Adult smokers with no plans to quit are more likely to stop smoking if they switch to daily vaping, according to new research led by Roswell Park Comprehensive Cancer Center.
Published in JAMA Network Open, the Roswell Park study used data collected from 2014 to 2019 as part of the Population Assessment of Tobacco and Health Study (PATH). When the researchers focused their analysis on a select group of 1,600 smokers who initially had no plans to quit and were not using e-cigarettes when the study began, they found that those who subsequently vaped daily experienced eightfold higher odds of quitting traditional cigarettes compared to those who didn’t use e-cigarettes at all.
“These findings are paradigm-shifting, because the data suggest that vaping may actually help people who are not actively trying to quit smoking,” says Andrew Hyland, chair of health behavior at Roswell Park and scientific lead on the PATH study, in a statement. “Most other studies focus exclusively on people who are actively trying to quit smoking, but this study suggests that we may be missing effects of e-cigarettes by not considering this group of smokers with limited intention to stop smoking—a group that is often at the highest risk for poor health outcomes from cigarette smoking.”
Overall, only about 6 percent of all smokers included in the Roswell Park study quit smoking combustible cigarettes completely, but the rates of quitting were significantly higher among those who took up daily e-cigarette use—28 percent of smokers quit when they started vaping daily. The association between vaping and cigarette quitting held up even after adjusting for underlying characteristics such as educational background, income, gender, ethnicity and the number of cigarettes smoked per day at the beginning of the study.
Using medical licensing to get smokers to switch to vaping products is like using a hammer to crack a nut.
By George Gay
On the face of it, the U.K.’s big tobacco/nicotine news story of 2021 was the announcement that e-cigarettes and other inhaled nicotine-containing products could in the future be prescribed through the National Health Service (NHS) in England. Of course, the problem with “could” stories is that they come pre-loaded with “might not” stories. And there is the nagging concern, also, that this story is not quite as new as it seems. But let’s start on a positive note.
An Oct. 29 press note issued by the peculiarly named Department of Health and Social Care and Office for Health Improvement and Disparities said the Medicines and Healthcare products Regulatory Agency (MHRA) had published updated guidance paving the way for medicinally licensed e-cigarettes to be prescribed for tobacco smokers who wished to quit smoking. The health and social care secretary, Sajid Javid, was quoted as saying that opening the door to a [sic] licensed e-cigarette prescribed on the NHS had the potential to tackle the stark disparities in smoking rates across the country, helping people to stop smoking wherever they lived and whatever their background.
“Manufacturers can approach the MHRA to submit their products to go through the same regulatory approvals process as other medicines available on the health service,” the story said. “This could mean England becomes the first country in the world to prescribe e-cigarettes licensed as a medical product. If a product receives MHRA approval, clinicians could then decide on a case-by-case basis whether it would be appropriate to prescribe an e-cigarette to NHS patients to help them quit smoking.”
In fact, this statement was qualified by a background note saying e-cigarettes could be prescribed only after the National Institute for Health and Care Excellence (NICE) had recommended them for use. It did not spell out the circumstances under which NICE might recommend or reject such prescribing, but it is likely that one possible case for rejection would be a poor cost/benefit ratio.
Nevertheless, the announcement was generally well received. Philip Morris International said in a note published on its website that it supported the U.K. government’s plan to simplify the pathway to license electronic cigarettes and other inhaled nicotine-containing products as medicines in England.
At the same time, John Dunne, director-general of the U.K. Vaping Industry Association, said in a press note the government deserved “huge praise for taking this bold decision to look more closely at the use of vaping when it comes to smoking cessation and for taking an evidence-based, science-led approach rather than the nonsensical anti-vaping, anti-harm reduction stance of some countries.”
Meanwhile, Doug Mutter, director of VPZ, which recently launched a vape clinic service across its retail network of 157 U.K. stores, said in a press note that he believed vaping products being prescribed through the NHS in England could provide a huge leap forward in the country’s ambitions to be smoke-free by 2030. “We fully welcome the news that the NHS in England is exploring opportunities to prescribe vaping products to help people quit smoking,” he said. But he added that he believed it was not simply about prescribing a vape product and smokers going away and quitting smoking. “People need education, expert knowledge, support, advice and a personalized service that meets their individual needs,” he said. “Our vape clinic service responds to this demand and is filling a huge void left by [cuts to NHS] stop-smoking services…”
This need for consumer support had echoes in a new nationwide initiative launched at the end of October and aimed at providing guidance to frontline nursing staff at U.K. hospitals. The initiative, which was being rolled out to every NHS trust by the U.K. Vaping Industry Association and the stop-smoking app, Smoke Free, provides access to a range of resources that provide healthcare practitioners with the knowledge needed for them to give sound advice on how to switch from conventional cigarettes to vape products. It follows a decision by the NHS earlier this year to trial the use of vapes in selected hospitals.
Qualified support
A number of health professionals working in tobacco control also welcomed the government announcement, but many qualified their support. Probably, the most common concern was that, because the process of obtaining a medicines license, even if simplified, would still be complex and expensive, only tobacco companies would be able to attempt it.
