Tobacco harm reduction 101: Difference between revisions
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*SOURCE: FDA grants first-ever modified risk orders to eight smokeless tobacco products. 22 October 2019. | *SOURCE: FDA grants first-ever modified risk orders to eight smokeless tobacco products. 22 October 2019. | ||
=The Evidence on Vaping, Young Americans, & Flavor Bans= | |||
*Is there a youth vaping “epidemic?” | |||
While some media reports have attempted to argue that there is an “epidemic” of youth vaping, these reports are not borne out by the evidence. These reports frequently conflate teenagers trying a puff of a vape at a party versus regularly using these products. Surveys routinely classify someone as a vaper if that person has tried even one puff in a 30-day period, resulting in artificially high response rates. A comprehensive analysis of the National Youth Tobacco Survey (NYTS) in the United States found that “data from the NYTS do not support claims of a new epidemic of nicotine addiction stemming from use of e-cigarettes, nor concerns that declines in youth tobacco addiction stand to be reversed after years of progress.” | |||
*One U.K. survey found that, while 40.5 percent of 15-year-olds reported ever having tried a vape, just 11.3 percent were current vapers (a definition that includes people who vape weekly as well as occasional vapers who vape less than once a week). Habitual vaping (i.e., those who vape weekly or more often) was estimated at just 3.9 percent. Another U.K. survey, which was more detailed and relied on a greater sample size than the aforementioned analysis, found that just 2.2 percent of 18-year-olds were habitual vapers; the figures were lower for younger participants. | |||
*In addition, academic analysis has found that data from the 2018 and 2019 National Youth Tobacco Survey (NYTS) survey “do not provide support for claims of a new epidemic of nicotine addiction stemming from use of e-cigarettes, nor for concerns that declines in youth tobacco addiction stand to be reversed after years of progress.” | |||
*SOURCE: Sarah Jackson, Robert West, Jamie Brown. (2020). Epidemic of youth nicotine addiction? What does the National Youth Tobacco Survey 2017-2019 reveal about high school e-cigarette use in the USA?. | |||
*SOURCE: West R, Brown J, Jarvis M. Epidemic of youth nicotine addiction? What does the National Youth Tobacco Survey reveal about high school e-cigarette use in the USA? (Preprint). Qeios, 2019. | |||
*SOURCE: McNeill A, Brose LS, Calder R, Bauld L, Robson D. (2020). Vaping in England: an evidence update including mental health and pregnancy, March 2020: a report commissioned by Public Health England. London: Public Health England, p. 40. | |||
=Does vaping lead to young people taking up the smoking of conventional cigarettes?= | |||
*Vaping has almost exclusively been taken up by smokers attempting to quit or lower their intake. As a result of the introduction of vaping products, smoking rates in the US have plummeted in recent years. In 2018, 13.7 percent of US adults smoked, a sharp decline from 20.9 percent in 2005. Most of this decline has occurred since the introduction of e-cigarettes, as smokers now have more options than ever to kick their deadly habit. Particularly promising, only 5.8 percent of high school students smoke, down from more than 15 percent in 2011. | |||
*A systematic review of all available evidence has shown that there is NO evidence that vaping serves to introduce young Americans to smoking. Only a miniscule 0.3 percent of adult vapers are people who have never smoked and almost all teens who use nicotine vapes had previously tried at least one cigarette. Similarly, fewer than 1 percent of US adolescents who have tried an e-cigarette went on to became established cigarette smokers. And, adolescent initiation with e-cigarettes has been found to be associated with a reduced risk of subsequent cigarette smoking. This suggests that, “e-cigarettes were unlikely to have acted as a gateway towards cigarette smoking and may, in fact, have acted as a gateway away from smoking for vulnerable adolescents.” In addition, other studies have found that any and all apparent relationships between e-cigarette use and current conventional smoking is “fully explained by shared risk factors.” | |||
*In fact, the only and main study which ever showed vaping associated with an increase in smoking rates recently admitted this was caused by an error and retracted the finding. | |||
