contrast to many media headlines covering the work he and his team have done, which often paint a one-dimensional picture.

Take a look and listen and please let me know what you think in the Comments.

Transcript:

Jeremy Faust:

Dr. Vivek Murthy, thank you so much for joining us.

Vivek Murthy:

Of course. I'm glad to join you, Jeremy.

JF:

Recently, I think there's been a lot of talk about social media and your advisory regarding social media use, and I've heard you speak very nuanced about this in a very nuanced way about this, that, and my initial take is that the dose makes the poison or that certain forms are less harmful than others. And right there on page five of your report, it says, social media has both positive and negative impacts on children and adolescents. And so I think we could talk about some of the negative ones, but I'd like to start with something positive. Do you think there are, what are some things that you think are actually positive about social media for young people?

VM (00:42):

Well, I think some young people do get some benefits, and those include things like the opportunity to express themselves more freely or creatively, the opportunity to find a community of people that they may not have in person, people who may share their life experiences or concerns or interests. And it's also an opportunity for some people to stay in touch with old friends, old high school friends, friends from college after you graduate.

All of that can be beneficial. But with any other product, and this is something I think clinicians understand well, you have to assess the risks and the benefits associated with the product. And one of the things I worry about is that the conversation around social media often is devoid of nuance. It's often very black and white, and people say, is it good or is it bad? Well, we know as clinicians that sometimes even when a medication has some benefits for a population, if there are significant risks associated with it overall, you may not say that that's advisable, right?

(01:38):

Remember with Vioxx for example, there were many patients who actually were helped by Vioxx in terms of pain reduction in terms of their arthritis pain or other types of pain. But when you looked at the overall risks of the population, productive cardiovascular risks, which became more evident down the line, it became clear that those benefits may not outweigh the risk for the population. So this is a case where, yes, there are some benefits, but what I have been really struck by Jeremy are the harms and the growing evidence of harms. And this is something I was hearing about a lot from actually not just parents, but from young people themselves across the country. It's what prompted me to actually do their research and ultimately issue a surgeon general's advisory on social media and youth mental health in 2023.

JF (02:23):

So I do want to talk about how this goes from here because I think that the report has as always, a lot of factual basis and public health research behind it. And then the question is, okay, now, and in the case of a black box warning on tobacco, for example, that's one thing that obviously led to a lot of positive public health impact. And I'm curious how this is going to look. When I open up social media, there is going to be terms and agreements that we all just click, okay, what's going to happen here? How is this going to play out in five years if you get what you envision?

VM (03:02):

Well, so I'm glad you asked because this isn't simple. Just like we experienced with tobacco, a warning label was helpful with tobacco. We know now from years of data, that warning label actually did help to increase awareness of risks and change behavior. But the warning label itself was not the entire solution. It was one part of a larger solution set. The same is true here with social media. I've called for a warning label to help parents understand and young people that, number one, we don't have enough data to tell us that social media is safe for your kids, which is what parents want to know all the time. But second, to let parents know that what we are seeing in the data is that social media uses associated with mental health harms among adolescents. But what I called for last year was actually even more important, which was a comprehensive set of regulations that would help make social media itself safer.

(03:54):

And that's regulations that would protect kids from harmful content, from features that would seek to lure their developing brains into excessive use like the infinite scroll, like the buttons, like the autoplay on videos, the availability 24/7. But also I called for a series of measures that would require companies to be transparent with the data they had about the impact of their platforms on the mental health of youth. And right now, Jeremy, one of the things that I find deeply disturbing not just as a doctor or a surgeon general, but as a parent myself, is that researchers tell me all the time around the country that they can't get full access to the data on the mental health impact of social media from the companies. And as a parent, I don't want to feel like products my kids are using that the companies are withholding or hiding information from me about its safety for my kids.

(04:44):

So these are a number of measures that we have to take. But lastly, I just say you asked about the warning. What would it look like? What we do with tobacco and alcohol labels is we actually undertake a rigorous scientific process to understand what kind of label would be most effective at driving the outcome of increased awareness. And so in that testing process, you test labels of different sizes with different fonts, with different texts, different placement, and then you ultimately see what happens and what would be most beneficial here too, I imagine a digital warning on social media would regularly pop up when people used their social media platform, but the frequency with which it pops up, the font size, what their graphics associated with it, what the text actually says, that would be determined in a rigorous scientific process.