There were basically two strands to this concern. One was that some healthcare professionals found the involvement of tobacco companies distasteful, tout court, while another was that consumers might be encouraged to try only licensed, tobacco-company products when other, unlicensed but more efficacious products were available.
This second argument is interesting partly because it raises the question of how much importance would consumers attach to a medicines license. After all, few smokers in the U.K. today started their habit at a time when the risks of smoking were unknown, so we can assume they are not severely risk averse.
Given this, I think it would be reasonable to assume that not all of those who tell researchers they are looking to quit smoking want to do so for health reasons. Additionally, the question raised about the importance smokers attach to health concerns is underlined in the U.K. because switching from smoking to vaping stalled some time ago even though Public Health England (an executive agency of the Department of Health and Social Care whose health protection and health improvement responsibilities were split between two other bodies at the start of October 2021) was on record as saying vaping is probably 95 percent less risky than smoking.
And despite PMI’s positive reaction, it cannot be assumed that all tobacco companies would want to go down the medicines license route. I cannot help thinking, for instance, that it would be something of a disadvantage in getting a product tied to a medicines license because, I assume, it would become petrified within an overall market that was dynamic. Unless the process of obtaining and holding a medicines license for vaping products in the U.K. is to be changed substantially, even obtaining permission to change the font size on the packaging would entail an involved process.
At least, this is what I was told while previously writing a few stories on Voke, which was or is a product developed over 12 years by Kind Consumer and licensed by the MHRA as a medicinal product that was a safer alternative to combustible cigarettes. Voke was not a vaping product but an alternative nicotine-delivery system that used pharmaceutical-standard inhaler technology in a device closely resembling a traditional cigarette in both the way it looked and in the way a consumer, in using the device, mimicked most of the rituals of smoking. Voke, which had no batteries and no electronics and therefore generated no heat and no chemical reactions and produced neither smoke nor vapor, just an invisible, cool, odorless aerosol, could be used anywhere. And its environmental credentials were good given that it was a relatively simple device made of metal, card and plastic: materials that can be recycled.
And yet, despite its medicines license and all the other apparent advantages it offered, it didn’t take off. It is worth noting, however, that British American Tobacco, which had cooperated with Kind in developing Voke, pulled out of the arrangement before the product was launched. It is worth noting, too, that Voke was launched as a consumer product in normal retail outlets, not in pharmacies, and not much seemed to be made of its having a medicines license. Finally, its much-delayed launch was not helped by coinciding with the arrival of the coronavirus pandemic.
Beyond the soundbites
I don’t want to be too downbeat, but it has to be said that the e-cigarettes announcement was made by a government better at sound bites than policy. The reference by Javid to tackling “the stark disparities in smoking rates across the country” would have been meant to have fed into government claims to be intent on levelling up the country, a strategy being honored more in the breach than the observance. Whether the policy announcement will survive mixing with the realities of an NHS struggling from the effects of more than 10 years of austerity and those of the Covid-19 pandemic remains to be seen.
In this regard, it was interesting that one healthcare professional who welcomed the announcement as “excellent news” went on to say one of the reasons why one in three U.K. smokers had not tried e-cigarettes was because of the perceived cost barrier. Having approved devices prescribed would therefore help those least able to afford e-cigarettes.
This raises some interesting questions, not least of which is whether the government has thought through the costs involved if e-cigarette prescriptions started to be given out liberally. And even if it has, has it decided whether ex-smokers should be allowed e-cigarettes on prescription for the rest of their lives rather as a diabetic is provided with insulin for life?
If you follow the logic of most thinking on nicotine addiction, you would have to say that cutting off prescriptions for e-cigarettes at some time in the future would lead only to relapse. Another question is whether the government could hold the line if, after prescribing came in, young, nonsmokers started to cut out the middleman and take up vaping in numbers, as seems possible.
The question has to be faced, also, as to whether general practitioners would be happy to prescribe e-cigarettes. The first step in encouraging them to do so would be convincing many of them that nicotine in the doses delivered by e-cigarettes was not harmful. But even so, there is the question of whether in asking them to do so you would be causing them to be conflicted.
Credit: kues1
The obvious answer to this is that healthcare professionals are generally accepting of the concept of harm reduction, but for some I’m sure there would be a difference between giving to heroin addicts clean needles from a medical supplies company and providing smokers with e-cigarettes from a tobacco company. Such conflicts have surely been reflected in the labored approach the U.S. Food and Drug Administration has taken since being saddled with overseeing a harmful product.
A simpler solution
To my way of thinking, one of the best comments on the government announcement came as part of a quote on the Science Media website by Peter Hajek, director of the Tobacco Dependence Research Unit at the Queen Mary University of London, who admitted to being ambivalent about the plan. Hajek welcomed the fact that the initiative provided a positive message that e-cigarettes were much less risky than smoking and helped smokers quit.
“Overall, it would seem easier to just recommend existing products, which are well regulated by consumer protection regulations,” he said. “There is sufficient evidence available now that these products are effective and dramatically reduce the risks of smoking.”