*SOURCE: McNeill A, Brose LS, Calder R, Hitchman SC, Hajek P, McRobbie H. E-cigarettes: an evidence update. A report commissioned by Public Health England. PHE publications gateway number: 2015260 2015. | |||
*SOURCE: Britton J, Bogdanovica I, McNeill A, Bauld L. Commentary on WHO report on electronic nicotine delivery systems and electronic non-nicotine delivery systems. UK Centre for Tobacco and Alcohol Studies. 2016. | |||
*SOURCE: Centers for Disease Control and Prevention, Current Cigarette Smoking Among Adults in the United States. 2018. | |||
*SOURCE: Hallingberg B, Maynard OM, Bauld L, et al. Have e-cigarettes renormalised or displaced youth smoking? Results of a segmented regression analysis of repeated cross sectional survey data in England, Scotland and Wales. Tobacco Control. 2020; 29:207-216. | |||
*SOURCE: Jarvis M, West R, Brown J. Epidemic of youth nicotine addiction? What does the National Youth Tobacco Survey reveal about high school e-cigarette use in the USA? Qeios, 2019. | |||
*SOURCE: Levy DT, Warner KE, Cummings KM, Hammond D, Kuo C, Fong GT, Thrasher JF, Goniewicz ML, Borland R. Examining the relationship of vaping to smoking initiation among US youth and young adults: a reality check. Tobacco Control. 2018; 20 p. 20. | |||
*SOURCE: Kim S, Selya AS. The Relationship Between Electronic Cigarette Use and Conventional Cigarette Smoking Is Largely Attributable to Shared Risk Factors. Nicotine and Tobacco Research. 2020; 22(7):1123-1130. | |||
*SOURCE: Shahab L, Beard E, Brown J. Association of initial e-cigarette and other tobacco product use with subsequent cigarette smoking in adolescents: a cross-sectional, matched control study. Tobacco Control. Published Online First: 17 March 2020. | |||
*SOURCE: Zhu S. E-cigarette use and associated changes in population smoking cessation. BMJ. 2017. | |||
*SOURCE: ASH. Use of electronic cigarettes (vapourisers) among adults in Great Britain. Fact sheet. May 2017. | |||
*SOURCE: Polosa R. A critique of the U.S. SG’s conclusions regarding e-cig use among youth and young adults in US. Harm Reduction Journal. 2017. | |||
*SOURCE: Smoking Toolkit Study. Trends in e-cigarette use in England, July 2017. | |||
*SOURCE: O’Leary R, MacDonald M, Stockwell T, Reist D. Clearing the Air: A systematic review on the harms and benefits of e-cigarettes and vapour devices. University of Victoria, BC: Centre for Addictions Research of BC. 2017. | |||
*SOURCE: Prevalence of vaping and smoking among adolescents in Canada, England, and the United States: repeat national cross sectional surveys. BMJ. 20 June 2019. | |||
=Do flavors induce adolescents to start vaping?= | |||
*A key argument behind banning the sale of flavored vapes is that these products are designed to hook teenagers. This, however, is not supported by the evidence. While the evidence shows that flavors encourage adult smokers to make the switch to vaping, these products have no effect on teen use. | |||
*A 2015 survey of nonsmoking teens aged 13-17 found interest levels in flavored e-cigarettes at 0.4 out of a possible score of 10. Additionally, fewer than a third of high school students self-report to care about flavors. Academic studies have found that teenage non-smokers’ “willingness to try plain versus flavored varieties did not differ” and a mere 5 percent of vapers aged 14-23 reported it was the different flavors that attracted them to e-cigarettes. | |||
*SOURCE: Friedman AS, Xu S. Associations of Flavored e-Cigarette Uptake With Subsequent Smoking Initiation and Cessation. JAMA Network Open. 2020; 3(6):e203826. | |||
*SOURCE: Czoli CD, Goniewicz M, Islam T, Kotnowski K, Hammond D. Consumer preferences for electronic cigarettes: results from a discrete choice experiment. Tobacco Control. 2016; 25(e1):e30-e36. | |||
*SOURCE: Wood GG, Waselewski ME, Bryant AC, Sonneville KR, Chang T. Youth Perceptions of Juul in the United States. JAMA Pediatrics. 2020; 174(8):800–802. | |||
=What would be the effect of banning flavors?= | |||
*Multiple studies have shown that banning all flavors in e-cigarettes (except tobacco flavor) would result in a decline in the use of e-cigarettes and an increase in the smoking of deadly combustible cigarettes. This deadly shift would occur because flavors “contribute to both perceived pleasure and the effort to reduce cigarette consumption or quit smoking.” One such study found a simple ban on all flavors but tobacco in e-cigarettes would increase smoking by 8.3 percent. | |||
