UCSF Center for Tobacco Research and Education Supports Near Complete Ban on E-Cigarettes but Only Minor Restrictions on Sale of Real Ones

In what I find a shocking policy revelation, the director of the UCSF Center for Tobacco Research and Education stated on ABC News that she supports a nearly complete ban on the sale of e-cigarettes in San Francisco while real cigarettes continue to be sold with almost no restrictions (the story begins at 37:58).

In 2019, the city of San Francisco banned the sale of virtually all e-cigarettes. The only products allowed to be sold are those which are tobacco-flavored. This represents about 95% of the e-cigarette market. On the other hand, the city allows the unfettered sale of deadly tobacco cigarettes. The only restriction is that menthol cigarettes may not be sold. This represents about 37% of the cigarette market.

The reason for the news story is that the city recently cracked down on two companies that were allegedly selling flavored e-cigarettes by mail order into the city. A court injunction now prevents them from continuing the illegal sale of flavored e-cigarettes online when the shipping address is in San Francisco.

The Rest of the Story

I never thought I would see the day when a tobacco control organization called for the removal of fake cigarettes from the market but the continued sale of the real ones.

If San Francisco did the exact opposite (banned real cigarettes and allowed the fake ones), it could potentially produce a huge reduction in smoking-related morbidity and mortality. 

Destroying the flavored e-cigarette market is the biggest favor that San Francisco could do for the cigarette industry. There are unequivocal data showing that flavored e-cigarettes are economic substitutes for cigarettes. Thus, a flourishing flavored e-cigarette market is a huge threat to the profits of cigarette companies. Eliminating this alternative market removes the bulk of the competition from cigarettes, which bolsters cigarette sales.

Why San Francisco helping to increase profits for cigarette companies?

Largely Ignored Study Shows that Switching from Smoking to E-Cigarettes Reduces Carcinogenic Exposures to the Same Extent as Complete Nicotine Abstinence

An important but largely ignored study published last week in the journal Biomarkers compared changes in exposure to toxic and carcinogenic chemicals among three groups: (1) smokers who switched completely to e-cigarettes; (2) smokers who continued to smoke their usual cigarette brand; and (3) smokers who discontinued all use of nicotine products (both cigarettes and e-cigarettes). A total of 89 smokers were randomized to one of these three groups for six days. Baseline measurements of biomarkers of exposure to carcinogens and toxins were compared to follow-up measurements after six days.

The results showed that there was massive reductions in biomarkers of carcinogenic and toxic exposures among those who switched from cigarettes to e-cigarettes. However, the most interesting finding was that the amount of reduction in these biomarkers of exposure among smokers who switched to e-cigarettes were not significantly different from the amount of reduction among smokers who quit all nicotine products completely.

For example, levels of 4-aminobiphenyl -- a known, potent carcinogen -- dropped by an average of about 90% among smokers who switched to e-cigarettes. A similar 90% drop occurred among smokers who abstained from nicotine products completely, and the difference between the magnitude of the reduction in the two groups was not statistically significant. 

Approximate reductions in exposure to other carcinogens among those who switched from cigarettes to e-cigarettes are shown below. In each case, the magnitude of the reduction in exposure was statistically equivalent between the group that switched to e-cigarettes and the group that abstained completely.

N'-nitrosonornicotine (proven human carcinogen): 85%

4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (metabolite of a proven human carcinogen): 68%

2-Naphthylamine (proven human carcinogen): 85%

monohydroxylbutenyl-mercapturic acid (metabolite of a proven human carcinogen): 90%

S-phenyl-mercapturic acid (metabolite of a proven human carcinogen): 92%

3-hydroxy-1-methylpropyl-mercapturic acid (metabolite of a proven human carcinogen): 80%

2-cyanoethylmercapturic acid (metabolite of a proven human carcinogen): 85%

1-hydroxypyrene (metabolite of a proven human carcinogen): 75%

ortho-toluidine (proven human carcinogen): 65%

 

Thus, for the 10 carcinogens studied, there was between approximately a 65% and 92% reduction in exposure, in just six days, among smokers who switched to e-cigarettes.