I’m not sure what Hajek meant by “recommend,” but all the government needs to do to promote the shift from smoking to vaping is to allow manufacturers of e-cigarettes complying with consumer protection regulations to state on packaging and advertising agreed wording to the effect outlined by Hajek: “these products are effective and dramatically reduce the risks of smoking.”
It seems to me that, as things stand, using medicines licensing to try to shift smokers from cigarettes to vaping products is like taking a hammer to crack a nut because I’m not convinced the changes made by the MHRA to its guidance for licensing e-cigarettes as medicines would produce the results sought.
I was told the key changes made relate to guidance on the quality standards for dose uniformity, nonclinical toxicological data requirements and the design of the clinical pharmacokinetic studies. The updates were said also to reflect changes to the regulatory environment post-Brexit.
John Britton, emeritus professor of epidemiology at the University of Nottingham, in generally welcoming the government announcement, made the point on Science Media that what was needed urgently was a bespoke regulatory system for all nicotine products that allowed market access and endorsement by health professionals in inverse proportion to those products’ health hazards.
This, to my mind, is correct. The question remains, however, just how bespoke the system needs to be to work. I’m not convinced the changes announced will be enough. In fact, I’m not convinced any bespoke system complying with the necessarily rigorous demands of the MHRA would give rise to a workable system. I hope I’m wrong.
Forty-two public health leaders have signed onto a letter urging the U.S. Food and Drug Administration Center for Tobacco Products (CTP) to review and update the 20-year old Clearing the Smoke report so that it can address the evolved tobacco and nicotine marketplace.
Two decades ago, the Institute of Medicine (now the National Academy of Medicine) issued its landmark report Clearing the Smoke—Assessing the Science Base for Tobacco Harm Reduction. The report had been compiled at the request of the FDA as it considered—even before Congress gave it the authority to do so—how best to regulate the growing tobacco and nicotine marketplace.
The signatories of the letter point out that much has changed in the tobacco and nicotine marketplace since the report was first published. Science, technology and innovation have dramatically advanced over the past two decades. Consumers can now choose from a range of nicotine delivery products spanning the entire continuum of risk—from deadly combustible cigarettes on one hand to less-harmful noncombustible products such as snus, e-cigarettes and tobacco heating products.
However, a slow product approval process means these products are not being made available to the public at a pace that would help significantly reduce the harms of cigarette smoking. What’s more, a lack of education efforts means consumers remain uninformed about the less-risky product choices available to them.
The signatories maintain that an update of the Clearing the Smoke report will help put all stakeholders on a track that will collectively advance public health objectives. They believe that the National Academy of Medicine, which produced the original report, is the most appropriate body to undertake such a review on behalf of the CTP.
The letter’s signatories include Scott Ballin, former vice president and legislative counsel of the American Heart Association; K. Michael Cummings, professor in the department of psychiatry and behavioral sciences at the Medical University of South Carolina; David Abrahams, professor in the department of social and behavioral science, at the College of Global Health at New York University; Aaron Biebert, former president and CEO of Clear Medical Solutions; Allan C. Erickson, former president for public education and tobacco control at the American Cancer Society; Ray Niaura, professor of public health global studies at New York University; and John R. Seffrin.
Ireland has made progress toward its goal of being smoke-free by 2025, according to the republic’s department of health, reports Joe.
The announcement follows the publication of the Tobacco Free Ireland 2020 Annual Report, which outlines “several key achievements” in 2020, despite Covid-19 disruptions. These achievements consist of the inclusion of information on the dangers of tobacco use in Healthy Choices 1, the first substance misuse module of Junior Cycle Social, Personal and Health Education; the launch of a new quit marketing campaign called The Last Stop; the completion of three comprehensive evidence reviews on electronic cigarettes and heated-tobacco products by the Health Research Board; and an increase of $0.50 per pack of cigarettes with pro-rata increases on other tobacco products included in Budget 2021.
“By working to remove smoking from daily life in Ireland and educating young people on the dangers of tobacco while making cessation assistance as widely available as possible, we can continue to build on the promising results we have seen in recent years,” said Health Minister Stephen Donnelly. “I urge anyone that is thinking of quitting to act now. Stopping smoking remains one of the best decisions a person can make for their health. The last 18 months has further highlighted the importance of being proactive about our own health and the health of those around us. The HSE quit service remains available to anyone that needs it.”
Tobacco companies should be allowed to transition to harm reduction products, but under history’s watchful eye.
By George Gay
I don’t go along with the oft-repeated idea that, if we don’t remember the past, we are condemned to repeat it. This is not to say that particular versions of the past, whether real or invented, are not repeated, just that mostly it is impossible to know whether an event is an original or a repeat. For one thing, memories of the past are mostly not the result of direct experiences and so are not fixed and generally agreed. History, into which the past is roughly sieved, is never objective. It is most often weighted, open to interpretation and subject to disagreements.
I would be happy to consign all versions of history to oblivion, but then, as somebody famously said, there would be no point. In saying that we consign something to oblivion, we suggest that it is simultaneously forgotten and preserved. We are incapable, it seems, of letting go of favorite versions of the past, which get stuck to our shoes like carelessly discarded chewing gum.
