The year in e-cigarettes: The good, the bad, the reason for optimism

As 2015 draws to a close, electronic cigarettes remain as controversial and as poorly understood among the general public as they were a year ago. Are e-cigarettes re-normalizing smoking? Are kids using them as a stepping stone to combustible cigarettes? Do flavors lure teens? Are e-cigarettes as harmful as the real thing? Are formaldehyde and other toxins a threat to vapers?

The answer to all those questions is no. As documented here by the National Institute on Drug Abuse, teen smoking is at historic lows, despite—or perhaps because of—an increasing number of teenagers experimenting with e-cigs. See here the evidence that teens who do not smoke regular cigarettes are not inclined to try e-cigs because of their flavors. See here for an explanation of the oft-cited estimate that e-cigarettes are 95 percent safer than combustible tobacco products. See here for evidence flatly debunking claims about carcinogenic formaldehyde levels in e-cigs and here for information on lower levels of other chemicals in e-cigs relative to standard cigarettes.

But who could blame the average American for being skeptical of e-cigarettes’ benefits? People are barraged by daily sorties of disinformation. The two biggest offenders in the crusade against e-cigarettes are the U.S. Centers for Disease Control and the California State Department of Health, whose campaign, “Still Blowing Smoke”, critiqued here, gets a “5-tar” rating for being among the most deceptive and biased public health announcements I have ever seen.

 As the year ends, CDC Director Frieden sets out priorities: “Old and new threats to our health, such as Ebola, dengue, HIV, e-cigarette use among kids, foodborne illness, prescription drug overdoses… are just a few of the threats that kept us up at night – and will keep us busy in 2016.” Imagine putting life-saving e-cigarettes in the same sentence with killers like Ebola, HIV, and OxyContin overdoses!

Now, months later, two new high profile entries join the disinformation sweepstakes: The National Institutes on Drug Abuse and the Chicago Department of Health.

NIDA is part of the National Institutes of Health. Its self-stated mission is “bringing the power of science to bear on drug abuse and addiction.” In that case, its fact sheet on e-cigarettes doesn’t meet its own standard. For example, consider the NIDA response to the question, “Are e-cigarettes safer than conventional cigarettes?”

Answer: Unfortunately, this question is difficult to answer because insufficient information is available on these new products.

… These products have not been thoroughly evaluated in scientific studies. This may change in the near future, but for now, very little data exists on the safety of e-cigarettes, and consumers have no way of knowing whether there are any therapeutic benefits or how the health effects compare to conventional cigarettes.

This is absurd. There is ample data showing the unequivocal relative safety of e-cigarettes. Indeed, longitudinal research is needed, but the agency’s warped statement is useless to those considering alternatives to smoking. Worse, it may well keep them smoking. What’s more, NIDA’s position is at odds with its avid promotion of opiate harm reduction in the form of needle exchange and opiate substitution drugs – that is, delivering opiates in a safer manner than heroin and street pills. If NIDA is enthusiastic about advancing safer means of opiate drug use as a means of improving public health, why is it unwilling to do the same for nicotine?

This brings us to Chicago where Mayor Rahm Emanuel and Chicago Department of Public Health Commissioner Dr. Julie Morita just launched “‘Vaping,’ a new public education and social media campaign. It is dedicated to informing youth and families of the truth about the dangers of e-cigarettes.’” The anti-vaping “Vaping” effort trafficks in alarmist claims, warning of “the highly addictive nature of nicotine” and “the toxic chemicals and poisons found in e-liquids.” Of the great advantages to smokers – no exposure to carcinogenic tar and carbon monoxide, or improved respiratory health – there is no mention.

But 2015 had some official bright spots, too. The best one came from across the Atlantic. The CDC’s British counterpart, Public Health England (PHE), an executive agency of the UK Department of Health, became the first national government agency to endorse e-cigarettes as safer options for smokers. In its report, E-Cigarettes: An Evidence Update, PHE estimated that vaping was 95 percent safer than smoking, based on aerosol emissions, and strongly rejected several common false claims about vaping, in particular that it is a pathway to smoking among youth.

 Back in the U.S., the issue received balanced coverage from New York Times columnist Joe Nocera, who devoted several columns to the virtues of vaping, and New York Times reporter Sabrina Tavernise. David Amsden wrote a masterful synthesis, E-cigs Inconvenient Truth: It’s Much Safer to Vape, in Rolling Stone this month.

And bravo to a handful of politicians who weighed in on the public health virtues of vaping, among them Iowa Attorney General Tom Miller who released a statement this month in support of vaping: “There has been an effort to say that combustible cigarettes and e-cigarettes are equally harmful, that their companies are equally evil, and that they should be strongly regulated the same way. This view is incorrect.” Also, Representative Duncan Hunter (R-CA) fought against, though lost, the 2007 grandfather date for pre-market approval of vaping products by the FDA.

What of the FDA? Within the next few months, the agency will make crucial decisions that will attest to the agency’s professed awareness that smokeless products reside on the very low end of the “continuum of risk” of tobacco products.

Early in 2016 should be a decision on Swedish Match snus. Will the FDA declare snus a “modified risk” tobacco product and allow the company to remove or change some of the four health warning labels on snus packaging, including a mouth cancer warning? It should; data on the relative safety of snus compared to combustible tobacco products are compelling.

Then come the “deeming” regulations regarding vaping products. If the FDA pursues an aggressive premarket approval regime for all vaping products, the cost of smoking-to-switching trials and administrative requirements will be burdensome enough to drive the overwhelming majority of e-cigarette products out of the market.

As I surveyed this tally of the bad, the good, and the yet-to-be decided, I found myself veering toward pessimism. The detractors of vaping seem to have the margin. But then I turned for solace to Clive Bates, the estimable brains (and charm) behind the superlative Counterfactual.com blog, among the best sites for public health literacy on the web.

Clive found the bright spot: “the free play of consumers, businesses and innovators in a market so far largely untroubled by clumsy and wildly excessive regulation, and increasingly by-passing the self-righteous cynics in public health.”

Indeed, vaping is up, smoking is down, and good businesses are making money by doing the right thing.

Consider Canada. Health Canada, the Canadian national public health service, opted to treat vaping products as medicinal. This meant that they could not be sold without nearly-impossible to obtain approval. The agency went so far as to warn smokers against e-cigarettes, and abstinence-only anti-tobacco groups attacked the products. “But the market essentially ignored them,” according to David Sweanor of The Centre on Health Law, Policy & Ethics at the University of Ottawa. “Vape shops started opening all over the country and ‎smokers in large numbers switched to vaping.”

 Of necessity, vaping – and more broadly, tobacco harm reduction – has become a bottom-up movement. The place to find energy and optimism is in the 8000 CASAA testimonials (“how vaping saved my life” and others) and similar consciousness-raising around the world. The swell of social media is strong and ungovernable. The weight of hypocrisy surrounding selective endorsement of harm reduction (it’s okay for heroin but not for nicotine) is great. And the data concerning relative safety of vaping become more compelling every day. Together, these forces, I am optimistic, will ultimately prevail.

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