The Center for Tobacco Control Research and Education at UCSF is Not Sure Smoking is Any More Hazardous than Vaping

I recently read an article written by the director of the Center for Tobacco Control Research and Education at UCSF. What struck me most was the article's answer to the question "Is vaping safer than smoking?" The answer given was: "We don't know for sure."

OK, I realize that many years ago there was not a lot of research on the health effects of vaping and it had only been around for a short period of time, so perhaps we didn't know for sure that vaping was any safer than smoking. That was in 2008 - a full 16 years ago. Before criticizing the article, I thought I should check the date. Perhaps this was an old article that simply was not taken down from the web site and there was no reason to make a big deal out of this.

The Rest of the Story

It turns out that the article was published on December 18, 2024 -- three days ago!

So you're telling me that in late 2024, the tobacco control center at UCSF is still not sure that smoking is any more hazardous than vaping? 

Even the tobacco industry doesn't claim that smoking is no more hazardous than vaping. In fact, unlike UCSF's tobacco control center, the tobacco industry readily admits that smoking is far more hazardous to your health than vaping. 

There are numerous clinical studies demonstrating that vaping is much safer than smoking, both in terms of respiratory health and cancer risk. We know, for example, that switching from smoking to vaping results in a reduction in respiratory symptoms as well as measurable improvements in lung function. We also know that people who vape rather than smoke have substantially lower levels of carcinogen biomarkers. 

So in 2024, to claim that we don't know if smoking is any more hazardous than vaping is not only absurdly wrong, it is also terribly irresponsible. If a doctor were to tell her patient that there's really no difference between vaping and smoking as we're not sure that smoking is actually any more hazardous than vaping, that would represent medical malpractice in my opinion. Even Dr. Stanton Glantz - the prestigious founder of the tobacco control center at UCSF - has no hesitation in acknowledging that smoking is more hazardous than just vaping (not counting dual use here). I'm not going to go into the voluminous data demonstrating that vaping is much safer than smoking, as I actually did that about 15 years ago. And the evidence has only become stronger and stronger since then.

In my view, then, making a public claim in 2024 that smoking may be no more hazardous than vaping represents what I guess we should call public health malpractice.

There's More to the Story

If that were the only false claim made in the article, it would be enough. But it doesn't end there.

The article goes on to claim that: "popular vapes can easily have the nicotine content of three cartons or 600 cigarettes."

So let's examine this claim:

The highest concentration of nicotine in any e-liquid that I'm aware of that is typically used is 50 mg/mL. Typically, a cartridge contains 0.5mL or 1.0mL. To be conservative, let's use 1.0mL. Thus, the highest nicotine content in a vape cartridge is 50mg. 

OK, what about a cigarette? The average nicotine content of a cigarette is 12-15mg. Again being conservative, let's go with 12mg.

So a single vape cartridge has 50mg of nicotine and a single cigarette has 12mg of nicotine. This means that a vape cartridge has the nicotine content of about 4 cigarettes.

So the claim that a vape cart has the same nicotine content as 600 cigarettes is off by a factor of 150!

Now, let's give the writer of this article the benefit of the doubt and assume they meant to be comparing the nicotine yield of a vape cartridge with the nicotine yield of cigarettes. This is quite a benefit since the statement clearly says "nicotine content".

Nevertheless, the highest average measured yield of a Juul-like (pod-like) vape device, standardized across multiple studies, is 2.83mg per 15 puffs. Let's assume you can get 150 puffs out of a 1mL cartridge. So the nicotine yield of a vape cartridge, conservatively, is 28mg. A cigarette delivers approximately 1mg of nicotine. So even if we make the comparison based on nicotine yield, a single vape delivers the equivalent amount of nicotine as 28 cigarettes. Not 600. The estimate in this article is only off by a factor of 21!     

Finally, let's just make the assumption that the full 50mg of nicotine in a 50mg/mL cartridge is delivered. The nicotine delivery of a cigarette is approximately 1mg. So at the very highest, a vape cartridge could deliver the nicotine equivalent of 50 cigarettes. The claim of 600 cigarettes is still off by an order of magnitude!

There's Even More to the Story

If only it ended there. The article goes on to claim that: "Teens who vape are 3 to 5 times more likely to start smoking cigarettes than their peers."

I have already explained why this is not true. Briefly, in 2011, smoking prevalence among high school students was 15.7%, while the prevalence of vaping was just 1.4%. By 2022, the prevalence of vaping among high school students had skyrocketed up to 14.1%, yet smoking among high school students dropped to just 2.0%. And by 2024, smoking prevalence among high school students was only 1.7%.

These data definitively refute the contention that e-cigarettes are a gateway to smoking among youth and are completely inconsistent with the claim that e-cigarette use leads to a 3-5-fold increase in youth smoking initiation rates.

The reason why all of these false claims are important is because they could well deter many smokers from trying to quit smoking using e-cigarettes and therefore, block a major pathway by which millions of smokers have successfully quit smoking completely. The author of the article herself has published data showing that perceptions of the harms of e-cigarettes are related to decreased success in smoking cessation. 

I'm not concerned about the false claims in this article merely because they are providing misinformation. I'm concerned because they may actually cause population health harm by deterring smoking cessation. After all, if we don't know that smoking is any more hazardous than vaping, then what is the rationale for switching from smoking to vaping? There is abundant evidence that the mistaken belief that smoking may be as harmful as vaping is a strong deterrent to smoking cessation on a population level. Why is this something the tobacco control center at UCSF would want to contribute to?