Specifically, it concerns me that history, or versions of it, are being allowed to act as a drag on advances that could be being made in reducing the health consequences of cigarette smoking. I recently attended a nicotine conference and, as part of one generally good presentation, a still of a video was shown in which CEOs from U.S. tobacco companies told a Congressional oversight committee sitting a quarter of a century ago that they did not believe nicotine was addictive. I have seen this still, or similar ones, on more occasions than I care to remember, often presented as shorthand for how heinous the tobacco industry was or even is.
But one problem in my view is that what is presented here is a version of history directed by the enemies of the tobacco industry who feel they won the moral war. In other words, a history presented by the victors. It implies that those CEOs were willing to lie about something that everyone knew to be true—that nicotine was and is addictive. There is no time for nuance in a single still. There is no room for other interpretations.
Credit: Sky Next
For instance, were all the CEOs referencing the same, agreed version of addiction? And if, as generally supposed, they were all referencing the same definition of addiction, were they acting in bad faith, or were they, or at least some of them, not informed or badly informed by the scientists working in their companies who did believe that nicotine was addictive? Is it possible the CEOs were right and everybody else was wrong? Was one or more of them delusional and in need of help?
I ask above whether all of the CEOs were referencing the same definition of addiction and, frankly, I have no idea what the answer to that question is. I tend to the view, however, that they were, because I find it difficult to believe their legal teams would have allowed them to give the answers they did without knowing exactly what they were signing up for.
But I have one troublesome doubt in this regard. As far as I am aware, five of the seven CEOs who testified in 1994 said they believed that nicotine was not addictive; one said he believed that neither nicotine nor his company’s products were addictive while another said he believed cigarettes and nicotine clearly did not meet the classic definition of addiction because there was no intoxication.
The reference to “the classical definition” surely suggests that it was admitted there was more than one definition, which possibly means the answers need to be interpreted individually. Additionally, it cannot be ruled out that even if a CEO knew that his company’s scientists believed nicotine to be addictive, his personal view might have been different. We all become fed up with experts at one time or another.
The oversight committee’s hearings later revealed that all sorts of skulduggery had gone on; for instance, at least some of the people within these companies knew or believed that nicotine was addictive and that some had manipulated their products to try to make them more addictive, whatever that means in the context of whatever definition you are using.
But where did this information come from? It came in part from documents voluntarily handed over to the committee at the behest of the CEOs. This seems to suggest that the CEOs were either not aware of what was in those documents or that they were not aware of all that was in them.
But let’s say for the sake of argument that the CEOs, or at least some of them, told the committee they believed nicotine was not addictive, knowing that all this skulduggery had been going on—would they not have been acting in exactly the way they would have been expected to act—perfectly in line with business and societal norms? After all, they were CEOs charged with maximizing company profits at a time when greed was good, so there was some collateral damage. But then, starting only with the “A’s,” look at the alcohol, arms and automobile industries.
I don’t want to defend what the CEOs said during that committee hearing or what the tobacco industry got up to because I don’t know enough about this stuff. But it seems a little odd to me that, at a time when the U.S. was deep in the grip of neoliberal dogma, these men (they were all men) were condemned for following the logic of the market and maximizing profits.
But the committee seemed to want to set itself above all of this tacky business stuff, somewhere on the moral high ground. This is, in part, what the chairman on April 14, 1994, said in opening the hearing: “For decades, the tobacco companies have been exempt from the standards of responsibility and accountability that apply to all other American corporations. … This hearing marks the beginning of a new relationship between Congress and the tobacco companies. The old rules are out; the standards that apply to every other company are in.”
I would imagine that what a lot of people took away from this, whether it was meant or not, is that there goes the wicked tobacco industry again, avoiding its responsibilities for decades. But, if the finger is to be pointed anywhere, it should surely be pointed at Congress, which, as is more or less admitted by the chairman, allowed this situation to exist and to continue. It cannot be expected that businesses will, in the normal course of things, lobby Congress to saddle themselves with additional regulations.
I thought the opening remarks strange in another way also. The chairman at one point says: “Nearly a half million Americans die every year as a result of tobacco. This is an astounding, almost incomprehensible statistic. Imagine our nation’s outrage if two fully loaded jumbo jets crashed each day, killing all aboard. Yet that is the same number of Americans that cigarettes kill every 24 hours.”
As I see it, the chairman is making a comparison as part of what I suppose was meant to be a moral argument, but that comparison does not stand up to even basic scrutiny. As human beings, we take risks every day, balancing those risks, either consciously or unconsciously, against perceived benefits. Smoking and drinking alcohol are two obvious everyday examples of this. And so, too, for a lot of people (though perhaps not recently) is getting on an airplane. As things stand, people get on airplanes because they are overwhelmingly safe to use, so the benefit-to-risk ratio is hugely positive.
But it is inconceivable that if two jumbo jets crashed each day in the U.S. alone, people would still board them. The chairman was ignoring the fact that people make risk assessments so as to conjure up a situation that would never occur. People understand that smoking might cause them to die in 40 years to 50 years, and they understand that falling from 30,000 feet brings on death a lot quicker.