JF (05:31):

And I'm curious about how you can get the companies to share that data, but I'm also curious how you envision regulating that content. Because for example, there's content that might be shown to my kids that might actually horrify me because of my particular values. I mean, I can even say that there are sections from the religious background of which I am a part that I would not want my kids to see, and someone's going to say, oh, you're going to ban the Bible. So how do you actually tell these companies, yeah, you know what? That line from that book is not okay, but this line is, do you see what I'm saying? They are violent, homophobic images that I don't want my kids to see.

VM (06:14):

Well, so I think what you're getting at is that there's a big gray area in terms of content where it's sometimes one person might file objectionable, another person may not, but this is where I think it's important for us to focus on what we do agree upon with youth. We all generally agree that minor should not be seeing pornographic content. I would hope that we can all agree on that. We certainly use that common understanding to help define what is acceptable in movies that kids can see in television shows, for example. Yet right now, kids who can't walk into a movie and watch a rated R movie are seeing extreme sexual content on their social media feeds. We should all agree that that's unacceptable. The other thing that we can agree on is the fact that kids should not be receiving video content to them suggested by the algorithm that's walking them through how they can take their own life, how they can attempt suicide.

(07:10):

And that might seem preposterous to some people who might say, oh my gosh, how could that ever happen? Well, I'll tell you that I've sat down with many parents who have had the experience, the tragic experience of losing a child to suicide after their child received numerous videos through the algorithm on their social media feed, walking them through how to hang themself or how to harm themself in other ways. The buckets of content we can all agree it should not be exposed to, but more broadly and how exactly to do that. This is where the companies have responsibility. They have created these platforms. They have created the algorithms that drive content to young people and call me old fashioned, but I believe if you create a product, you should be responsible for the outcomes. If you or I, Jeremy got together and built a hospital and we're providing care to patients, yet we had high rates of line associated infections, people were getting clots all the time because we weren't prophylaxing patients when they came in and people were slipping on floors because we weren't wiping the floors and there was water dripping all over the floors.

(08:13):

We couldn't turn around and say, wait, wait, hold on. Don't hold us accountable because we're actually taking care of people who are coming in with mis and with cellulitis and with other clinical complications. People would rightly say, yes, that's great you're doing that, but you're responsible for creating a safe environment for your patients and your visitors. And if you're not doing that, then you need to be held to account. What I find really striking Jeremy, is how we have largely held companies to account when it comes to the products and services that they provide to our kids, with the exception of social media, despite the fact that 95% of our kids are on it, despite the fact that we have now hundreds if not thousands of reports of kids who have been harmed through their use of social media yet what would've triggered an investigation and action in other products and what we've seen trigger action when it comes to food or car seats or cars when they have safety issues, has not triggered similar action when it comes to social media. And I find that highly problematic. It's why I've called for a fundamental change in our approach to social media and safety,

JF (09:13):

And I really appreciate the sort of harm benefit conversation that you're talking about, especially, and I think it's a perfect analogy with hospital care, right? That if you are having nosocomial infections, then CMS is going to shut you down if you're not doing enough work on that. But I am curious, what does a safety study look like here? How do I know? I've heard people say we don't know how safe or unsafe social media for kids is or for adolescents. What would a safety study look like? I know what a Kaplan-Meier curve will look like for a cancer therapy. I know what that study looks like. How am I going to know as a parent and even as a physician guiding people, yes, this is safe, this is unsafe. What kind of studies are we looking for?

VM (09:54):

Well, this is where I think it is so important to be investing in the research in this space, not just so we can do the studies, but so we can actually cultivate the research community that can, independent research community that can help drive these studies. Look, there are a number of things we can do to assess safety. We know the companies actually test new features all the time, right? Features which may seek to limit use, limit use at certain times of the day, limit exposure to certain types of content. One of the first things we can do is try to understand what have those data points and experiments taught us about the mental health impacts on youth. So there's data right there for us to draw from. We also know that what are called sometimes deprivation studies or studies where you have people actually stop using social media for a period of time and then assess them afterward in terms of their self-reported subjective mental health benefits as well as clinical outcomes, that that can be helpful as well.

(10:49):

I'll tell you anecdotally what young people tell me all the time on college campuses in particular is that when they pull back and stop using social media for a period of time, it positively affects their mental health and wellbeing. The first couple of days they feel jittery because many of them actually will describe themselves as being addicted to social media, have a hard time getting off. But after three, four or five days, when they settle into a rhythm, they start feeling really good. Now, I'd want that validated in a study, right? I'd want that looked at in a broader population. But the bottom line is there are a lot of research questions that investigators are asking right now that they need the resources and data to be able to answer. And if we can do that, then my hope is that we can get a better sense of safety. But also, Jeremy, my hope is that we can empower parents and young people themselves to engage in the kind of practices that can ultimately lead them to find that better balance between the benefits of social media while they avoid the harms.