*In the U.K., Public Health England canvassed a number of vaper surveys and found that “banning flavored liquids would deter them [vapers] from using vaping products to help them quit or reduce their smoking. It could also push current vapers towards illicit products.” Public Health England therefore concluded that, “a ban on flavored liquids could have adverse effects and unintended consequences for smokers using vaping products to quit.” Concerningly, one nationwide British survey from 2019 found that if a vaping flavor ban were enacted, then 25 percent of vapers would still try to get flavors through the black market. Nearly 10 percent who use flavored liquids said they would stop vaping, and 20 percent said that they would either smoke more tobacco or return to smoking tobacco entirely. | |||
*In fact, adults who used flavored e-cigarette products have been found to be more than twice as likely to quit smoking combustible cigarettes than adults using non-flavored vaping products. | |||
*SOURCE: McNeill A, Brose LS, Calder R, Bauld L, Robson D. (2020). Vaping in England: an evidence update including mental health and pregnancy, March 2020: a report commissioned by Public Health England. London: Public Health England, p. 13. | |||
*SOURCE: Buckell J, Marti J, Sindelar JL. Should flavours be banned in cigarettes and e-cigarettes? Evidence on adult smokers and recent quitters from a discrete choice experiment. Tobacco Control. 2019; 28: 168-175. | |||
*SOURCE: Farsalinos KE, et al. Impact of Flavour Variability on Electronic Cigarette Use Experience: An Internet Survey. International Journal of Environmental Research and Public Health. 10 December 2013; 7272–82. | |||
*SOURCE: Friedman AS, Xu S. Associations of Flavored e-Cigarette Uptake With Subsequent Smoking Initiation and Cessation. JAMA Network Open. 2020; 3(6):e203826. | |||
=What about vulnerable populations?= | |||
*Smoking disproportionately affects those most in need, such as the indigent, racial minorities, LGBTQ persons, and those suffering from mental illness and substance use disorders. | |||
*In particular, smoking is the leading cause of the poor health of persons suffering from mental illness, who are more likely to smoke and smoke more heavily than other smokers. Vaping is critical to assist these vulnerable populations in quitting their deadly habit. E-cigarettes have been found to be particularly successful for persons suffering from mental health problems; far more so than any other form of quitting aid, including pharmaceutical products such as varenicline and bupropion, or other nicotine replacement therapies. | |||
*SOURCE: Tobacco use among U.S. racial/ethnic minority groups—African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, Hispanics. A Report of the Surgeon General. Executive summary. MMWR Recomm Rep. 1998; 47(RR-18). | |||
*SOURCE: Levinson AH, Hood N, Mahajan R, Russ R. Smoking cessation treatment preferences, intentions, and behaviors among a large sample of Colorado gay, lesbian, bisexual, and transgendered smokers. Nicotine and Tobacco Research. Aug 2012; 14(8):910-918. | |||
*SOURCE: Brose LS, Brown J, McNeill A. Mental health and smoking cessation—a population survey in England. BMC Medicine. 2020; 18, 161. | |||
*SOURCE: Royal Australian and New Zealand College of Psychiatrists, Inquiry into the use and marketing of electronic cigarettes and personal vaporisers in Australia. March 2018. | |||
=How Should Reduced Risk Products be Taxed & Regulated?= | |||
=How should vaping be regulated?= | |||
*E-cigarette sales should be regulated and safety standards must be ensured by enforcing strict product guidelines on battery development, ingredients, and other associated technologies, in the same manner as other consumer goods. All ingredients contained in their vapor products and, in particular, the ingredients contained in any e-liquid In additions should similarly be listed by manufacturers. In addition, regulations should ensure underage persons are unable to access these products, and these must be enforced to ensure high levels of compliance. However, regulations prohibiting advertising ought to be treated with a great degree of caution so as not to prevent smokers receiving accurate information about the health benefits of making the switch to these life-saving reduced-risk products. | |||
=What is the impact of taxes on vaping and smoking rates?= | |||
*To tax safer products at a higher rate than deadlier ones goes against every principle of sound public or health policy. In addition, these regressive taxation policies ensure that the poorest members of society are the hardest hit. As stated earlier, poorer individuals are disproportionately likely to be addicted to tobacco products and stand to lose the most through the penalization of reduced-risk alternatives. | |||