The idea of risk can be manipulated, and often is, as in the story about the therapist with a patient who is still nervous of flying even after being told that the chances of a bomb being on board a plane is a billion to one; the therapist advises her to take her own bomb on board next time she flies because the chances of there being two bombs on board are a trillion to one.
I need to emphasize that I am not trying to defend the past behavior of the tobacco industry or the CEOs in question. What concerns me here is that a single picture is being regularly presented as telling a story that is far simpler than it really is. What has passed into history—what I would imagine most people would “remember” from the picture of the subcommittee hearing—was that all of the CEOs lied in saying that nicotine was not addictive. I doubt that many people would realize that what they said was they believed nicotine was not addictive, let alone the back story to this event.
This is the problem with the versions of history we drag around with us. In the end, what did the hearings bring about? Reputational damage to tobacco companies for sure. But they are still operating in one form or another, and part of their business is largely unchanged. It is said that the number of smokers fell after the hearings, but who knows whether the hearings were a causal factor in this.
It is more interesting to examine what continued: taxes. Local, state and federal agencies continued to benefit from people smoking through the taxes they paid, and later was added the proceeds of the Master Settlement Agreement, very little of which is ever spent on ameliorating the toll of tobacco smoking; so who gets to stand on the moral high ground?
Credit: Gawriloff
Well, the answer to that question might seem strange. I say above that it is not usual for businesses to lobby Congress to try to saddle themselves with additional regulations. But, in fact, odd as it might seem, this is exactly what many nicotine and tobacco companies have been doing in recent times.
I’m not saying they are perfect and that part of this new way of thinking hasn’t to do with competition, but in part it is a genuine attempt to ensure that the new generation products that are being developed and offered to help people transition to safer forms of nicotine consumption are not causing, and can be seen not to be causing, unintended consequences.
And for those people who tend still to be wedded to the idea portrayed by the still of the tobacco CEOs, it is worth noting that, importantly, in the recent past the major tobacco companies have found a way of offering reduced-risk products while roughly maintaining the sorts of business models that were so successful for them in the past. Does this put them on the moral high ground? Of course not, but it has mapped out a route to that ground.
Times are changing, and we desperately need to stop slowing the transition into a new world of nicotine consumption by constantly dragging behind us a little-examined history of what went on 20 years to 30 years ago—a time that few working in the nicotine and tobacco industries could probably remember.
There was a furor just after I started to write this piece about a proposed takeover by Philip Morris International of the pharmaceutical company Vectura, which in news reports was said to be developing inhaled treatments for respiratory diseases. Why the furor? Well, it’s all about history, of course. PMI has in the past sold traditional cigarettes and still does; so, the detractors claimed, we cannot let it near a pharmaceutical company.
There seems to be no way such people can accept that, in order to move ahead with the transition from smoking to other forms of nicotine consumption, we have to look at innovative, even daring ways of doing things.
I have no insights into what PMI is up to beyond what has been reported in the general press, but it doesn’t take a genius to figure out that it might be looking, in part, to benefit from some cross fertilization of ideas in respect of inhalation technologies—ideas that just might allow it to make a breakthrough in respect of reduced-risk, next-generation nicotine products.
At least we should allow companies to try such things—while keeping an eye on them, of course. We should not let history stand in the way.
Considerable evidence suggests that e-cigarettes are an effective smoking cessation tool for adults in the United States, where hundreds of thousands of people die of smoking-related illness each year.
Kenneth Warner, dean emeritus and the Avedis Donabedian Distinguished University Professor Emeritus at the University of Michigan’s School of Public Health, says, however, that the potential of vaping to increase smoking cessation has been largely overshadowed by media coverage and policies that focus on the potential risk vaping represents for teens.
Warner and 14 other past presidents of the Society for Research on Nicotine and Tobacco co-authored an article that argues that the media, legislators and the general public have developed a negative view of e-cigarettes because of the heavy emphasis public health organizations have placed on protecting kids from vaping while ignoring the potentially substantial benefits of e-cigarettes in helping adults quit smoking. The article is published online in the American Journal of Public Health.
In an interview with Michigan News of the University of Michigan, Warner discusses why the group, all of whom have presided over the top tobacco research society in the world, decided to take on this issue.
What prompted this group to write this article?
In my 45 years in the field of tobacco control research, I’ve never seen an issue that is as divisive as this one, and maybe none that is as important to public health. We have a large group within public health who are very much opposed to vaping because they see it as imposing huge risks on kids. On the other end of the spectrum, we see a number of researchers and members of the vaping community who believe that vaping is a great tool for helping people to quit smoking and that it is far less hazardous than smoking. These polar opposite views have created much of the contention within the tobacco control community.
Our goal in this paper is to try to inject some sense of balance, to get public health organizations, the media and legislators to recognize that their appropriate but singular desire to keep e-cigarettes out of the hands of kids may actually be harming public health. Policies oriented exclusively toward protecting kids may be responsible for more adults smoking than would be if we had policies that also emphasized helping adults to quit with vaping, and frankly, if we had honest characterizations of the risks of vaping.
