In the Poisonous Vaping Debate, Are Anti-Smoking Groups the New Big Tobacco?

Apr 27 2016

In the Poisonous Vaping Debate, Are Anti-Smoking Groups the New Big Tobacco?

April 27th, 2016

With the release of new FDA rules regulating e-cigarettes expected to come any day now, our attitudes to these devices—and to tobacco harm reduction in general—matter more than ever. A debate over whether they should be viewed as a danger, as a lesser evil, or as a miracle, is splintering both the public and private realms, creating unexpected alliances and enemies. It is no exaggeration to say that millions of lives may hang in the balance.

The Disturbing Subplot

Since the surgeon general’s warning was mandated onto cigarette packs in 1966, the US smoking rate has been more than cut in half: In 1965, 50 percent of adults smoked; in 2014, 16.8 percent did. But according to the CDC, about 480,000 deaths annually are still attributable to smoked tobacco, which remains the leading cause of preventable death in the United States, responsible for about one in every five deaths.

Who still smokes cigarettes? The answer to that question is a “disturbing subplot” to the general decline in smoking rates. Cigarette smoking is highest among people living below the poverty level, about 26.3 percent of whom smoke, as opposed to 15 percent of people at or above the poverty line.

High-income families decreased their smoking by 62 percent from 1965 to 1999, versus only 9 percent for low-income families. Smoking is also disproportionately high among people with (other) problematic substance use, and psychiatric issues: 36 percent of people with mental illness smoke cigarettes, and a full 48 percent of people with mental illness living below the poverty level smoke—that’s nearly the same rate as that of the general population in 1965. Within specific populations, some of the numbers are even higher: In the US, 80 percent of people with schizophrenia smoke cigarettes.

Reducing harms associated with smoking cigarettes should obviously be of huge concern to anyone involved in public health. But it should also be a high priority for people who care about reducing inequalities.

The Future Is Here

Last week, Dr. Michael Siegel, a professor at Boston University School of Public Health, Skyped in to a conference in downtown Brooklyn to ask an audience what people would say if he told them he had a device that “looked and worked like a cigarette” but didn’t cause any of the harms.

He answered his own question: “People would say ‘wow, that sounds really intriguing.’ At which point I would tell them, the future is here. We have that: The electronic cigarette.”

“There’s certainly room for improvement,“ he admitted. “But we have it.”

His rapt audience of about 60 was gathered at the first ever Tobacco Harm Reduction conference in the US, held at the New York City College of Technology. Attendees included nursing students, health providers, members of the e-cigarette industry, policy leaders and “consumers”—i.e., “vapers.” The particular focus was on tobacco harm reduction among people with mental illness and substance use disorders.

Tobacco harm reduction is the replacement of tobacco with lower-risk products in order to reduce death and disease. There are currently seven FDA-approved products for smoking cessation; according to the FDA, they “supply you with nicotine in controlled amounts while sparing you from other chemicals found in tobacco products.” These include the patch, nicotine gum and lozenges, nicotine inhalers, and drugs like bupropion, an antidepressant which has been found to cut cravings.

Most who were at the conference believe that e-cigarettes should be added to the list—and indeed, should top the list for having the most potential to move people away from “combustibles.”

The alternatives are largely unpalatable or just not effective enough.

“Unfortunately, smoking is a very difficult addiction to break, even for those with a strong desire to quit,” writes Dr. Ricardo Poloso, director of the Institute for Internal and Emergency Medicine of the University of Catania in Italy, and a speaker at the conference. “It has been shown that approximately 80 percent of smokers who attempt to quit on their own relapse within the first month of abstinence, and only about 5 percent achieve long-term abstinence.”

It’s disheartening stuff. But there is hope in nicotine replacement, according to Polosa, because “nicotine per se does not cause much risk when separated from inhaling smoke.” (It may potentially be harmful during pregnancy, but less so than continued smoking). A study conducted by Public Health England concluded that “e-cigarette use is around 95% less harmful than smoking.”

Given this, why not embrace a method of nicotine delivery that can successfully encourage cigarette smokers to actually reduce their use, or even quit altogether?

Why E-Cigarettes Work

Conference attendees highlighted three interesting reasons why e-cigarettes may work better than other forms of nicotine delivery:

1. Drug Use as Ritual
Conference organizer and Influence contributor Helen Redmond works in supportive housing for people with a range of psychiatric diagnoses. “When it comes to drug use,” she said, “ritual is very important. For people who use drugs and particularly for people in some kind of psychological distress, the sensory aspects are really powerful.” Dr. Siegel talked about this sensory aspect as well: E-cigarettes are the first product, he said, “to mimic smoking” in terms of the “oral stimuli, throat-hit, vapor cloud and inhalation,” thereby maintaining smoking associations. Smoking cigarettes is also often “a social activity; vaping mimics this aspect as well, with things like “social support, vaping clubs, and vape fest.”