National Academies Report on Effects of Moderate Drinking is a Death Knell for Recommending Moderate Alcohol Consumption

The viability of recommending moderate alcohol consumption as a step to reduce all-cause mortality was given a death blow yesterday by the release of a report by a National Academy of Sciences expert panel which concluded that low-dose (moderate) drinking increases the risk of breast cancer and may increase the risk of colon cancer as well.

The long-awaited report concluded that although moderate drinking appears to reduce all-cause mortality, primarily through a reduction in cardiovascular disease, it also increases breast cancer risk and there is some evidence that it increases colon cancer risk as well. The panel concluded that there was moderately strong evidence that low levels of alcohol consumption increase breast cancer risk and some evidence, although not strong, that low levels of alcohol consumption increase colon cancer.

A major purpose of the report is to inform the next Dietary Guidelines for Americans. The alcohol industry has a vested interest in the Dietary Guidelines including a recommendation of moderate drinking as part of a healthy diet. They funded an ill-fated clinical trial of the health effects of moderate drinking which was halted by NIH after an investigation revealed impropriety in the NIAAA's solicitation of funding directly from the industry, which violates NIH policy.

The Rest of the Story

This report is a death knell for the alcohol industry’s hopes of ever having moderate drinking recommended as part of a health diet. The report concluded that moderate drinking increases the risk of breast cancer and may also increase the risk of colon cancer. Even though the report suggests that moderate drinking may lower all-cause mortality, there is no way that physicians—or any public health body—can issue a recommendation for healthy people to take an action that knowingly increases their risk of cancer, which could be fatal. 

A key principle of medicine is “to do no harm.” We do not recommend preventive measures that significantly increase the risk of one disease in order to prevent another disease. We cannot knowingly recommend that people consume a known, strong carcinogen as a method to reduce their risk of cardiovascular disease. There are other safe, effective, and proven ways to reduce cardiovascular risk without increasing your risk of cancer.

Recommending moderate alcohol consumption to reduce cardiovascular disease, in light of the findings of this report, would be unethical. 

Imagine walking into a doctor's office and asking your doctor for recommendations about how to decrease your risk of cardiovascular disease. And the doctor says: "Boy have I got the carcinogen for you. Take this carcinogen once or twice a day, depending on your sex, and your cardiovascular risk will go down." 

But this is precisely what would be happening if a physician--or a public health body such as the National Dietary Guidelines--recommended moderate alcohol use to reduce cardiovascular disease risk. 

The only time when we can recommend that people take a medication or product that is effective in treating a disease but may have side effects by increasing the risk of another disease is when the patient already has the disease. And in those circumstances, the FDA is very careful about weighing the risk levels, the alternative treatments available, and the severity of the disease. We absolutely cannot recommend that healthy people take a medication or product that is effective in preventing a disease but increases the risk of another disease. In other words, medication or product side effects can potentially be tolerated for medical treatment. But they are unacceptable in medical prevention. The reason is that with prevention, the patient is healthy and to expose them to a higher risk of cancer would be doing harm. This violates a central tenet of medicine and public health.

Knowing that this report concludes that the link between moderate drinking and a potentially fatal cancer is real, there is no way that any public health body can possibly recommend moderate drinking as part of a dietary guideline. Given the findings of this report, doing so would be a serious breach of medicine and public health ethics.

Misinformation By Parents Against Vaping E-Cigarettes Appears to Be Part of a Longer-Term Campaign of Deception

Yesterday, I reported that Parents Against Vaping E-Cigarettes (PAVE) is essentially lying on its website about the prevalence of daily e-cigarette use among youth. The site claims that "More than 1 in 4 youth use e-cigarettes daily." Using data from the 2024 National Youth Tobacco Survey (NYTS), I showed that the actual proportion of youth who use e-cigarettes daily is 1.6%, meaning that PAVE is exaggerating this statistic by a factor of 16.

I had assumed that this was just a one-time error and that PAVE was just misreporting data from the 2024 National Youth Tobacco Survey.

But how wrong I was.

The Rest of the Story

With the use of the Wayback Machine, I was able to find that PAVE made the identical fallacious claim nearly one year ago that it stated was based on the results of the 2023 National Youth Tobacco Survey. Their web site on February 11, 2024 stated: "More than 1 in 4 youth use e-cigarettes daily" and attributed this to the 2023 NYTS.

So it appears that this deception has now been going on through two cycles of the release of the NYTS. 

Unfortunately, this misinformation seems to be spreading rapidly, probably from PAVE to other organizations and even supposedly reputable health agencies. The PAVE misinformation appears to have first appeared on or around February 11, 2024. On March 1, 2024, the New Haven Health Department included this fallacious claim in a letter to the city council. The letter stated: "Nationally, more than 1 in 4 youth use e-cigarettes daily and almost 9 out of 10 use flavored e-cigarettes." The fact that the second claim follows the first on the PAVE website suggests that this may be where the New Haven Health Department obtained this erroneous information.