Exaggerations of the risk have led a majority of Americans, including a majority of smokers, to the erroneous belief that vaping is as dangerous as, or more dangerous than, smoking. The National Academies of Science, Engineering and Medicine has determined that vaping is likely substantially less dangerous.
What do you want people to take away from the AJPH article?
We call for a rebalancing of society’s consideration of vaping and specifically for more attention being paid to its potential to increase smoking cessation. We should continue working to decrease young people’s use of e-cigarettes—of all nicotine products, for that matter—but we must increase our focus on adult smokers.
In the article, my colleagues and I express concern that we have forgotten about the adults who are going to die as a consequence of smoking. We lose 480,000 Americans every year as a result of smoking. Understandably and justifiably, all Americans were enormously concerned by the toll of Covid-19 this past year. Consider that we have a Covid-level disaster created by smoking every year, year after year after year.
How would you characterize the risks associated with e-cigarettes? What are the potential benefits of vaping for adult smokers?
Vaping is clearly not risk-free, but it is also substantially less dangerous than cigarette smoking. Inhaling combusted tobacco smoke, which includes over 7,000 chemicals, is what causes the disease and death associated with tobacco use.
Multiple types of evidence, identified in our article, demonstrate that vaping can increase smoking cessation. The highly respected Cochrane Review has concluded that it is likely that vaping is more effective than FDA-approved nicotine-replacement products like gum and patches. The CDC has also found that more smokers use e-cigarettes than other aids in attempts to quit smoking—and with a higher self-reported success rate.
Still, the public is largely unaware of the potential vaping has to aid in smoking cessation. As I mentioned previously, a majority of adults, including a majority of smokers, believe that vaping is as dangerous as, or more dangerous than, cigarette smoking. This misunderstanding has actually worsened over time. That reflects, in part, the media’s coverage of vaping.
A recent study cited in our article found that 70 percent of U.S. news coverage on vaping mentioned vaping’s risks to kids while only 37 percent noted the potential benefits for adult smokers. As such, it’s likely that fewer smokers are trying e-cigarettes as a method of quitting smoking than would be the case if they were accurately informed about its potential to help them quit and its smaller health risk compared to smoking. That means fewer people are quitting smoking.
Put simply, research shows that the potential benefits of vaping for adult smokers are substantial. Those benefits are not being fully realized in today’s environment of misinformation and a singular focus on the welfare of kids, to the detriment of the health of adults who smoke.
What is known about the risks of youth e-cigarette use?
Vaping does have risks for kids, including the potential of addicting some to nicotine. But in our article, we point to evidence that the percentage of kids being addicted to nicotine by vaping is much smaller than popularly believed.
We also note that while prospective studies have found that vaping by kids who had never smoked increases their risk of trying cigarettes 6–24 months later, much of this may be explained by what is called “common liability,” meaning that kids who try e-cigarettes are more prone to risk-taking than are kids who don’t vape, so the former may be more likely to try cigarettes anyway, even if e-cigarettes had never existed.
Further—and very importantly—even if there is an increased risk, doing the math indicates that this factor would increase overall smoking initiation by kids by only a very small amount. However, even that seems unlikely since we’ve seen smoking rates fall among young people (both adolescents and young adults) at unprecedented rates precisely during the period of vaping’s ascendancy. That certainly is not consistent with the idea that vaping increases smoking.
Why has e-cigarette use in adults not been a focus in policy or the media?
First, the concern for young people’s welfare is a compelling one, and the rapid increase in youth vaping in 2018 and 2019 understandably created a great deal of anxiety. The focus on youth drowned out attention to the welfare of adults who smoke. Youth vaping decreased significantly in 2020. We will have to monitor future years’ trends closely.
Second, I think a lot of people may believe that the problem of smoking is pretty much resolved. I’m referring mainly to the higher education, upper socioeconomic status population. They don’t smoke, their friends and colleagues don’t smoke, there’s no smoking in their workplaces, and there’s no smoking in the restaurants and bars that they frequent. They don’t see smoking and thus may believe the problem has largely been solved.
And yet one out of seven adult Americans is a smoker today. When we take a look at who’s smoking, it’s the underprivileged members of our society, those who don’t have a voice in politics. African Americans as a group, although they don’t smoke more, have higher rates of smoking-produced disease and death than do [white individuals]. There are groups like low socioeconomic populations, people with mental health problems and the LGBTQ community that all have higher than average smoking rates.
My fear, frankly, is that many nonsmokers are ignoring smokers because they may not care that much about them. There is a very large life expectancy differential between the rich and the poor in the United States, and perhaps the single most important behavior-related variable is differences in smoking. The data show that low-income, low-education populations smoke at much higher rates than the high-income population, and they die at much younger ages. If we could reduce smoking among these often marginalized populations, we might be able to reduce the gap in life expectancy. This is fundamentally a matter of social justice.
What are some policy changes that might help achieve a more balanced approach to e-cigarettes?