2. Vaping Is Fun
“Vape fest”? Sounds pretty fun, right? That’s another point for e-cigarettes. Dr. Christopher Russell, Ph.D., a researcher from Scotland, where the attitude toward e-cigarettes is much more receptive than in the US, highlighted this. He said: “People used to think of quitting smoking as a terrible time in your life you have to grit your teeth and get through.” But with vaping, it can be a “hobby.” There are different flavors, ways to experiment with mixing and matching e-cigarette parts and juices and “neat devices.” There’s also “skill formation.” He quoted a vaper who said: “I learned about the different bases and juices. There’s so much knowledge out there and I became a nerd. And it became a hobby.” Julie Woessner, executive director of CASAA (the Consumer Advocates for Smoke-free Alternatives Association), echoed these sentiments. She showed the audience different versions of e-cigarettes that she likes to carry with her: “I love those puppies when I’m traveling—they’re fun,” she said. “The fact that we’re enjoying what we’re doing doesn’t detract from the fact that we are enjoying significant health benefits.”

3. Identity
Smoking cigarettes can become an identity for some people, and with the patch or gum, Dr. Siegel explained, “you’re not really getting a substitute”—there’s not a vibrant community of people who identify as patch-users. Siegel quoted one vaper who illustrated how vaping, in contrast, fills the void: “You know, for years, I loved being able to carry around my pack of cigarettes and my Red Sox lighter. I miss carrying my Red Sox lighter. I still could but it’d be stupid. That’s how you feel about your [vape]; it’s your Red Sox lighter. It becomes who you are.”

The Devil We Know

But like the opioid-replacement treatments methadone and buprenorphine, e-cigarettes and other nicotine “replacement technologies” are still viewed with suspicion in some quarters. Many believe that nicotine users should be pressured to “taper off.”

For example, Dr. Shadi Chamany, Director of Science for the Division of Prevention and Primary Care at the New York City Department of Health and Mental Hygiene, stated at the conference that her department recommends that if people try to quit smoking combustibles by using e-cigarettes, they “set a quit date for e-cigarettes.”

For the most part, public health organizations in the US have promoted the idea that e-cigarettes are an unknown variable. They may be less harmful than combustibles, they may be more harmful, but we just don’t know yet.

Yet to tobacco harm reductionists, it seems like many mainstream public health organizations fan fears of e-cigarettes. For example, in a press release last year, the CDC director, Tom Frieden, MD, MPH said: “We want parents to know that nicotine is dangerous for kids at any age, whether it’s an e-cigarette, hookah, cigarette or cigar. Adolescence is a critical time for brain development. Nicotine exposure at a young age may cause lasting harm to brain development, promote addiction and lead to sustained tobacco use.”

Some health groups go even further. The American Lung Association states its concern about “the potential health consequences of e-cigarettes….Nicotine is not safe.”

Dr. Siegel presented slides of the distorted facts and outright lies against e-cigarettes that he believes many anti-smoking groups propagate. For example, he pointed out, Tobacco-Free UK (University of Kentucky) says: “It [vaping] causes cancer.” Dr. Siegel responded, with exasperation: “They don’t even say that it may cause cancer! There is absolutely no evidence for this.”

The FDA has said: “Studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive.” Again, that is simply not true, said Dr. Siegel. They are conclusively less harmful.

True or not, public health campaigns against e-cigarettes have had an effect. One study showed that in 2010, 84.7 percent of smokers surveyed believed e-cigarettes were less harmful than traditional cigarettes, but by 2013, that number dropped to 65 percent.

Given the power of health organizations to shape public opinion, when Dr. Chamany of the NYC Health department, the only conference contributor representing a “mainstream” health organization, spoke, there was palpable tension. After all, her department was responsible for the very anti-smoking ads that organizer Helen Redmond had earlier criticized as ineffective and insensitive attempts to shame or scare people out of smoking cigarettes.

smoking ad

One of the NYC health department ads criticized by Helen Redmond.

Dr. Chamany addressed this tension head-on: “When Helen told me about this conference,” she said. “I thought it was a good opportunity, not to peddle our wares, but to put the question out of how well is this working…from what I can tell, we’re getting a big F.” The audience agreed.