Beacon Mental Health appears to have picked up the claim shortly before November 7, 2024, and used it to promote a conference on vaping and youth that it was cosponsoring with the North Kansas City Hospital. In promoting this November 7 event, they asked: "Did you know that nationally, more than 1 in 4 youth use e-cigarettes daily?"

The Wilson Area School District (Easton, PA) picked up the same claim: "Teen vaping has become a serious health issue in the United States. According to the annual National Youth Tobacco Survey,  more than 1 in 4 youth use e-cigarettes daily and almost 9 out of 10 use flavored e-cigarettes."

The same claim was picked up by the Johnson County (KS) government: "More than 1 in 4 youth use e-cigarettes daily." This was almost certainly derived from PAVE, as they appear to have copied it directly from PAVE's web site.

This story shows how misinformation can spread rapidly over the internet and eventually come to dominate public "knowledge." This is why it is so important for public health organizations like PAVE to be honest and accurate in their communications.

Why Does Parents Against Vaping E-Cigarettes (PAVE) Have to Lie in Order to Scare Parents?

If I seriously thought that one-fourth of today's youth were vaping e-cigarettes daily, I would be quite alarmed. Daily use suggests possible addiction and so if 25% of all youth were vaping daily, we would be talking about 6.25 million middle-school and high-school students who are vaping every day. Moreover, the overwhelming majority of every day youth e-cigarette users are not just vaping nicotine, but they are also using THC vapes, mostly off the black market. So if this statistic were true, it would drastically change my assessment of the relative benefits of electronic cigarettes for adult smoking cessation compared to the risks for youth vaping and addiction.

Well, according to Parents Against Vaping E-Cigarettes (PAVE), this very statistic is in fact true! According to PAVE: "More than 1 in 4 youth use e-cigarettes daily." So it's actually more than 25% of youth who are daily e-cigarette users. This means there are well over 6 million youth daily vapers. Even worse, only 3.2% of adults vape daily, so the proportion of youth who vape daily is 8 times higher than the proportion of adults who vape daily. Perhaps even more alarming, this means that for 2 adult vapers, there is one youth daily vaper.

The Rest of the Story

There's only one problem with this statistic from PAVE ...

...

...

... It isn't true!

According to data from the 2024 National Youth Tobacco Survey, the proportion of youth who use e-cigarettes daily is not 25%, it is 1.6%. So PAVE is off by a factor of 16. Another way of saying this is that PAVE has inflated the proportion of youth who use e-cigarettes daily by 16 times its actual value in an apparent effort to create quite a scare among parents and the public at large.

Compare PAVE's "facts" with those of the FDA:

PAVE - More than 25% of youth use e-cigarettes daily.

FDA - Only 1.6% of youth use e-cigarettes daily. 

So how does PAVE get this 25% number? Well, you might call it sleight-of-hand. It turns out that of youth e-cigarette users, more than 25% are daily users (26.3%). However, only 5.9% of youth are e-cigarette users, so the proportion of youth who are daily e-cigarettes users is 26.3% times 5.9%, which is 1.6%.

The truth is that PAVE is not telling the truth when they claim that more than 1 in 4 youth use e-cigarettes daily. The truth is that 1 in 62 youth use e-cigarettes daily.

So why lie? 

Possibly it's because 1 in 4 youth sounds way more alarming than 1 in 62 youth. Somehow 1 in 62 youth doesn't quite have the same kick as 1 in 4. 

But why the need to lie in the first place? Possibly it's because the youth e-cigarette craze has subsided somewhat and the truthful statistics just aren't alarming enough to make youth vaping the kind of catastrophic problem that PAVE would like to promote it as.

The problem is that truth, honesty, and transparency are three important core values of public health. We do not misrepresent statistics in order to scare people. We do not provide false statistics to the public in order to increase public concern about public health problems. In other words, the ends of getting the public to take action do not justify the means of lying to or deceiving the public.

Obsession with Youth Vaping Has Made Us Lose Sight of Far More Serious Threats to the Health of Adolescents and Young Adults

While public health agencies and anti-tobacco groups have made youth vaping nearly the sole focus of their adolescent health agendas over the past decade, far more serious substance abuse threats to the health of teens and young adults are escaping attention and wreaking greater havoc on the current generation of young people. 

For example, a new article just published in the American Journal of Medicine reveals that over the past two decades, the death rate from alcohol in the United States has doubled. The largest increase in the death rate from alcohol was among young people ages 25-34, among whom the rate nearly quadrupled.

According to a press release accompanying the article: "Results of the clinical research study, published in the American Journal of Medicine, reveal that alcohol-related deaths in the U.S. have surged dramatically in the last two decades, with the mortality rate nearly doubling from 10.7 per 100,000 in 1999 to 21.6 per 100,000 in 2020. The total number of alcohol-related deaths soared from 19,356 to 48,870, a dramatic twofold increase. Every age group has suffered increases, with the most alarming spike – nearly fourfold – in those aged 25 to 34.

According to data from Dr. Charles Gardner, approximately 4,000 teenagers die every year from alcohol (due primarily to binge drinking, motor vehicle crashes, and other injuries). Another 1,900 die from opiate overdose (due primarily to fentanyl). According to CDC, there were another 2,200 teenage deaths in 2022 from suicide. Thus, the combination of alcohol, opiates, and suicide are resulting in the deaths of approximately 8,000 teenagers each year. 

In contrast, the number of teen deaths from electronic cigarettes during the past two years is approximately 0.