JF (11:48):

And I think that it's really important, as you say here and elsewhere, that there are people, I think of a teenager who may be emerging L-G-B-T-Q and doesn't know where to turn, and we don't want parental consent on their ability to access a community online, that kind of a thing. Would you agree with that? Those kinds of people, that population, there's a benefit there to having a little bit of privacy as well.

VM (12:12):

So I'm glad you brought this up, Jeremy. I do think, and I've spent a lot of time with LGTQ, youth on topics related to mental health over the last three and a half, four years. Here's what we know. We do know that L-G-B-T-Q youth, many of them do find community online at a time when they may not have that person in-person community. And that can be really valuable. It can be lifesaving. What we also know is that L-G-B-T-Q youth are significantly more likely to experience harassment and bullying on social media, which can also have its harms. And the question becomes how do you balance this out? Well, what I worry about Jeremy, is we put L-G-B-T-Q youth and their families in an impossible situation where we've said, in order to get some of these potential benefits, you have to expose yourself to all of these harms. And that is not a choice that L-G-B-T-Q youth should have to make. They deserve to have a safe place where they can find and build community, whether that's in person or online. And so this is where, to me, pushing for safety measures. It's not about preventing people from using social media altogether. It's about ensuring that those people who are benefiting from it can continue to do so without being exposed to all of these harms that we were seeing.

JF (13:24):

So way back in 2016, you wrote a report that taught me a lot on vaping. And when I read that, I took two things. One, nicotine exposure in young people could be really harmful and that 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?

VM (13:52):

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

JF (14:44):

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, and I've heard colleagues that you and I both admire and respect say things like, don't let anybody tell you that these end devices, these electronic nicotine delivery systems are any safer than traditional tobacco and cigarette products. And that makes me my head spin because as you say, there's no safe level, but I think by definition they're safer. Would you agree?

VM (15:16):

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, it had to do with the fact that we didn't even actually 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.

(16:15):

And that's part of where we need actually additional study and evidence because think 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 there 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.

JF (16:49):

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 has said on Twitter, now X, “Covid is airborne” in a very rigorous moment—if there had been a rigorous misinformation platform in place—that kind of messaging would've been suppressed. And in fact ends up being true or at least very true enough. How do we do misinformation when science is always a moving target?

VM (17:23):

Well, gosh, one place where we've had to do with this journey has been in the field of nutrition, how much in our own lifetimes and careers we've seen nutritional science and information evolve and the recommendations change and 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 and mass, but that's something that clinicians actually have to do every day in the exam room. When we're with patients, a lot of times we have to tell 'em what we know, what we don't know.

(18:06):

We may tell 'em, 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 proceeding the Covid pandemic. And 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.

(18:55):

You don't put up better ads, and 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 and with their patients, but that means what are we doing in our schools, in our communities and our faith organizations and 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 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. They're led to believe, ah, that person wasn't trustworthy, whereas that may not be the case.

JF (19:35):

Your predecessor, speaking of messaging, your predecessor, Dr. Jerome Adams, will sometimes post pictures of himself traveling, wearing a mask. And 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 as it was four 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?

VM (20:05):

Well, it's a good question, and you're right. A lot has changed and evolved in our masking practices. Dr. Adams was my predecessor in this iteration. He was the 20th surgeon General of the United States. He's a good friend of mind. 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 that Dr. Adams masks in part because his wife is living with cancer and is undergoing treatment, and he wants to make sure that if he is a family because he is a family member who's immunocompromised potentially because of a treatment that he's protecting her. And that absolutely makes sense. That's a very reasonable thing to do in my case. Yeah, there are circumstances where I do mask. Certainly when I'm in a clinical setting where mask is recommended, I will certainly do that if I'm around people who are immunocompromised, I will certainly mask. If I'm in myself feeling like I may be getting sick, I will mask to protect people around me. So there are certain sense where I mask as well, and 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, and not only setting an example, but explaining his rationale for masking and in recognizing that the exact practices that each person takes depends on their circumstances. And

JF (21:23):

I know we're short on time, but I do want to touch on firearms because again, very recently you did something that I think was anticipated and very much desired by the public health community, which is to issue an advisory, a public health advisory on firearm violence and looking through it. Again, these are very fact-based documents that your team and you produce. And I'll share some of them. 54% of US adults report that they have either personally or know someone in their family who experienced a firearm related incident, 21% threatened with a firearm, the one that I thought two, really two numbers really struck out, stuck out to me. 17% have witnessed someone being shot. But this one really shocked me in a kind of different way. 4% have shot a firearm in self-defense. And that actually really kind of in a way bothered me. Not that a fact can really bother a person, it's a piece of information. But elsewhere in your report, you talk about something that's known to many of us, which is that a big, huge independent risk factor for unintentional accidents, especially with kids, is having a gun. And so if 4% of our colleagues or our community feels that they had to use a gun to protect themselves, what does that tell you? Because there are people who think the answer to this problem is more guns and 4% of the people apparently agree because that number just really struck me.