Currently, we have very unbalanced policies that are directed exclusively at trying to reduce youth vaping. Two of the most prominent are eliminating or seriously restricting flavors in e-cigarettes and trying to equalize the taxation of e-cigarettes and cigarettes. Both of these policies can have adverse consequences for adult smokers. Adult smokers like flavors just like kids do, and in fact, they tend to like the same flavors.
Banning flavors would eliminate adult smokers’ access to the flavored e-cigarettes that they prefer in attempts to quit smoking. So that’s a real concern. We propose restricting the sale of e-cigarettes to adult-only establishments, such as vape shops. This is a compromise—flavors are a significant attraction to vaping for kids, and our recommended policy would not eliminate flavors; at the same time, the policy would restrict access for adults, thereby creating an inconvenience for them. But this policy would strongly limit youth access to flavored e-cigarettes while allowing adults to get the flavored e-cigarettes they want to aid in their attempts to quit smoking.
We also suggest a substantial increase in excise taxes on cigarettes and other combusted tobacco products, and a much more modest tax on e-cigarettes. This is the opposite of what is happening now, with states imposing “equalizing” taxes on e-cigarettes without raising taxes on cigarettes. Significantly raising the tax on cigarettes will discourage both adults and kids from smoking. A big differential in price between very expensive cigarettes and less expensive e-cigarettes creates an incentive for adults who don’t quit smoking to switch to e-cigarettes. For kids, a modest tax on e-cigarettes will discourage them from vaping because they’re the most price-sensitive group when it comes to nicotine and tobacco products.
A new paper co-authored by a majority of recognized tobacco control experts in the United Sates endorses the harm reduction benefits of vaping for adult smokers trying to quit combustible cigarettes. The group of experts state that the public image of vaping products must be improved and electronic nicotine-delivery systems (ENDS) should be promoted as a safer alternative to combustible cigarettes.
“Opponents focus on e-cigarettes’ risks for young people, while supporters emphasize the potential for e-cigarettes to assist smokers in quitting smoking. Most US health organizations, media coverage, and policymakers have focused primarily on risks to youths,” the report states. “Because of their messaging, much of the public—including most smokers—now consider e-cigarette use as dangerous as or more dangerous than smoking. By contrast, the National Academies of Science, Engineering, and Medicine concluded that e-cigarette use is likely far less hazardous than smoking. Policies intended to reduce adolescent vaping may also reduce adult smokers’ use of e-cigarettes in quit attempts.”
The paper, published August 19 in The American Journal of Public Health, was led by Kenneth Warner, a professor emeritus of health management and policy at the University of Michigan and a distinguished tobacco control expert. Fifteen former presidents of the Society for Research on Nicotine and Tobacco (SRNT), the leading scientific professional society focused on nicotine and tobacco, co-authored the paper.
The authors present four categories of evidence supporting vaping as a quit aid for combustible tobacco use: the results of randomized trials, which show e-cigarettes outperform other cessation methods like nicotine patches; population studies, the findings of which “are consistent with a near doubling of quit attempt success”; cigarette sales, which decrease rapidly as vaping sales increase; and the unintended consequences of policies restricting vaping, such as bans that unintentionally shot up cigarette smoking.
“The major elements of the public health community that are concerned with tobacco have been singularly focused on the risk to kids,” Warner told Alex Norcia of Filter. “They seem to truly have no interest whatsoever in adult smokers. The other piece is that you’re seeing lots of allegedly scientific papers that are raising health concerns that are unwarranted.” One such paper, which claimed that vaping increased the likelihood of having a heart attack, was later retracted.
The paper also presents “a sensible mix of policies” to boost ENDS use, including taxing traditional cigarettes higher than e-cigarettes to encourage adult smokers to switch, allowing flavored vaping products available only at vape shops, restricting advertising to limit youth initiation and reducing the nicotine levels in cigarettes while ensuring the availability of “consumer-acceptable” reduced-risk nicotine products.
“Because evidence indicates that e-cigarette use can increase the odds of quitting smoking, many scientists, including this essay’s authors, encourage the health community, media, and policymakers to more carefully weigh vaping’s potential to reduce adult smoking-attributable mortality,” the paper states.
A parliamentary group in the U.K. has released a report that criticizes anti-vaping groups funded by Bloomberg Philanthropies for being hostile to tobacco harm reduction (THR). The report also states that Bloomberg diminishes the rights of consumers and vapers in low and middle-income countries (LMICs) such as the Philippines.
Credit: Olrat
The UK’s All-Party Parliamentary Group for Vaping (APPG) said these anti-vaping “civil society observers” will be allowed to participate in the World Health Organization Framework Convention on Tobacco Control Conference of the Parties 9 (FCTC COP 9) in November this year, concluding that the WHO continues to attempt to discredit UK’s science and policy approach to address the smoking problem, reports the Manila Bulletin. It said THR is a public health approach which is supposedly one of the original commitments of FCTC.
The APPG warned about the participation of The Union, a group funded by Bloomberg Philanthropies, as well as other anti-vaping non-government organizations in the FCTC COP 9 meeting in November. The APPG is asking the UK delegation to the FCTC COP9 meeting to ensure that its national experience and real-life evidence/data are reflected in the discussions within the WHO.