Yet she drew further disagreement when she said that, according to the health department, e-cigarettes, “while likely safer, are still unregulated.” Members of the audience spoke up: “It’s misleading to say that e-cigarettes are likely safer. They are safer.”

They Can’t Handle the Truth

Dr. Siegel can’t understand what’s going on. Why, he wonders, can’t health organizations “handle the truth” that e-cigarettes are much safer? After giving the matter years of thought—and having once worked at the CDC with the people he now finds himself railing against—he believes that e-cigarettes are a threat to “the status” of anti-smoking groups.

The ultimate reason for their opposition to these products, he believes, may be as simple as: They didn’t think of them first.

“I believe that if someone within tobacco control had invented the idea of the electronic cigarette, it would have been a completely different story,” he elaborated. Instead, “there’s a feeling that if this is something that the [tobacco] industry created and it ends up being a solution to the problem, we can’t accept that.”

Although e-cigarettes didn’t, in fact, come out of the tobacco industry, the industry is now involved in making and profiting from the product—and this is just not acceptable to many in public health.

“Essentially,” Dr. Siegel told me later, “It represents a threat to a lot of these groups because it violates their way of looking at the world. This is not supposed to happen…How could something that looks like smoking possibly be good?”

The CDC seems to prefer the fantasy of “the perfect” at the expense of “the good.” A CDC spokesperson told me that they want to wait until longitudinal studies can be carried out on the effects of e-cigarettes before commenting one way or another on their relative risks. And furthermore, he tells me, e-cigarette companies “have to play by the rules.”

So what are the “rules,” exactly?

FDA’s Rules Expected This Month

In 2014, the FDA’s Center for Tobacco Products first proposed a rule that would extend their authority to regulate e-cigarettes, based on the fact that they contain nicotine, a product which comes from tobacco. But it hasn’t yet been finalized.

In an email to The Influence, FDA spokesman Michael Felberbaum said: “Finalizing the rule to bring additional products under the agency’s tobacco authority is one of our highest priorities, and we look forward to a day in the near future when such products are properly regulated and responsibly marketed.” Industry and advocacy groups reportedly expect the decision this month.

Though e-cigarettes are seen by many to contribute to the FDA’s stated goal of ending smoking-related diseases and deaths, the framework proposed by the FDA would ironically wipe out most independent e-cigarette companies, and hand the remainder of the market over to Big Tobacco.

That’s because the rule would require any e-cigarette products that came on the market after February 15, 2007 (which is to say, almost all of them), to go through Pre-Market Tobacco Applications (PMTA), a process that the FDA itself estimates would take 5000 hours and cost $300,000. The only companies with that kind of capital are Big Tobacco, which presently control about 30% of the e-cigarette market.

Also, one of the provisions of the rule is that you cannot claim that your tobacco product is any safer than any other tobacco product. This provision was originally intended to stop tobacco companies that were advertising certain cigarettes as “light” or “mild.” However, says Siegel, “If [the FDA] applies these regulations, which it seems like they’re going to, it will mean that an e-cigarette company is not allowed to say they are less harmful than cigarettes. And that is counter-productive, because that is keeping from consumers the key piece of information that you need to know.”

If the rule is passed, Siegel says it would be “disastrous” for public health.

Read more from The Influence:

“Streets Covered in Zombies”—What’s Behind New York’s K2 Drug Panic?

Meet the Victims of Russia’s War on Methadone

…and follow us on Facebook and Twitter.

When I asked why e-cigarette companies aren’t trying to follow the path of the FDA approved smoking cessation tools (like the patch and gum), he explained that that process is even more time-consuming and expensive, but also suggested that “part of the key to the success of the [e-cigarette] market is that vaping is not viewed as a medicine or a drug.”

So tobacco harm reduction proponents believe that e-cigarettes require a “unique regulatory framework,” different to that for regular cigarettes and different from the one for medication like the patch.

The outlook for vapers may bleak, but they’re not going out without a fight. On April 19, the House Appropriations Committee passed an amendment which, among other things, would push back the date by which e-cigarette products had to enter the market in order to be exempt from the PMTA process. Instead of 2007, the entry date requirement would be any time before the date on which the FDA issues its final deeming regulations. If the amendment becomes law, it could “save 99 percent of e-cigarette products from prohibition.”

In the midst of this uncertainty, one thing is certain: Vulnerable populations will continue to inhale smoke and die preventable deaths unless anti-smoking groups reckon with the idea that something that looks just like smoking might possibly be a force for good.


Sarah Beller is an associate editor for The Influence. You can follow her on Twitter: @JulesBesch.