VM (22:50):

Yeah, I mean, there was so much that was striking to me in putting this report together and look, and I would say to your earlier point, I think numbers can bother a person, and many of these numbers bothered and worried me, again, not just as a doctor, but as a father as well. I'll tell you that in particular, seeing that more than 50% of our kids are worried about a shooting in their school, that bothers me seeing that 60% of Americans are worried about losing a loved one to gun violence. That bothers me too. And I would dare say, I think it should bother all of us because I think one of the things that has happened, Jeremy, whether it's looking at the 4% stat or the other broader stats around how people are experiencing firearm violence, that 54% of Americans is that we have accepted as normal, something that I don't think is normal, which is that we live a fair amount of our life in fear, worried about normal activities that we should be able to undertake safely.

(23:44):

We should be able to go to the grocery store, go to the movies, go to church or synagogue or mosque or temple, go to school, take a walk in our neighborhood. We should be able to do these things without worrying that we are going to be shot and potentially lose our life. Yet millions of Americans do not feel safe in that way. I think Jeremy about a mom who actually a fellow physician who was at a mass shooting event that took place not just a few years ago, and she had to run with her children away from the shooter, and she happened to be in flip flops that day, and it was hard to run in flip flops. And ever since then, whenever she leaves the house, she hesitates to wear flip flops because she doesn't know if this is going to be another day when she encounters a shooter who she's going to have to run away from.

(24:37):

And you think about simple decisions like that. I think about the grandmother told me her grandkid does not want to wear LightUp shoes, the kind of shoes the way when you step on them, like a light flashes that a lot of kids wear because he's worried that he'll be an easy target for a shooter if there's a school shooting in his neighborhood. Kids should, and parents should not be worrying about these things. And I worry that we've accepted this as somehow just normal as the way things are, but it does not have to be the way things are. Last thing I'll point out is that we put in this advisory, our international comparisons. The US is an outlier here and not, and it's not a close call, but we have dramatically higher rate of firearm related death and violence compared to our economic peer countries. When you look at the other OECD countries to our 28 29 countries, we make up about 30% of the population, but we comprise more than 80% of the firearm related deaths. And so I laid out a series of strategies in this advisory that I think can help us to pull back from where we are to ultimately creating a safer community for all of us, but especially for our kids.

JF (25:48):

Just linking that to another topic. We've discussed mental health and kids, I worry in many worry that one response to this crisis has been active shooter drills at schools, which comes out of a really understandable place, but I worry in many worry that it's just traumatizing and doesn't add anything. What do you think about those kinds of endeavors?

VM (26:13):

Well, I underst certainly understand where they're coming from. We want our kids to know how to react in the case of such an emergency. But I also think that these kind of trainings need to be designed in a trauma-informed way, so they help create a feeling of safety and not actually create a sense of trauma and fear among kids. And to do that means that, frankly, that you've got to approach it with a trauma-informed mindset, and you have to study the impact of different training strategies. And I certainly don't think that we have done enough of that. It's one of the reasons I was certainly happy to see in 2022, the passage of the Bipartisan Safer Communities Act, which did put a lot of funds towards schools in particular. It was an important first step, or I should say an important step toward addressing the gun violence in America, but certainly should not be a last step because there's still a lot more we've got to do.

(27:01):

And fundamentally, we want our kids to be prepared for what could come, but we also want them to feel safe in their school environment when children, we know for them to grow up and to thrive, they need to have safety in their relationships and safety in the spaces that they grow up in. Those two things are really vital. Kids spend a lot of time in school if they're not feeling safe in school because they're worried constantly about school shootings. If they're traumatized by the active shooter drills that they're going through, that does not make school a safe space. And that's again, one more reason why we've got to address gun violence in America with the urgency that it deserves. And I don't think that we have been approaching it, frankly, with the urgency that it requires. This is something that all of us, whether you're hospitals and healthcare systems, whether you're policymakers, whether you're community organizations that have a role to play here, we've all got to look seriously what we can do and look at the steps that we've laid out in this advisory. I think there's something here for all of us to take part in.

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