Even if one includes the deaths that did occur due to vaping during the so-called EVALI outbreak, 0 of those deaths were due to e-cigarette use. They were due to the use of illicit THC vape carts.

The Rest of the Story

While many anti-tobacco groups lament the near disappearance of cigarette smoking due to the vaping fad among teens and would have us believe that vaping is an epidemic every bit as devastating as smoking, I believe that these groups have contributed to an obsession with youth vaping that has overshadowed more serious threats to adolescent health and allowed these threats to blossom unchecked because of the diversion in our focus. 

Because of these misplaced priorities, health agencies instructed youth not to use e-cigarettes during EVALI, rather than to avoid buying THC vape carts off the black market. Because of these misplaced priorities, public officials have banned flavored e-cigarettes, and in some places the sale of all e-cigarettes, while leaving the sale of flavored real cigarettes unchecked. Because of these misplaced priorities, the FDA has devastated the e-cigarette market, while leaving the deadly cigarette market completely unchecked. Because of these misplaced priorities, schools are using video surveillance to make sure no one is vaping in the bathroom, while letting kids use alcohol to their hearts content and while an opioid overdose epidemic rages. 

Don't get me wrong. I'm not saying that youth vaping is not a problem that needs to be addressed. But I think it needs be be addressed in a more reasonable (and more effective) way, as part of a more holistic approach to adolescent health that prioritizes the substances and behaviors that are the greatest threats to the lives of our children.

New Article in American Journal of Medicine Claims that Youths Who Use E-Cigarettes are 5 Times More Likely to Become Cigarette Smokers

I've only been back at this for one day and the very first new article that I came across makes the preposterous claim that use of e-cigarettes increases by 5-fold the initiation of cigarette smoking among youth. The article, published as a commentary in the American Journal of Medicine, states as follows: "E-cigarette use by adolescents increases by up to 5-fold their initiation of tobacco cigarette smoking."

The Rest of the Story

It is difficult to believe that anyone could look at the actual data on the prevalence of youth cigarette smoking in 2024 and make the claim that vaping by youth leads to a 5-fold increase in smoking initiation. If that were true, then given the tremendous rise in vaping that we have observed over the past decade, one would certainly expect to see that translate into a substantial increase in the prevalence of youth smoking. As I pointed out yesterday, an analysis by Dr. Brad Rodu demonstrated that in 2011, smoking prevalence among high school students was 15.7%, while the prevalence of vaping was just 1.4%. By 2022, the prevalence of vaping among high school students had skyrocketed up to 14.1%, yet smoking among high school students dropped to just 2.0%. And by 2024, smoking prevalence among high school students was only 1.7%.

These data definitively refute the contention that e-cigarettes are a gateway to smoking among youth and are completely inconsistent with the claim that e-cigarette use leads to a 5-fold increase in youth smoking initiation rates. 

Interestingly, the article in question fails to provide any citation or source for its preposterous claim that vaping is greatly accelerating the initiation of smoking by youth. Apparently, we are supposed to just take it on faith that this is true.

The article also makes two additional assertions that are hard for me to believe are still being made in 2024. 

First, the article claims that: "At least 4.5% of adults, 10% of high school students, and 4.6% of middle school students now use tobacco e-cigarettes." The problem with this statement is that there are no such things as "tobacco e-cigarettes." By definition and by intention, electronic cigarettes do not contain any tobacco. That is the entire point! If an e-cigarette did contain tobacco then I would not consider it to be an e-cigarette; it would be a heated tobacco product. Even the American Cancer Society admits that e-cigarettes do not contain tobacco. 

It has now been 17 years since e-cigarettes were first introduced in the United States. One would have thought that by now, smoking cessation experts of all people would appreciate the fact that the unique selling proposition for e-cigarettes is that they do not contain tobacco.

Second, the article claims that: "Nonetheless, in one trial, up to 80% of those who ceased tobacco cigarette smoking for 12 months with e-cigarettes continued to smoke e-cigarettes." This is apparently news to the authors of this commentary but you do not smoke an e-cigarette. You vape an e-cigarette. This is why e-cigarette use is referred to as vaping rather than smoking. E-cigarettes do not produce any smoke because they involve no combustion. Again, that is the entire point!  

It has now been 17 years since e-cigarettes were first introduced in the United States. One would have thought that by now, smoking cessation experts of all people would appreciate the fact that the unique selling proposition for e-cigarettes is that they do not involve any combustion and therefore do not produce any smoke; hence, you cannot smoke an e-cigarette. 

The question arises, then, whether the authors of this commentary are really so uninformed about the nature of e-cigarettes that they simply are not aware that these products do not contain tobacco and do not involve combustion, or whether they are intentionally using smoking-related terminology to create the impression that vaping and smoking are essentially equivalent.

American Heart Association and American Cancer Society are Still Spreading Misinformation about Vaping

After the start of the COVID-19 pandemic, I took an almost complete break from blogging about tobacco policy to concentrate on some other public health topics. Now that more than 4 years have passed, I decided to take a look at the websites of some of the major national health organizations to see whether they have started to accurately communicate the facts about vaping and smoking. I figured that during the past 4 years there has been so much definitive science about the relative risks of vaping and smoking, the cause of EVALI, the question of whether youth vaping is a gateway to smoking, and the effectiveness of vaping in helping smokers quit that the major anti-tobacco groups would by now be communicating accurately to the public. I also figured that with all the public attention being given to misinformation, these groups would certainly be a lot more careful about the validity of the public claims they were making.