The APPG also wanted to ensure that the WHO would not move away from the fundamental objectives set forth by the FCTC given its original commitment to harm reduction—a public health approach being opposed by some influential non-government organizations. “The majority of NGOs listed as ‘Observers’ are hostile to the concept of tobacco harm reduction and thus the UK’s policy approach. For instance, ‘The Union’ has advocated a complete ban on e-cigarettes and heated tobacco products in low and middle-income countries, which are home to 80 percent of the world’s smokers,” the APPG said in the report.
Juul Labs paid $51,000 to buy out an entire issue of the American Journal of Health Behavior (AJHB) and make it publicly available, the New York Times reported.
The AJHB’s May/June issue published 11 company-funded studies that promote the health benefits of Juul devices in helping smokers quit traditional tobacco products.
“Electronic nicotine delivery systems (ENDS) represent a significant opportunity to realize tobacco harm reduction at the population level around the world,” the authors write in an introduction to the journal.
Juul Lab’s five-figure buyout of the journal issue is part of a public influence campaign that the Center for Responsive Politics tallied at more than $3.9 million in 2020 alone.
Juul Labs recently reached a legal settlement with the state of North Carolina in which it will pay $40 million to avoid a jury trial over the question of whether it illegally marketed nicotine products to teens.
You don’t have to be a doctor, or even play one on TV, to see the conflict: American healthcare policy that promotes taxpayer-funded needle exchanges for drug addicts, but opposes vaping as an alternative for smokers.
The Biden administration recently announced a robust plan to address the nation’s crippling opioid epidemic, which was responsible for 500,000 American deaths between 1999 and 2019. That harm reduction includes needle exchanges, long a controversial policy. In 1988, Congress barred the use of federal funding for needle exchange programs. In 2015, amid the growing opioid crisis, then-President Barack Obama signed the Consolidated Appropriations Act, “which modified the restriction on use of federal funds for distributing sterile needles or syringes,” and allowed for funding to be used for other services, but not syringes.
The Biden administration plan mentions “harm reduction” a total of 12 times and hopes to “enhance” and “support” emerging harm reduction efforts. Although attempting to tackle the opioid epidemic is an admirable goal, the administration is doing an about-face in terms of adult access to all harm reduction products, and they’re not the only ones.
Rhode Island lawmakers recently held hearings on a series of bills that would ban flavored tobacco substitutes like vaping products. But those same Ocean State legislators held a floor session for the final vote on a bill that would establish “harm reduction centers.” A spirited debate took place for nearly an hour. Ultimately the measure passed by a vote of 62-9.
Harm reduction centers for opioid users are a worthwhile goal, but it is overwhelmingly hypocritical for lawmakers to support government funding those, while simultaneously blocking adult access to tobacco harm reduction products including e-cigarettes, heat-not-burn, and smokeless tobacco.
It is the smoke in combustible cigarettes that is responsible for the damage wrought by tobacco. Tobacco harm reduction products eliminate that smoke while allowing adult users to access nicotine, which in itself is not the harmful component of cigarettes. The U.S. Food and Drug Administration (FDA) has noted that it is the “mix of chemicals – not nicotine – that causes serious disease and death in tobacco users.”
The FDA currently regulates vapor products. But the agency, which fought so hard to regulate these products, has yet to approve a single premarket tobacco product application for any e-cigarette product. During a U.S. House oversight subcommittee meeting last month, lawmakers urged the agency to not approve any flavored e-cigarette product to “protect youth.”
In the Rhode Island House hearing, a spokesman for Campaign for Tobacco-Free Kids (CTFK) urged lawmakers to ban flavored tobacco and vapor products while supporting lawmakers’ efforts in increasing access to clean syringes and opioid antagonist medications, including methadone.
This makes no sense.
Is anyone arguing that more Americans should smoke? Or that health policy should promote smoking? Of course not, just as needle exchange advocates aren’t hoping more people will get hooked on heroin. It’s simply an acknowledgment of human nature, and an effort to reduce harm.
The infamous anti-tobacco and vaping crusader Michael Bloomberg similarly supports opioid harm reduction, but not tobacco harm reduction. A recent New York Times article interviewed the director of drug use initiatives at Vital Strategies, a Bloomberg-backed “philanthropic group.” The director noted that harm reduction programs help persons “stay safe and healthy and alive first and foremost.” Since 2016, Vital Strategies has worked in tandem with the World Health Organization to ban adult access to tobacco harm reduction products. In 2019, the organization highlighted India’s ban on e-cigarettes as a victory. Bloomberg himself has donated $160 million over a three-year period to “fight flavored e-cigarettes.”
In Rhode Island, the CTFK spokesperson noted that opioid harm reduction programs don’t create new users. That may be true, but e-cigarettes create former smokers by helping adults quit smoking. Moreover, they don’t cost taxpayers a dime, and as a harm reduction product, they help to reduce health care and other smoking-related costs.
The FDA has the ability to save millions of lives by approving tobacco harm reduction products. They shouldn’t let misinformed entities and people like CTFK and Michael Bloomberg stand in the way of science and common sense.
