E-cigarette risk perceptions – an American crime scene

Most Americans now incorrectly believe that e-cigarettes are just as harmful or more harmful than cigarettes. US health organisations have unethically cultivated this misunderstanding and compare unfavourably with UK equivalents. Their duplicitous behaviour resembles that of Big Tobacco 50 years ago.

Note: ‘Don’t know’ is handled inconsistently across the surveys, so I have merged ‘don’t know’ and ‘never heard of e-cigarettes’ (some care needed)

I have drawn the chart above from the US National Cancer Institute HINTS survey, picking up results from 2014, 2017 and the most recent data from 2020. The current situation is shocking and the trend is a disgrace. But how has this happened?

In this blog, I compare the vaping risk communications of four major American health organisations with four similar UK organisations. The comparison is damning.

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FDA spreads confusion about nicotine and smoking

FDA has authorised 22nd Century to claim a reduced nicotine cigarette is a reduced risk product. This will spread confusion and divert smokers from better choices.

In one of its most ill-judged moves to date, the US Food and Drug Administration has today granted 22nd Century Group the right to market its VLN King and VLN Menthol King combusted, filtered cigarettes as modified risk tobacco products.

It has done this because these products are reduced in nicotine and, FDA concludes, anyone who is willing to smoke them will experience lower exposures to nicotine. But we have known for a long time that “people smoke for the nicotine but die from the tar” (Mike Russell). This is a product that reduces the nicotine but keeps the tar. What could possibly go wrong?

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Twenty reasons to be sceptical about rules lowering nicotine levels in cigarettes – and what to do instead

Using regulation to remove nearly all the nicotine from cigarettes is similar in effect to a prohibition – with all that entails. That will trigger a wide range of responses by consumers and suppliers. These have barely been studied or understood.

What matters is how users respond to a rule, not what the rule and rule-makers intend. The graphic illustrates various response pathways to a reduced nicotine rule. These may be combined or evolve over time as producer and consumer behaviour adapts. These pathways are in competition with each other.

Updated: December 2021: I am revisiting this post with a new graphic (above). July 2022: reflecting the return of this rule to FDA’s regulatory agenda, updates on (4) public perception; (8) youth. August 2022: added a pro-VLN commentary.

What would be the biggest possible tobacco control measure? That would be a proposed rule lowering nicotine levels in cigarettes with a view to making “Very Low Nicotine Cigarettes” (VLNC) sub-addictive – thereby persuading adults to quit and adolescents to never start.  The trouble is that consumers, markets, producers, and criminal networks have a way of thwarting such bold ambitions.

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The WHO tobacco control treaty meetings are closed bubbles of cultivated groupthink – a comparison with the UN climate change treaty

Stakeholders with legitimate (and sometimes life-or-death) interests are deliberately excluded from FCTC meetings.

At the start of COP-9, the head of the FCTC convention secretariat proudly drew a comparison with the other COP, the one going on in Glasgow dealing with the UN Framework Convention on Climate Change (UNFCC).  Perhaps she hoping some of the interest in UNFCCC COP-26 would rub off on the altogether more tawdry FCTC COP-9.  But the tobacco COP takes an aggressive exclusionary and insular approach to stakeholders that would never be tolerated in the climate COP.  This post compares the two COPs.

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Prohibitionists at work: how the WHO damages public health through hostility to tobacco harm reduction

Gangsters celebrate their good fortune with drinks at a speakeasy during US alcohol Prohibition

This post examines how WHO and related institutions aggressively promote the prohibition of much safer alternatives to cigarettes, such as vaping and heated tobacco products. The effect, if not the intent, is to protect the cigarette trade from competition, to promote black markets, to stimulate harmful workarounds, to nurture criminal networks, to harm young people, and to prolong the epidemic of avoidable smoking-related disease.  It’s a reckless policy, built on misplaced righteousness, defended by bureaucratic inertia, sustained by group-think, and cultivated by elitist billionaire foundation money. It’s a curse and a blight on public health, and government representatives should apply real-world policy disciplines and reject it.

The post is broken into six sections:
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One hundred specialists call for WHO to change its hostile stance on tobacco harm reduction – new letter to FCTC delegates published

Just want the letter? PDF version: English, Français, Español, Deutsch (new) – and text below.

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Expert statements on WHO and tobacco harm reduction

100 experts sign a public letter on the failure of the WHO approach to tobacco smoking and public health. In this post, they express their views in their own words 

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Psychoactive Podcast: The E-cigarette revolution – vaping, nicotine and harm reduction

I had an excellent conversation with Ethan Nadelmann, the founder of the New York-based Drug Policy Alliance for his outstanding Psychoactive podcast series about all aspects of drugs and drugs policy, which I highly recommend.

In this episode, “The E-cigarette revolution”, we covered vaping, nicotine, harm reduction – science, policy, politics and controversy – with Ethan as host putting the challenging questions.   Listen via your usual podcast provider (search on Psychoactive)… or via these links.

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CHEST journal point and counterpoint – E-cigarette use for harm reduction in tobacco use disorder: Yes/No?

A debate about the merits of e-cigarettes for tobacco harm reduction

The September 2021 edition of CHEST, the respiratory journal, features a point/counterpoint debate on the value of e-cigarettes for tobacco harm reduction.  I am making the case in favour (the Point) and Dr Hasmeena Kathuria (Boston University) and Dr Frank T. Leone (University of Pennsylvania) are making the case against (the Counterpoint).  We each provide a shorter rebuttal to the arguments made by the other.  We also recorded a 30-minute podcast to air these arguments face-to-face.  Recognising the broader interest in the subject, CHEST has kindly made this content open access so far.

Whatever you think of the respective arguments, it was refreshing to find a forum willing to air them in a respectful and measured way, I am grateful to Drs Kathuria and Leone for engaging and making their case and to CHEST for providing the platform.  I wish we could have much more debate like this.

For ease of access, I have added the relevant links below.

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Will FDA harm health, destroy businesses, and protect the cigarette industry through regulatory overkill? A preview.

This blog gives my take on how to think about the FDA’s decisions (some taken, some forthcoming) on approving or denying thousands of “pre-market tobacco applications” (PMTAs) to allow vaping products to remain on the US market.  FDA must make decisions no later than 9th September 2021, following legal action brought against the agency. FDA’s Director of the Center for Tobacco Products, Mitchel Zeller, provides the background in a February 2021 blog.

There’s a lot to be written on this, but I will settle for 16 observations and questions that will shape my take on FDA’s announcements.

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