The study concludes as follows: "Data from this randomized controlled study demonstrate that adults who switch completely from smoking cigarettes to use of a new pod-based ENDS product, JUUL2, were exposed to similar levels of nicotine relative to continued cigarette smoking and substantially reduced their exposure to multiple toxins associated with smoking-related disease. Additionally, reductions in exposure to such HPHCs among participants who switched to JUUL2 products were similar in magnitude to participants who stopped using tobacco and nicotine products entirely. This study extends prior evidence that ENDS can be effective harm reduction products to a new pod-based ENDS."

The Rest of the Story

This is a very important study but it has been largely, if not completely ignored by most tobacco control and health groups. These groups continue to claim that vaping is just as harmful as smoking, that there is no value in smokers quitting by switching to e-cigarettes, and that there are no health benefits to switching from real cigarettes to e-cigarettes.

This study demonstrates that there are immediate health benefits of switching from smoking to vaping and provides evidence that smokers who do so can greatly reduce their risk of cancer. The reduction in exposure demonstrated by this study probably underestimates the longer-term reductions because it takes a period of time before these toxins are cleared out of the body. For example, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol has a half-life of as much as 45 days, so it could take as long as seven months to completely clear it.

In spite of the findings of this study (and several others like it, including national studies with huge sample sizes), the American Cancer Society still claims that vaping causes cancer. Hopefully, smokers will not listen to what the American Cancer Society is saying and will choose to quit smoking by whatever means they can, including by switching to electronic cigarettes.

Thanks to Efforts of Anti-Vaping Groups Like PAVE, ALA, ACS, and AHA, the Products that Kids are Vaping Could Pose True Serious Health Effects

Through the lobbying efforts and misinformation of multiple anti-vaping groups, of which Parents Against Vaping E-Cigarettes, the American Lung Association, American Heart Association, and the American Cancer Society are just a few, many states and the federal government have implemented a near total ban on flavored e-cigarettes. Because of the hare-brained Pre-Market Tobacco Application scheme, the FDA has to date approved only 34 e-cigarettes for sale in the United States. All of these brands are either tobacco or menthol flavored. As Bill Godshall, Alan Blum, I, and several others predicted about ten years ago, every single one of the approved products is produced by tobacco companies. Most anti-vaping and anti-tobacco groups view this as a huge victory - one that will protect the health of the nation's youth by ensuring that only "FDA-approved" vaping products remain available on the market.

The Rest of the Story

Recent retail sales data reveal that more than 86% of the e-cigarette market is comprised of products that are technically illegal. These are products that have not been reviewed and approved by the FDA; thus, they are essentially not regulated by any safety standards. 

This is the expected result of a prohibitionist approach to electronic cigarettes. The development of a "black market" for e-cigarettes was predicted by many us many years ago. There is simply too much demand for vaping products for a prohibition approach to be effective.

What are the repercussions of having the majority of the e-cigarette market be essentially unregulated?

Well ... just yesterday, the BBC reported that a batch of illegal vapes in England were found to have alarmingly high levels of heavy metals, including cadmium, copper, nickel, and lead. At the same time, a number of illegal vapes in the U.S. have been found to be laced with fentanyl. 

The upshot of the prohibitionist approach taken by the anti-vaping groups, the FDA, and many state governments, is that rather than actually having a regulated market, we essentially have an unregulated market. Now, youth may truly be at risk of serious health consequences or even death if the wrong vapes get into their hands. Had the FDA taken my suggestion of simply promulgating safety standards for these products, all of this could have been prevented.

The rest of the story is that ironically, the very groups claiming to be trying to protect youth from the harms of e-cigarettes have actually exposed youths to the risk of serious harms far worse than what they were trying to protect our youth from in the first place.

Surgeon General Calls for Cancer Warning Labels on Alcohol

The United States Surgeon General, Dr. Vivek Murthy, today issued a report calling for cancer warning labels on alcohol. To my knowledge, he becomes the first Surgeon General to make such a recommendation. Dr. Murthy's call for cancer warning labels is based on scientific evidence that even low levels of alcohol consumption (i.e., one drink a day) increase the risk of breast, mouth, and throat cancers. It is also based on the fact that unless a non-linear dose-response relationship has been demonstrated, carcinogens are assumed not to have a threshold response; thus, there is no level of exposure that can be deemed "safe." According to the Surgeon General, there are nearly 100,000 cancer cases and 20,000 deaths each year that are attributable to alcohol use.