I start today by reviewing recent "fact" sheets from the American Heart Association and the American Cancer Society.

American Heart Association

In a 2024 article entitled "Is Vaping Better than Smoking," the American Heart Association makes the following claims:

1. "E-cigarette promoters claim the devices can help people quit smoking. But much more evidence is needed to determine if they are an effective way to quit. Research suggests that users are more likely to continue smoking along with vaping, which is referred to as dual use."

2. "Many people think vaping is less harmful than smoking. While it’s true that e-cigarette aerosol doesn’t include all the contaminants in tobacco smoke, it still isn’t safe."

3. "E-cigarettes have been linked to thousands of cases of serious lung injury, some resulting in death. While the exact cause is still not confirmed, the CDC recommends that people not use e-cigarettes."

4. "E-cigarettes’ biggest threat to public health may be this: The increasing popularity of vaping may “re-normalize” smoking, which has declined for years. Reversing the hard-won gains in the global effort to curb smoking would be catastrophic."

American Cancer Society

In a November 7, 2024 article on the risks of vaping and smoking, the American Cancer Society makes the following claims:

1. "Misconception: Many people believe vaping doesn’t carry the same health risks as cigarette smoking because e-cigarettes do not contain tobacco."

2. "Misconception: Some people also think vaping is safer than smoking because they believe the vapor from e-cigarettes does not contain the same harmful chemicals as smoke."

The Rest of the Story

Let's analyze each of the above claims. Below are the claims followed by the actual facts.

American Heart Association

In a 2024 article entitled "Is Vaping Better than Smoking," the American Heart Association makes the following claims:

1. "E-cigarette promoters claim the devices can help people quit smoking. But much more evidence is needed to determine if they are an effective way to quit. Research suggests that users are more likely to continue smoking along with vaping, which is referred to as dual use."

The Truth: There is plentiful evidence that e-cigarettes can help smokers quit. The most recent evidence found that among smokers who tried vaping daily in an attempt to quit smoking, more than one-fourth (28%) quit smoking successfully. In the most recent clinical trial of vaping as a smoking cessation aid, subjects who were randomly assigned to receive e-cigarettes were twice as likely to quit smoking as those who did not receive e-cigarettes. As of 2022, there were 6.1 million e-cigarette users who had quit smoking by switching to vaping. If 6 million successful ex-smokers is not enough evidence to show that e-cigarettes are an effective way to quit, then no data ever will be for the American Heart Association. This is blatant misinformation.

2. "Many people think vaping is less harmful than smoking. While it’s true that e-cigarette aerosol doesn’t include all the contaminants in tobacco smoke, it still isn’t safe."

The Truth: This is intentional misinformation. The American Cancer Society avoids telling an overt lie by failing to explicitly answer the question. They intentionally use the word "safe" rather than "safer." However, few readers are going to pick this up and the implication of the first sentence is that the belief that vaping is less harmful than smoking is untrue. The clear intention here is to mislead the public into believing, falsely, that vaping is just as harmful as smoking. Even my long-time hero and mentor - Dr. Stan Glantz - acknowledges that smoking is more dangerous than vaping. And the Food and Drug Administration has concluded unequivocally that smoking is more hazardous than vaping.

 3. "E-cigarettes have been linked to thousands of cases of serious lung injury, some resulting in death. While the exact cause is still not confirmed, the CDC recommends that people not use e-cigarettes."

 The Truth: This is essentially an outright lie. Vaping THC carts, not e-cigarettes, was shown to be the cause of the so-called EVALI outbreak of serious lung injury that resulted in many deaths. The cause has been confirmed. The lung injury was caused by vitamin E acetate, a substance added to black market THC vapes to create the illusion of a more concentrated product so that it would reap in more money on the street. There is no evidence that e-cigarettes (nicotine-containing vapes produced for what at the time was an entirely legal market) have caused a single case of severe or fatal lung injury.

4. "E-cigarettes’ biggest threat to public health may be this: The increasing popularity of vaping may “re-normalize” smoking, which has declined for years. Reversing the hard-won gains in the global effort to curb smoking would be catastrophic."

The Truth: This statement is the exact opposite of the truth. Rather than re-normalize smoking, vaping has hastened the near complete elimination of smoking among youth. A brilliant analysis by Dr. Brad Rodu has revealed that the use of electronic cigarettes among youth has not served as a gateway to increased smoking but on the contrary has led to the virtual disappearance of smoking among high school youth. In 2011, smoking prevalence among high school students was 15.7%, while the prevalence of vaping was just 1.4%. In 2022, the prevalence of smoking among high school students dropped to just 2.0%, even though past-month vaping prevalence increased to 14.1%. It should be noted that in 2024, e-cigarette use among high school students dropped to 7.8%, while smoking declined further to 1.7%. Second only to e-cigarettes causing popcorn lung and possibly to e-cigarettes causing EVALI, the claim that youth vaping is a gateway to smoking has to go down in history as one of the greatest tobacco-related myths of all time not propagated by Big Tobacco.