*As the price of a product increases, it is likely that its use decreases. The same occurs with taxes on vaping, which have been proven to increase smoking rates as people shift back to deadly combustible cigarettes. According to a study released in December 2020 and posted by the National Bureau of Economic Research, taxing e-cigarettes at the same rate as cigarettes would boost traditional cigarette smoking by about 8 percent, and deter some 2.75 million smokers from quitting. | |||
*Another study funded by the National Institutes of Health determined that a 10 percent increase in e-cigarette prices results in traditional cigarette sales increasing by 11 percent. Extrapolating from here, a national e-cigarette tax of $1.65 per milliliter of vaping liquid would increase the proportion of adults who smoke cigarettes daily by approximately 1 percent, translating to 2.5 million more adult daily smokers. Overall, the sale of cigarette packets would increase by a staggering 291,820,000 nationally. | |||
*Similar results were found in Europe, where an analysis of e-cigarette prices in six countries found that a 10% increase in price reduces e-cigarette sales by 11.5% in the longer term. | |||
*SOURCE: Saffer H, Dench D, Grossman M, et al. E-cigarettes and adult smoking: Evidence from Minnesota. Journal of Risk and Uncertainty. 2020. | |||
*SOURCE: Pesko MF, Courtemanche CJ, Maclean JC. The effects of traditional cigarette and e-cigarette tax rates on adult tobacco product use. Journal of Risk and Uncertainty. 2020. | |||
*SOURCE: Stoklosa M, Drope J, Chaloupka FJ. Prices and E-Cigarette Demand: Evidence From the European Union. Nicotine Tob Res. 2016 Oct;18(10):1973-1980 | |||
=Do taxes on vaping reduce youth vaping rates?= | |||
*While evidence is still preliminary, given the relative recent imposition of vaping taxes, states such as Pennsylvania, which imposed a 40 percent vaping tax, have reported no impact on youth vaping rates – to the contrary youth vaping increased in the followinng year. This is highly suggestive that these taxes prevent smokers from switching to vaping but do not prevent youth use—the exact opposite of the intended policy outcome. | |||
*SOURCE: 2019 Pennsylvania Youth Survey Empowering Communities to Develop Strategic Prevention Programming. | |||
*SOURCE: Stroud, L. | |||
=What about revenue lost from tobacco taxes as people make the switch?= | |||
*It is grossly unethical to argue that persons should continue to smoke – and die – just so that governments can continue to receive revenue from tobacco excise. Such an argument should be dismissed out-of-hand and not be taken seriously. | |||
*However, it is worth noting that persons making the switch to vaping will, in fact, save the government money through reduced health care expenditures. Estimates suggest that Medicaid savings will be $2.8 billion annually if just one percent of enrollees switch from smoking to vaping. Similarly, tobacco use costs the military $1.6 billion annually, and savings from this could be utilized to offset the cost of tobacco tax revenues falling. | |||
*SOURCE: Belzer, RB. Expected savings to Medicaid from substituting electronic for tobacco cigarettes. R Street Institute. 2017. | |||
*SOURCE: Pentagon aims to curb tobacco use by military: memo. Reuters, 26 April 2016. | |||
=Why is it important that reduced risk products devices can be ordered online and delivered via mail?= | |||
*Given the clear public health benefits for persons transitioning from traditional cigarettes to reduced-risk products, it is imperative that they be as widely available and easy to access as possible. Unfortunately, many Americans live significant distances from distributors. This is particularly acute in areas outside of major cities, an issue even more pressing due to higher incidence of smoking in remote areas. For many individuals wishing to quit smoking by way of reduced-risk products, purchasing online and obtaining them via mail is the only method available. By prohibiting online sales, these people will have no choice other than return to easily obtainable deadly combustible cigarettes, or to purchase e-cigarettes and other alternatives through dangerous black market suppliers. Therefore, while strict enforcement measures to ensure, for example, age verification, are necessary, prohibition on online sales will doubtless lead to an increase in easily avoidable deaths from tobacco-related illnesses. | |||