Importantly, the Surgeon General noted that although cancer risk is lower at lower levels of alcohol consumption, the number of people drinking at this level is so much higher than the number of heavy drinkers that there are actually more alcohol-related cancer cases among people who drink 2 drinks or less per day than among those who drink 4-6 drinks per day. Globally, the Surgeon General estimates that 25% of all alcohol-related cancer cases occur among people who are light drinkers (no more than 2 drinks per day). 

Among the Surgeon General's recommendations are:

• "Update the existing Surgeon General’s health warning label on alcohol-containing beverages to include a warning about the risk of cancer associated with alcohol consumption. Pursue changes to label characteristics to make the warning label more visible, prominent, and effective in increasing awareness about cancer risks associated with alcohol consumption.
• Reassess recommended limits for alcohol consumption to account for the latest evidence on alcohol consumption and cancer risk.
• Strengthen and expand education efforts to increase general awareness that alcohol consumption causes cancer."

The Rest of the Story

I have already explained why I think the conclusions of the NASEM report were a death knell for the possibility of the Dietary Guidelines recommending low dose alcohol consumption for the reduction of cardiovascular risk. The Surgeon General's report puts the nail on the coffin.

The evidence is strong that alcohol consumption - at low doses within the current Dietary Guideline limits - increases cancer risk at multiple sites including the breast and the GI tract. There is no dose of alcohol consumption that can be considered safe. For this reason, it is no longer tenable for national dietary guidelines to recommend any level of alcohol consumption, even if it were to turn out that moderate drinking lowers cardiovascular disease risk. Just as we would not recommend smoking for the prevention of Parkinson's disease and Alzheimer's disease (there is some evidence that this is the case), we cannot recommend drinking for the prevention of heart disease.

New Study Recommends that FDA Require E-Cigarette Warnings that Mislead People into Believing Smoking is Less Harmful than Vaping

A study published in the new issue of the journal Tobacco Control tested a series of new potential warning labels for electronic cigarettes. Currently, the FDA requires that e-cigarettes carry a single warning about the addiction potential of these products. The investigators in this study tested additional types of warnings on 1,629 adult vapers and smokers. The themes of these warnings included: metals exposure, DNA mutation, cardiovascular problems, chemical exposure, lung damage, impaired immunity, and addiction, in addition to the current FDA warning.

The study findings were as follows: "Regarding intended effects, new warning themes all discouraged vaping more than the current FDA-required warning (all p<.001), led to greater negative affect (all p<.001), and led to more anticipated social interactions (all p<.001). The most discouraging warnings were about toxic metals exposure. Regarding unintended effects, the new themes led to more stigma against people who vape (6 of 7 themes, p<.001) and led to a greater likelihood of thinking vaping is more harmful than smoking (all 7 themes, p<.001), though unintended effects were smaller than intended effects. Images of harms (internal or people experiencing) discouraged vaping more than images of hazards (all p<.001)."

The study concluded that: "Vaping warning policies should communicate a broader range of hazards and harms, beyond addiction, to potentially increase awareness of health harms. ... novel warnings should contain text-based information about harms and hazards, including metals exposure, DNA mutation, cardiovascular problems, chemical exposure, lung damage, impaired immunity, and life disruptions from addiction. Pairing text warnings with images showing internal harms (e.g., diseased organs) or someone experiencing harms (e.g., suffering symptoms) will likely discourage vaping more than showing the  hazards (e.g., chemicals)."

The Rest of the Story

I have two major problems with this paper. For both, keep in mind that this paper is focused on adults, not youth.

First, I question the very basis (i.e., goal) of the paper. The conceptual basis for the paper, expressed in the Conclusion section, is: "E-cigarette warnings can be an important tool to discourage vaping among people who currently vape, smoke, or use both products."