American Cancer Society

In a November 7, 2024 article on the risks of vaping and smoking, the American Cancer Society makes the following claims:

1. "Misconception: Many people believe vaping doesn’t carry the same health risks as cigarette smoking because e-cigarettes do not contain tobacco."

The Truth: Like the nearly identical claim by the American Heart Association, this appears to be intentional misinformation. The clear implication is that these people--who believe vaping doesn't carry the same health risks as smoking--are wrong. Thus, the American Cancer Society is suggesting to readers that vaping does carry the same health risks as cigarette smoking. The truth, however, is that the Food and Drug Administration has concluded unequivocally that smoking is more hazardous than vaping.

2. "Misconception: Some people also think vaping is safer than smoking because they believe the vapor from e-cigarettes does not contain the same harmful chemicals as smoke."

Like the claim above, the clear implication is that these people--who think vaping is safer than smoking--are wrong. Thus, the American Cancer Society is again suggesting to the public that vaping is just as hazardous as smoking. This is unequivocally false.

Conclusion

In this age of misinformation as well as distrust of health authorities, it is more important than ever that public health organizations communicate accurately, honestly, and transparently with the public. After being away from blogging about tobacco issues for about 4 years, it is extremely disappointing for me to come back and find the situation no better than when I left. It is difficult for me to believe that this has now been going on for 15 years. It all started with that 2009 press conference when the FDA announced it was seizing e-cigarette products of Smoking Everywhere and NJOY. That was when what was to become a decade and a half long campaign of disinformation about electronic cigarettes began. It is disheartening to know that we are still talking about this campaign of disinformation in the present tense. And so the battle for truth and honesty within public health continues.

New Data Show that E-Cigarettes are Saving Lives and Debunk Claims by Opponents that Vaping is a Gateway to Smoking

The claim by opponents of e-cigarettes that vaping is a gateway to smoking and will increase the long-term hazards of tobacco product use have now been completely debunked by longitudinal trend data demonstrating that the truth is the exact opposite.

The results of a Gallup poll conducted last month revealed that adult smoking prevalence has reached an all-time low (11%) and that the decline in smoking has been driven largely by a dramatic drop in smoking among young adults. The prevalence of smoking among adults ages 18-29 was only 6%.

The Rest of the Story

What caused this dramatic decline in smoking among adults, and especially young adults? The data suggest that use of electronic cigarettes is the primary reason for the dramatic declines in smoking observed over the past few years. The amount of decline in smoking prevalence is very similar to the increase in e-cigarette use. Among adults, approximately 7% reported vaping in the past week. Among young adults, approximately 18% reported vaping in the past week.

These data confirm the results of numerous other studies which have demonstrated that cigarettes and e-cigarettes are economic substitutes. This means that e-cigarettes have served as a much lower risk alternative option for youth who most likely otherwise would have smoked cigarettes. And because of this substitution effect, it is very difficult to find a young adult today who is smoking tobacco cigarettes. Another way of putting this is that we have almost completely eradicated tobacco use among young adults. And of course, this means that as these young people age, we are on a path to eradicate cigarette smoking entirely.

The public health benefits that will accrue from these long-term trends will be mind-boggling. While not supported by most tobacco control organizations and agencies, the advent of electronic cigarettes will -- if trends are allowed to continue -- one day be looked at as the end game strategy that made smoking history. 

Sadly, many of the tobacco control groups and health organizations that have opposed vaping from the beginning and made many false claims about both the gateway effect and the health effects of e-cigarettes will not be able to take credit for the millions of lives that will be saved because of this innovation. If anything, they have done everything they can to prevent this life-saving intervention from taking place.

And ironically, it was the regulation of vaping products that almost brought the whole project to an end. What saved the day was the loophole in the regulation that allowed disposable e-cigarettes to remain on the market.

It will be very interesting to hear what the major tobacco control groups say now that there is very clear evidence that vaping was responsible for decimating smoking among today's generation of young adults. Since it is rare for people to start smoking as adults, the prevalence of smoking among this cohort of young people will almost certainly not rise above 6%. This is undoubtedly the greatest public health victory of my lifetime.

Why is Congress Interfering With Science to Protect the Alcohol Industry?

Background

In 2004, the U.S. Department of Health and Human Services created an interagency committee to direct federal efforts to reduce underage drinking. The committee, which is called the Interagency Coordinating Committee on the Prevention of Underage Drinking (ICCPUD), is led by the Substance Abuse and Mental Health and Mental Health Services Administration (SAMHSA) and includes agencies such as the Centers for Disease Control and Prevention (CDC), the Surgeon General, and the National Institute on Alcohol Abuse and Alcoholism (NIAAA), which is part of the National Institutes of Health (NIH). 

The ICCPUD recently decided to undertake a study, which it calls the Alcohol Intake and Health Study, to review the scientific evidence on the health effects of alcohol. In part, this study is intended to inform the upcoming development of the 2025 Dietary Guidelines, which will presumably make a recommendation regarding the use of alcohol as it relates to health. The current guideline (2020-2025) recommended as follows: "A healthy dietary pattern doesn’t have much room for extra added sugars, saturated fat, or sodium—or for alcoholic beverages. ... Adults of legal drinking age can choose not to drink, or to drink in moderation by limiting intake to 2 drinks or less in a day for men and 1 drink or less in a day for women, when alcohol is consumed. Drinking less is better for health than drinking more. There are some adults who should not drink alcohol, such as women who are pregnant."