 

  • Elizabeth Merchant

    I am 59 years old and have smoked for 47 years. When my health went down hill, I was told I had to quit or die. I tried the “Patch”, the “Pills” and quitting cold turkey but to no avail. Then I found Vaping. I started with a nicotine count of 18 mg,s. I have been Vaping for 10 Months now and am down to just 3 mg.s of nicotine. In a few more months I will stop nicotine all together. I can breath again. I can smell and taste again my health has greatly improved. How can anyone say that this is a bad thing. I just don’t get it. Because of the possibility of these new Regs coming out about vapor liquid, I have started to dabble in making it myself. This is what most of us will do (It’s not hard to make), OR we will go to the Black Markets that will pop up everywhere. I don’t understand why the government has to ruin this for all of us who really need this product. The only thing I can think of is the money. They want their fingers in the profit.

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  • aikanae

    The FDA, CDC, and other public health groups fail to realize just how much their lies underscore their credibility, not just with vaping but in other areas as well. I don’t trust them anymore, on anything. I also question their value to society. That should scare them since most health products and decisions have been based on their questionable advice.

  • LaysMA

    This statement is false, plants within the Solanaceae family including eggplants, tomatoes, and potatoes contain nicotine. — In 2014, the FDA’s Center for Tobacco Products first proposed a rule that would extend their authority to regulate e-cigarettes, based on the fact that they contain nicotine, a product which comes from tobacco.

    • StormFinch

      While it’s true that vegetables in the Nightshade family contain nicotine, (consuming 10 grams of eggplant gets you the same dose of nicotine as being locked up with a smoker for approximately 3 hours) what the author stated was that the FDA based their decision on the fact that the nicotine in e-liquid is extracted from tobacco. Of course, so does the nicotine in every NRT on the market, it comes from the same handful of extraction facilities. The only reason NRTs get a free pass is because they went through drug trials when they first entered the market as prescriptions and are classified as such.

  • Darla McGahan

    Bravo! Thank you for doing your research before writing. E-cigarettes are helping so many get away from cigarettes, and in this there are many that are taking a hit from it, like those companies that make the NRTs. I think you will find big pharma plays a big part in all the negative attitude out there among the ABC health agency’s, doctors and hospitals, CDC and even those in Congress. Big pharma have planted their long tentacles deep into the health profession,health groups, and governments for many many years. The fight against tobacco (cigarettes) has been a big win for them, they cornered the market on smoking cessation, a gift that keeps on giving. They are seeing a profit hit in their bottom line with the onset of e-cigarettes. The health agency’s, groups and governments are turning their backs on joe public by not seeing the safer benefits e-cigarettes present. In the end money is a huge driving force, many stand to loose, the war has been going on so long and many have been getting rich off the tobacco war. E-cigs threaten to cut into this bottom line. Hence we see states wanting to tax the hell out of e-cigs. Is this because they are concerned about health or lost revenue with less people smoking? I believe there is much more to the story than what you see on the surface.

    I’m 58 years old, smoked for 40+ years, at least a pack a day if not more. I quit cigarettes the day I started vaping. I had tried all the conventional smoking cessation products, and some not so conventional methods. Nothing worked, I would end up going back to smoking each and every time. I enjoyed smoking and only because of health issues did I want to quit. Now 3 years 3 months 25 days later I am still smoke free. This is the longest period of time ive gone without touching a cigarette ever. The greatest thing about my journey away from cigarettes is now I have no cravings what so ever, triggered or other wise. The monkey on my back is gone.

    Nicotine for me is no more different than caffeine, I can go for hours with out it, but I still enjoy it. If it were not for e-cigarettes I would have died with a cigarette in my hand, i’m totally convinced of that. I’m just one person of millions with this same kind of story. The vaping community does more to get people to switch than all of what the health agency’s ever have done. They do not get people to quit smoking by scaring them, taxing them, they get people to change by teaching and showing them how e-cigs can work for them. The vaping community is the largest support system I’ve ever seen. The vaping community is not big tobacco like the people against vaping seems to think. Its regular Jane’s and Joe’s from all walks of life coming together with one common cause, to live better, to be healthier, and do away with combustible tobacco harm and to help other people to that same end. We seem to threaten the status quo that has been going on for years and years and excepted.

  • Thank you Sarah Beller with all due respect for an incredibly thorough and accurate explanation of where we are with Electronic Cigarettes that have saved 9 million smokers lives. They the CDC and FDA say that is anecdotal, as though they doubt our existence, they can just wait and see we will show ourselves, if forced to and smokers can join in too, for the unfair unscientific, inhumane treatment of those who desire to continue smoking. I smoked for 43 years, symptoms of ill health became an issue, so 6 years ago, I tried my first Electronic Cigarette. I dual used for a couple of years although 95% vaping 5% still smoking, until I found more advanced mods and better delivery methods. I have been completely smoke-free since August 2013. There is no going back. Smokers and Vapers should form a solid front. We have the right to choose.