That may sound rationale on its face, but let's think about it. Let's start with warnings to smokers. Why would we want to warn smokers about the harmful potential effects of e-cigarettes in order to discourage them from vaping? Shouldn't we be encouraging smokers to switch to e-cigarettes as a way to quit smoking, especially if they have tried medications and failed. Discouraging smokers from quitting is essentially the same as encouraging smokers to continue smoking. This doesn't make sense to me.

Now what about discouraging dual users from vaping? That seems even more problematic because if you have someone who is vaping and smoking, the message should be to quit smoking and move to vaping only. Discouraging these people from vaping by warning about it causing DNA mutations seems irresponsible when the likely outcome is that they will return to just smoking. Shouldn't we be trying to tip them in the other direction?

Even among people who are currently vaping, it isn't straightforward that our message should be to scare them about how dangerous vaping is. Suppose that they are a former smoker who quit by switching to vaping. Do we really want to scare them away from vaping so that they return to smoking? Certainly, among young adults other vapers who never smoked, it is reasonable to encourage them to stop vaping. But this is a relatively small audience when you consider all adults who either smoke, vape, or both.

Second, I question the recommendation to proceed with these "more effective" warnings when they have the demonstrated "unintended" consequence of misleading people into believing that smoking is less harmful than vaping. And remember, once you implement such warnings, the "unintended" consequences now become "intended" consequences since they are a known result of your intervention. Misleading the public into believing that smoking is less harmful than vaping is bound to have negative consequences for public health. It will almost certainly encourage many ex-smokers to return to smoking (those who vape) and discourage many smokers from switching to vaping. After all, why should I quit smoking and switch to vaping if vaping is actually more hazardous?

Third, there is the ethical question of whether it is acceptable to knowingly create a massive deception of your target audience about a critical public health principle (that smoking is more hazardous than vaping) even if the intended result (discouraging people from vaping) may be a good one.

The rest of the story is that our analysis need not proceed that far. The recommendations in this paper are problematic and if implemented, would likely cause more harm than good.

Most Egregious Statement About Electronic Cigarettes for 2024

Although there was plentiful competition, I have selected as the most egregious statement about electronic cigarettes in 2024 the following communication from the World Health Organization:

"Q: What looks cute, smells good, but is designed to kill? A: A vape!"

The Rest of the Story

This is an award winner because it is the exact opposite of the truth. It could not be more wrong. Electronic cigarettes were not designed to kill people. On the contrary, they were designed to save people. These products were not developed by tobacco companies at all. Instead, they were invented by a Chinese entrepreneur for the very specific purpose of helping people quit smoking. The inventor--Hon Lik--actually invented them to help himself quit smoking. He had tried nicotine replacement therapy and found it to be unsatisfactory and ineffective. He wanted something that better simulates the smoking experience, but doesn't deliver the deadly tar. Electronic cigarettes entered the market in China in 2005 and were being sold in the U.S. within 2 years. The tobacco companies did not even come into the picture until 2011, by which time there was already a thriving vaping market in the U.S., and it would probably have grown to current levels even in the absence of any tobacco company involvement.

This statement by the World Health Organization is not only inaccurate but it is also insensitive. It maligns all of the independent companies that manufacture e-cigarettes as well as the vape shops that sell these products. And so far as I know, the World Health Organization has not even made the same statement about real cigarettes.

Furthermore, there is no evidence that e-cigarettes do kill anyone. Vaping has not been linked conclusively with any chronic disease and I'm not aware of any deaths that were attributable to e-cigarette use. So if e-cigarettes were designed to kill, they were designed quite poorly.

Fortunately, there have been many community comments, and they have been found helpful enough so that they appear on the X page along with the WHO's fallacious statement. So at least there is an opportunity for readers to have the WHO's misinformation corrected.

The Top 12 Most Irresponsible Statements About Vaping by Health Groups in 2024

Of all the false and misleading claims about e-cigarettes being made by health groups, there are two types of claims that I find inexcusable and severely damaging because they obscure public knowledge at a very basic level: understanding the difference between smoking and vaping. Both of these claims inform the public that electronic cigarettes are simply another form of smoking or another form of tobacco use. Both claims incorrectly assert that e-cigarettes contain tobacco.

The claims come in two varieties. 