After the ICCPUD had begun its review process, the alcohol industry successfully lobbied Congress to fund another study, this one to be conducted by the National Academy of Sciences, Engineering, and Medicine (NASEM), to also review the health effects of alcohol consumption with an eye towards informing the 2025 Dietary Guidelines.

The NASEM study was tainted by alcohol industry influence from the start. As I revealed this past January, NASEM selected two researchers with severe conflicts of interest with the alcohol industry to be on its review panel. These two alcohol industry-funded researchers (Dr. Kenneth Mukamal and Dr. Eric Timm) were principal investigators in a research grant funded by the alcohol industry, to the tune of $67 million, which promised in advance to produce findings showing that moderate alcohol consumption is good for one's health. The principal investigator actually courted the alcohol industry funding by essentially promising Big Alcohol positive results (meaning a positive overall effect of moderate drinking on health). 

After the story of this scandal was broken by Roni Rabin of the New York Times, NASEM backtracked and removed the two conflicted researchers from the panel. However, one of the scientists they chose as a replacement (Dr. Luc Djousse) was another conflicted researcher with a history of alcohol industry funding. This scandal, too, was broken by Roni Rabin, but this time NASEM did not relent.

The Story

Three weeks ago, 25 members of Congress wrote a letter to the director of the NIAAA suggesting that it was inappropriate for ICCPUD to study the health effects of alcohol use, that this was duplicative of the work by NASEM, and questioning the appointment of four specific researchers to serve on a scientific review subcommittee to inform ICCPUD's consideration of the scientific issues around alcohol consumption and health. In addition, the letter claimed that: "ICCPUD participants have already formed an opinion and are working towards a predetermined result." Two of the researchers who the Congressmembers called out were Dr. Tim Naimi and Dr. Kevin Shield.

Ultimately, the letter asserts that the ICCPUD is not an appropriate body to be reviewing the health effects of alcohol, asking: "Is an interagency coordinating committee tasked with stopping underage drinking an appropriate venue to conduct a comprehensive review of legal adult alcohol consumption?"

The Rest of the Story

This letter is an absolutely inappropriate intrusion into the scientific workings of the federal public health agencies that are entrusted with protecting the nation's health. Congress has no business interfering with research being conducted by the National Institutes of Health, with the sole exception of impropriety in the research, such as undue financial influence by corporate interests or research misconduct. 

Here, the opposite is occurring. These members of Congress are clearly intervening to protect the interests of the alcohol industry, whether intentionally or not. It certainly has the appearance of undue alcohol industry influence and there is enough evidence of wrongdoing in the degree of alcohol industry influence on the 2025 Dietary Guidelines that I believe the Inspector General of the House should conduct an investigation to determine whether the alcohol industry played any role in this unseemly and political encroachment on the ability of the NIH to conduct independent and unbiased research.

The question of whether an interagency coordinating committee tasked with stopping underage alcohol use is an appropriate venue to conduct a review of the health effects of alcohol is laughable. Are these members of Congress seriously suggesting that CDC, NIH, DHHS, NIAAA, NIDA, and SAMHSA are not the appropriate agencies to be involved in a review of the scientific evidence regarding alcohol use and health? 

If, in fact, these members of Congress are successful in their attempt to intimidate these federal public health agencies into halting their scientific review of the health effects of alcohol, it would be a travesty because it would be yet another example of politics interfering with science. And the very thing that these members of Congress are purporting to try to prevent--conflict of interest--is precisely what they are introducing into the process by suggesting that NASEM is the only body that should conduct this review. The NASEM review is being conducted at the behest of the alcohol industry in the first place. That is the likely explanation for the attempt to pack the expert panel with alcohol industry-funded researchers and for the replacement of the experts whose conflicts of interest were called out with another scientist who has a conflict of interest by virtue of previous funding from Big Alcohol.

Incidentally, Dr. Tim Naimi and Dr. Kenneth Shield are unassailable in terms of their qualifications to review the health effects of alcohol and in terms of their scientific objectivity and absence of conflicts of interest.  

Dr. Naimi "received his bachelor’s degree from Harvard College, his M.D. degree from the University of Massachusetts, and his M.P.H degree from the Harvard School of Public Health. He completed a combined internal medicine-pediatrics residency program at the Massachusetts General Hospital, the Epidemiologic Intelligence Officer program with the Centers for Disease Control and Prevention (CDC), and a preventive medicine residency with the CDC. Prior to his time at Boston Medical Center, Dr. Naimi worked as a clinician for the U.S. Indian Health Service, and as a senior epidemiologist with the Alcohol Team at CDC. His current research interests, for which he receives grant support from the National Institutes of Health and CDC, include binge drinking, youth drinking, health effects of low-dose ethanol, and substance use policy including the impact of alcohol control policies, cannabis policies, and opioid policies on substance use and other health outcomes. He has co-authored more than 100 published manuscripts and book chapters." Moreover, he has never received any funding from the alcohol industry so he is clear of any financial conflicts of interest that would disqualify him from being a part of the scientific review subcommittee, unlike Dr. Djousse.