  • StormFinch

    Dr. Chamany needs to request a refund on her degree as it doesn’t seem to be functioning properly. Nicotine in patches, gums, lozenges, inhalers, etc. obviously went through medical trials, as all were at one time only available via prescription. The nicotine solution used to make those nicotine replacement products is the exact same one used to make e-liquid. Additionally, the FDA dropped the labeling requirements for a cutoff date, concomitant use and dual use with smoking back in 2013. You simply can’t have it both ways, Dr. Chamany. Either nicotine is not safe and NRTs should be pulled off store shelves and returned to prescription only status, or the nicotine found in e-liquid is safe for use by smokers trying to quit.

    • catlady60

      Why can’t the pharma companies sell their liquid nicotine to e-liquid manufacturers and make their profits that way instead of trying to muscle vapor products off the market?

      • mobile mayhem

        I whole heartedly believe that these people believe the wrong group came up with this whole vaping idea, I believe that they will try to decimate the industry and reinvent the industry on their terms, give political contributions in exchange for regulation changes after they decide to change their stance on vapor if the regulations go down the way they seem to be going I guarantee somewhere down the road we will see our scientifically supportive positive position on vapor products being used by the very people working against us now, vaping will be the future its just that the money humping health institutions of America have to burn the industry to the ground first, then bring it back in an unopposed market seized for their profitability.

      • StormFinch

        Because pharma doesn’t even manufacture their own liquid nicotine.

        Synthetic nicotine has been found to be cost prohibitive and, the last I heard, the best they could manage was industrial grade rather than pharma grade. The nicotine found in patches, gums, inhalers and e-liquid is made from the leavings after the whole tobacco leaves are processed for cigarettes, cigars, etc. Those leftovers are then sent to a lab where the nicotine is extracted and processed.

        On the other hand, if pharma was to create their own e-liquid the markup would probably be so high that no vaper could afford to buy it. Currently Nicorette sells a spray in Canada and England called Quickmist which has the same ingredients as e-liquid plus a handful of extras. There’s 150 sprays or 10.5 mLs to a canister and each ML contains 1 mg of nicotine. To a vaper, that translates to 10.5 mL of 1 mg liquid. Price? $28.95 online plus shipping. You can buy e-liquid without all the other chemicals in a variety of strengths from around $6 for 10 mL.

  • Alan Selk

    The idea of tobacco harm reduction has been around for at least two decades, so the idea that the tobacco control industry is suddenly opposing harm reduction is simply false. The Irony is that it has been Michael Siegel who was among those that opposed it.

    Smokeless tobacco has the same vanishingly low risk we hope vaping has, yet Michael has consistently lied to the public about the relative risk of smokeless tobacco, and still does so today. Now he is standing up claiming the mantle of harm reduction. The hypocrisy is to much for credibility.

  • EKeller

    I find it ironic that the anti-smoking proponents are upset that the tobacco industry has entered the e-cigarette market, yet they are pressing for the FDA’s deeming regulation to be finalized. As the article explained, if the deeming regulation goes through as proposed, the tobacco companies likely would be the ONLY companies left in the market. The anti-smoking proponents claim to hate tobacco companies. So why are they working to give tobacco companies the competitive advantage?

    • Desmond Smith

      Because tobacco companies paid out billions and states/territories took up front money on their settlement in the way of prospective tobacco sales of the future offered by Wall Street. These potential tobacco sales have plummeted with far more people quitting smoking then initially estimated when the deal was struck. This has left most of these states/territories swimming in debt owing most if not all of their settlement to Wall Street. They have to make vaping a tobacco product to make up the loss of revenue to save their bottom line. Part of the deal was that states/territories could not use tax increases to repay the debt to Wall Street and hence we have this all to familiar capitalistic money grab at the expense of the people. Making America great again is the biggest joke going, but America is filled with cattle that believe that they are part of that plan. Unfortunately the only plan is taking them out to slaughter.

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  • Rojeans

    This ladies and gentlemen is what I call a great piece of journalism..Bravo.

  • John Davies

    I love what the the Scotish prof said. I agree that vaping can be fun and as a fellow Brit I have to say Vapfest is one of the high lights of my year. Look for Vapefest UK on Google and come along you will have a ball 🙂