The type A claim is that if you quit smoking by switching to vaping, you somehow haven't really quit smoking because you're still using a tobacco product that contains nicotine and is addictive. This shows a lack of understanding of the answer to a very simple question: What do you call a smoker who switches completely to vaping? The answer is simple: a former smoker. Switching to e-cigarettes is absolutely a form of smoking cessation and in fact, in 2024 it was probably the most common form of smoking cessation.

The type B claim is that youth e-cigarette use is threatening to addict a new generation of youth to tobacco. This claim is false on its face because e-cigarettes contain no tobacco. So while a youth may become addicted to the nicotine in e-cigarettes, they do not become addicted to tobacco because these products don't contain any tobacco. You can't become addicted to a substance that is not present in the product that you are using.

Here are the 12 most irresponsible claims of 2024. Note that all of them are being made by major regional, national, or international health organizations.

 

A. The Claim that Quitting Smoking by Switching Completely to E-Cigarettes is Not Quitting Smoking

1. American Lung Association: "Despite what e-cigarette, vape and other tobacco product companies want you to believe, switching to use of any other tobacco product is not quitting."

2. World Health Organization: "Switching from conventional tobacco products to e-cigarettes is not quitting as it still exposes the user to the nicotine and the other toxic compounds in the aerosols of e-cigarettes."

3. MedStar Health: "Vapes with nicotine can be as addictive as cigarettes, which doesn’t do anything to help you quit."

4. MD Anderson Cancer Center: "Switching to e-cigarettes is not a quit-smoking plan. Even if you transition completely to e-cigarettes, you’re still dependent on nicotine (a tobacco product), and putting harmful chemicals into your body."  

5. Lung Foundation Australia: "Given the known risks and the unknown health impacts, Lung Foundation Australia does not support the use of nicotine e-cigarettes as a smoking cessation tool."

 

B. The Claim that E-Cigarettes are Creating a New Generation that is Hooked on Tobacco

6. American Heart Association: "A new generation of tobacco products is addicting a new generation of users to tobacco... ."

7. American Cancer Society: "E-cigarettes are creating a new generation of tobacco addicts."

8. American Lung Association: "Over the past five years, we have seen an alarming rise in youth vaping. In fact, almost 20% of high school students use e-cigarettes ... Steps must be taken by parents, educators and especially policymakers to end the youth e-cigarette epidemic. The introduction of the PROTECT Act will give us the tools we need to help kids quit and prevent another generation of Americans from becoming addicted to tobacco.” 

9. John Snow Institute: "Tobacco companies have not skipped a beat in morphing their products and promotional tactics toward a new generation of tobacco users. [talking about e-cigarettes] E-cigarette manufacturers know full well that adolescent brains are not completely formed and are more susceptible to the effects of addiction."

10. American Medical Association: "Flavored e-cigarettes and vaping products are quickly erasing decades of progress in decreasing youth tobacco use." 

11. Truth Initiative: "These declines in youth smoking, coupled with the fact that 98% of tobacco users start before they’re 26, presented an existential threat to the U.S. tobacco industry — until a product innovation emerged: a sleek device that re-branded tobacco as “cool” again, and delivered high levels of nicotine to keep users coming back." 

12. American Academy of Pediatrics, American Lung Association, American Heart Association, American Cancer Society, Campaign for Tobacco-Free Kids, Truth Initiative: "We look forward to working with you [on e-cigarette restrictions] to ensure that a new generation does not become addicted to tobacco." 

The Rest of the Story

In addition to providing false information, these claims are irresponsible because they are actually contributing toward increased tobacco use. By misleading so many smokers into thinking that there is no point in their switching to vaping, they are deterring smoking cessation by large numbers of people. In addition, they are throwing vapers under the bus by suggesting that they haven't quit smoking "the right way." People who have been able to overcome a very powerful addiction to smoking by switching to vaping should be praised and congratulated for this accomplishment, not scorned or undermined. 

Will any of these organizations acknowledge their irresponsibility, apologize, and correct their statements? I will offer a $200 donation to the first organization that does so. Sadly, I'm not worried about having to pay out the money because I've come to learn that these organizations are not about honesty, accuracy, and transparency. They are about making the most alarming statements possible so that they can attract more money from donors.