Dr. Shield "is a scientist with the Institute for Mental Health Policy Research at the Centre for Addiction and Mental Health (CAMH), and an assistant professor in the epidemiology division of the Dalla Lana School of Public Health at the University of Toronto. Dr. Shield is also the head of the World Health Organization (WHO)/Pan American Health Organization (PAHO) Collaborating Centre in Addiction and Mental Health at CAMH. Dr. Shield’s multi-disciplinary public health surveillance research programs generate scientific data that inform individuals, clinicians and policymakers on how best to reduce the public health harms caused by alcohol and other drugs." He conducts research to estimate "the first- and second-hand mortality and morbidity attributable to alcohol consumption at the country and global levels," which is a perfect fit for the review subcommittee. Most importantly, he has no history of alcohol industry funding; thus, there is no financial conflict of interest as there is with Dr. Djousse.

The Congressional letter makes the error of asserting that if a researcher has previously asserted a position on a scientific issue, that represents a conflict of interest. This is a bogus argument because if true, it would mean that no scientist could ever conduct more than one study on a topic before having a conflict of interest. If such an absurd policy were adopted, the only scientists who could serve on review panels would be those who don't know a thing about the topic being discussed!

In the field of scientific ethics, the worldwide accepted consensus is that conflicts of interest occur when an investigator has financial interests (including research funding) with an entity (typically a corporate entity) whose financial status could be affected by the results of the research. Thus, funding by the alcohol industry is a clear conflict of interest. Having written a previous scientific article about a topic is not.

Ironically, despite my previous criticism of the NIAAA for its previous relationship with the alcohol industry, the Institute appears to be holding fast to scientific principles and not allowing the alcohol industry to direct its work. I praise Dr. Koob (NIAAA director) for changing the ethic in his institute and not allowing politics to interfere with science. I trust that he will ignore or dismiss this undue intrusion into the scientific working of his institute.

Note: This commentary is being submitted as a formal complaint to the Office of the Inspector General of the U.S. House of Representatives.

National Academies Replaces Big Alcohol-Conflicted Researcher on Review Panel with Another Big Alcohol-Conflicted Researcher

Just over one month ago, I reported that the National Academies had appointed to their newly formed expert committee to review the health effects of alcohol two scientists who were principal investigators of a research grant funded by the alcohol industry to the tune of $67 million (Dr. Eric Rimm and Dr. Kenneth Mukamal). After New York Times reporter Roni Rabin exposed these conflicts of interest in an article, the National Academies announced that it had pulled both Dr. Rimm and Dr. Mukamal from the panel and would replace them.

The National Academies recently announced the replacement panelists, and one of them is Dr. Luc Djousse, an associate professor of medicine at Harvard Medical School. 

Shockingly, it turns out that Dr. Djousse also has a conflict of interest with Big Alcohol, as he has received research funding from the Alcohol Beverage Medical Research Foundation, an alcohol industry front group that funnels money from the industry to researchers, serving as a "middle-man" that hides the connection between Big Alcohol and the research.

Furthermore, Dr. Djousse is a member of the International Scientific Forum on Alcohol Research (ISFAR), a supposedly "independent" panel that reviews alcohol research studies. However, ISFAR was funded by the alcohol industry and most of its panelists have conflicts of interest with Big Alcohol. Dr. Djousse's biography on the ISFAR site fails to reveal that he has received funding from the alcohol industry - specifically, the Alcoholic Beverage Medical Research Foundation. Not surprisingly, ISFAR is critical of any study that reports harmful effects of moderate drinking and praises any study that finds benefits of moderate drinking. In its reviews, ISFAR does not reveal the conflicts of interest of panel members.

Even worse, Dr. Djousse has not always been forthright about disclosing his previous funding from the alcohol industry. For example, in a paper published in 2019, he discloses current research funding but not his previous alcohol industry funding. That article, as well as many others that Djousse has authored, touts the health benefits of moderate alcohol consumption. 

Finally, Dr. Djousse is a close colleague of Dr. Mukamal's and has co-authored papers with him that tout the benefits of moderate alcohol consumption. Having him on the panel is the next closest thing to having Dr. Mukamal on the panel himself.

The Rest of the Story

Because of his conflicts of interest, Dr. Djousse should be removed from this panel in order to preserve the integrity of both the panel and of the National Academies itself.

Moreover, the fact that the National Academies has now twice selected researchers with conflicts of interest with the alcohol industry to serve on this panel suggests that something more sinister is going on than simply a coincidence. The National Academies has now selected three different panelists, all of whom have received alcohol funding and all of whom have published articles touting the benefits of moderate alcohol consumption. At the same time, the National Academies has failed to appoint to the panel any of the numerous non-conflicted researchers who were nominated. And even after it was called out publicly for appointing members with conflicts of interest with Big Alcohol, the National Academies simply replaced one conflicted panelist with another conflicted panelist who was a close colleague of the first conflicted panelist.

When this happened once, I was suspicious that there was something going on behind the scenes because the appointments of Dr. Rimm and Dr. Mukamal have the appearance of suggested that some sort of alcohol industry influence was taking place. But now that this has happened a second time, I think that a formal investigation into the formation of this panel is warranted. It smells of alcohol industry influence in some form. In the absence of an investigation, the conclusions of this panel will be forever tainted and cannot be trusted or viewed as impartial.

If the National Academies fails to remove Dr. Djousse from the panel, it will be a slam dunk case of their promoting the interests of the alcohol industry over objective scientific review.