Top Ten Ridiculous E-Cigarettes Cause Popcorn Lung Claims of 2024

Perhaps the most misleading and damaging claim that is still being made about e-cigarette use in 2024 is the contention that vaping e-cigarettes causes bronchiolitis obliterans, or "popcorn lung," which is a severe lung disease characterized by inflammation and scarring in the deepest airways of the lung. The most recent iteration of this fallacious claim appears to have originated, at least in part, from a widely-cited 2016 American Lung Association article entitled "Popcorn Lung: A Dangerous Risk of Flavored E-Cigarettes." The only evidence presented to support this claim was that low levels of diacetyl were detected in the e-liquids of a number of e-cigarette brands and that massive acute exposure to diacetyl has been linked to bronchiolitis obliterans in popcorn factory workers. The claim was not based on a single documented case of popcorn lung occurring in someone who used e-cigarettes.

Today, I list 10 of the most fallacious vaping-popcorn lung claims made in 2024. I only included claims if I could verify that they were made in 2024.

Top 10 Most Fallacious Claims About E-Cigarettes Causing Popcorn Lung -- 2024

1. University Hospitals (Cleveland, OH): On April 25, 2024, University Hospitals published an article entitled "Popcorn Lung: A Dangerous Risk of Vaping." The article definitively links vaping electronic cigarettes with popcorn lung, stating: "In recent years, there’s been a sharp increase in the use of e-cigarettes, also known as vaping. Many people believe that it is a safer alternative to smoking; however, the inhaled vapor contains more than 7,000 potentially harmful chemicals that can damage the lungs and lead to serious conditions, including popcorn lung." 

Reason for ranking: There is no evidence that vaping electronic cigarettes causes popcorn lung. This myth developed because e-cigarette aerosol in tests of a few brands detected diacetyl, which is the chemical which if inhaled in large doses can cause popcorn lung. But the level of diacetyl in e-cigarette vapor is on average 750 times lower than in a real cigarette. Yet cigarette smoking itself has not been recognized as a cause of popcorn lung. Moreover, there has not been a single, credible, published case of popcorn lung in an e-cigarette vaper that was attributable to the use of e-cigarettes. That's pretty definitive evidence that vaping e-cigarettes does not present a risk of popcorn lung. There have been reports of a condition similar to bronchiolitis obliterans (popcorn lung) occurring in patients who vaped THC vape carts that were laced with vitamin E acetate, a thickening agent that some black market wholesalers of THC vape carts were adding to the product to increase its street value. However, there is no evidence that nicotine e-cigarettes purchased from stores or vape shops have caused any cases of popcorn lung.

2. Public Health, Delta and Menominee Counties (Escanaba and Menominee, MI): According to this local health department's Facebook statement on November 5, 2024: "Vaping can cause popcorn lung, a respiratory condition that can cause your airways to become inflamed, damaged, and scarred." The health department simply states this as a fact, providing no references, citations, or explanatory reasons.

Reason for ranking: There is no evidence that vaping electronic cigarettes causes popcorn lung.

3. M.D. Anderson Cancer Center (Houston, TX): In a January 5, 2024 article, the M.D. Anderson Cancer Center claimed that: "Vaping has also been linked to a type of lung damage called bronchiolitis obliterans, or popcorn lung, which is caused by a chemical called diacetyl used to sweeten some vape liquids." 

Reason for ranking: There is no evidence that vaping electronic cigarettes causes popcorn lung.

4. MedicineNet: MedicineNet not only informs us that vaping causes popcorn lung; it also tells us the exact time course: "The symptoms of popcorn lung from vaping can appear anywhere from two to eight weeks after inhaling certain irritants." This article was medically reviewed on August 1, 2024.

Reason for ranking: There is no evidence that vaping electronic cigarettes causes popcorn lung.

5. WebMD: In an article reviewed on November 21, 2024, WebMD asks "How Else Can Vaping Affect Your Lungs" and then lists as the first entry "Popcorn Lung." 

Reason for ranking: There is no evidence that vaping electronic cigarettes causes popcorn lung.

6. Ask Dr. Zac (Australia): I don't know whether Dr. Zac is the Australian equivalent of Dr. Oz, but he is a physician trained at the University of Sydney. In his August 25, 2024 column, in response to a question from a woman whose husband uses e-cigarettes, Dr. Zac states: "Popcorn lung is very real, and will affect your husband eventually if he does not stop."

Reason for ranking: This one had to be included to represent the widespread misrepresentation of the health effects of vaping that is prevalent in Australia. It is quite a claim because not only does it tie e-cigarette use to popcorn lung, but it states that anyone who vapes will eventually get popcorn lung. That is news to the more than 20 million regular vapers in the U.S. who have not yet developed popcorn lung. Miraculously, Dr. Zac seems to believe that popcorn lung somehow evades smokers, even though their exposure to diacetyl is much higher. By the way, Dr. Zac goes on to say: "The only thing that should be in our lungs is air, nothing else. I like to compare vapes to a fast-food restaurant’s salad. It seems healthy compared to the other items on the menu but when you look closely, you realise it is just as bad as the other menu items." A side salad from Burger King with Ken's Lite Honey Balsamic Vinaigrette dressing has 230 calories, 16g of fat, and 15mg of cholesterol. In contrast, a Burger King's Texas Double Whopper delivers 1,090 calories, 75g of fat, and a whopping 195mg of cholesterol. So the side salad is no more healthy than the Texas Double Whopper? It's no surprise, I guess, that he believes that vaping is no more healthy than smoking.

7. Verywell Health: In an article posted on August 22, 2024, Verywell Health stated: "Research indicates that flavors that contain a sweetener known as diacetyl can lead to a serious lung condition known as bronchiolitis obliterans, also known as popcorn lung." 

Reason for ranking: There is no evidence that flavored e-liquids, even those that contain diacetyl, cause popcorn lung.   

8. Regional Cancer Care Associates (New Jersey, Connecticut, Maryland, DC): In answer to the question "What are the Health Risks of Vaping," the first effect listed is "Bronchiolitis Obliterans" (popcorn lung). The web site states: "Also known as popcorn lung, bronchiolitis obliterans can develop because of the presence of an organic compound called diacetyl that is found in e-cigarettes." This post is from February 21, 2024.

Reason for ranking: There is no evidence that e-cigarette use causes popcorn lung.

9. Houston Methodist: In a December 9, 2024 article, Houston Methodist asks "How else does vaping affect your lungs?" One of the answers is: "Also known as "popcorn lung," this condition is caused by the food additive diacetyl." This article is from just two weeks ago. The fallacious claim about e-cigarettes causing popcorn lung appears likely to be alive and well going into 2025.

Reason for ranking: There is no evidence that e-cigarette use causes popcorn lung.

10. Cancer Institute NSW (Australia): This cancer institute states on its website, dated 2024: "Experts are very concerned about flavouring chemicals found in vapes. These have been linked to ‘popcorn lung’ (bronchiolitis obliterans)." 

Reason for ranking: There is no evidence that flavored e-liquids, even those that contain diacetyl, cause popcorn lung.

"Quit Our Way or Die": Lifestyle Control in the Modern-Day Tobacco Control Movement

There is strong evidence that smokers who switch to e-cigarettes completely are more likely to succeed in quitting than smokers who use nicotine replacement therapy (NRT). There is similar evidence that smokers who try to quit using e-cigarettes are more successful than those who utilize smoking cessation counseling. In fact, the difference in effectiveness between the use of daily e-cigarettes and the use of nicotine replacement therapy is large: there is about a 2-fold difference. In other words, smokers who try to quit by switching completely to vaping are twice as likely to succeed than those who try to quit by using nicotine replacement therapy.

The Rest of the Story

In spite of the evidence establishing daily vaping as a highly effective method for smoking cessation, I was recently surprised to see that most health organizations--including smoking cessation clinics--are recommending that smokers should NOT attempt to quit smoking using electronic cigarettes, even if the individual is strongly motivated to quit by switching to vaping, specifically prefers vaping to nicotine replacement therapy or other medications, and has tried to quit using NRT or medications in the past but failed.

Here are just a few of the many health organizations and smoking cessation programs that don't want smokers to succeed in quitting by using e-cigarettes. It is what I call the "Quit Our Way or Die" approach to smoking cessation.

Partial List of "Quit Our Way or Die" Organizations

1. UCSF: The University of California at San Francisco provides a list of treatment options for smoking cessation, but daily use of electronic cigarettes (that is, switching completely to vaping) is not among the options. Shamefully and irresponsibly, their medical advice is based on a 2008 reference and apparently ignores all of the changes in scientific evidence in the past 16 years. Even in their current smoking cessation guidebook, e-cigarettes are not mentioned, even as a possible smoking cessation aid, and in fact, patients are specifically advised not to use e-cigarettes in a quit attempt (even though more than 3 million people have used this approach successfully). 

2. American Cancer Society: The American Cancer Society denies that electronic cigarettes can help people to quit smoking and recommends against their use in smoking cessation, even though more than 3 million people have used this approach successfully: "E-cigarettes are not approved by the FDA as aids to help people stop smoking. This is because there is not enough research to show they help people stop using tobacco. On the other hand, there are other proven methods that can help you quit using tobacco. This includes FDA-approved nicotine replacement and other medicines. There is a lot of evidence showing that these methods work. They are safe and effective, especially when combined with counseling. Some people choose to try e-cigarettes to help them stop smoking. But e-cigarettes have as much if not more nicotine as regular cigarettes and other tobacco products." The reason e-cigarettes are not approved by the FDA as aids to help people stop smoking is not because there is a lack of evidence that they can help people stop smoking, but because no company has ever applied for FDA approval of e-cigarettes as smoking cessation devices. Further, the fact that e-cigarettes have nicotine, just like regular cigarettes, is not a reason to avoid them; on the contrary, it is the exact reason why these products work. NRT products contain nicotine, but the American Cancer Society is not discouraging people from using those products.

3. American Lung Association: The American Lung Association denies that electronic cigarettes can help people to quit smoking and recommends against their use in smoking cessation, even though more than 3 million people have used this approach successfully. The American Lung Association states: "Despite what e-cigarette, vape and other tobacco product companies want you to believe, switching to use of any other tobacco product is not quitting. E-cigarettes are still tobacco products, and FDA has not approved any e-cigarette as a way to quit for good. In fact, the FDA must crack down on the unproven health claims made by the e-cigarette industry because it's confusing people who want to quit." Thus, the American Lung Association doesn't even consider single-use vapers as having quit smoking. This is absurd. If you have switched from smoking to vaping, then you have quit smoking. What the American Lung Association is telling vapers is that if you have quit smoking by switching completely to vaping, you might as well go back to smoking because what you did doesn't count.

4. American Heart Association: The American Heart Association also denies that electronic cigarettes can help people to quit smoking and recommends against their use in smoking cessation, even though more than 3 million people have used this approach successfully. The American Heart Association states: "E-cigarettes are sometimes marketed as a way to quit smoking, but there is not enough scientific evidence that it works. One study reported adult smokers who used e-cigarettes were 28% less likely to quit successfully. The American Heart Association recommends using proven methods to quit smoking." E-cigarettes are a proven way to quit smoking. And there is plenty of strong scientific evidence that they work; in fact, they work more effectively than NRT.

Final Thoughts

I have to seriously say that I have so much respect for people who have quit smoking by switching to vaping. To do this in an environment when health authorities all around them are urging them not to and telling them how dangerous it is, but to have the wisdom and insight to discount that advice and instead rely on their own research and the experiences of friends, family members, vape shop owners, and others in the vaping community is wise, courageous, and admirable.

But while I praise vapers who have quit smoking, so many of my tobacco control colleagues are lambasting them for it. Moreover, they are completely ignoring their experiences, calling them nothing but anecdotes. Of course, when you have 3 million anecdotes, you can call it rock solid evidence.

The rest of the story is that most of the major medical and health organizations have deviated from the practice of medicine and public health. Instead, they are practicing lifestyle control. You have to quit their way or you haven't actually quit. Who gives them the right to define what smoking cessation is? How can they possibly argue that quitting smoking by switching to e-cigarettes isn't quitting smoking? Apparently, it isn't the health of smokers that these organizations really care about. It is controlling people's lifestyles and telling them how they should be living their lives, regardless of whether that advice is in the best interests of the health of the public.

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.