American Lung Association Finds It "Appalling" that Nicotine Pouch Maker is Allowed to Tell the Truth

It used to be that we castigated the tobacco companies for lying to or misleading the public. Now, apparently, we think that it's appalling that a tobacco company be allowed to tell the truth.

Years ago, I testified in the Engle case, a class action suit brought by Florida smokers against Big Tobacco that resulted in a $145 billion punitive damage verdict against the companies. The basis of the lawsuit was that for years, the tobacco companies lied about the health effects of their products and were liable for damages based on their fraudulent behavior. And in a more recent lawsuit, the tobacco companies were forced to put corrective statements on cigarette packs in order to atone for deceptive statements they had made in the past. Clearly, a major problem for which we held tobacco companies responsible was lying to the public about the health effects of their products.

Today, for some reason, the tables have turned. Instead of demanding that tobacco companies tell the truth about the health effects of their products, the American Lung Association is appalled that the FDA is allowing them to tell the truth. 

Earlier this week, the FDA authorized Swedish Match - the manufacturer of Zyn nicotine pouches - to tell consumers that: "Using ZYN instead of cigarettes puts you at a lower risk of mouth cancer, heart disease, lung cancer, stroke, emphysema, and chronic bronchitis." This decision was based on what is called an MRTP [modified risk tobacco product] application, which required Swedish Match to provide solid scientific documentation that the product is in fact safer than cigarettes and poses a lower risk of heart disease, stroke, mouth cancer, lung cancer, and chronic obstructive pulmonary disease. 

The FDA's authorization of this modified risk claim was based on its conclusion that: "as actually used by consumers, would significantly reduce harm and the risk of tobacco-related disease to individual tobacco users and benefit the health of the population as a whole, taking into account both users of tobacco
products and persons who do not currently use tobacco products."  

According to an NBC News article, the American Lung Association responded to the FDA's action by calling it "appalling" and demanding that the agency reverse this decision: "Mike Seilback, assistant vice president of nationwide advocacy and state public policy at the American Lung Association, called the move “appalling.” “The Lung Association calls on the FDA to reverse this action,” Seilback said in an emailed statement. “We must protect our children from a lifelong addiction to nicotine.”"

The Rest of the Story

What's actually appalling is that the American Lung Association would prefer that Swedish Match not be allowed to tell consumers that nicotine pouches are much safer than cigarette smoking because they pose a lower risk of lung cancer and COPD. You would think that an organization devoted to preventing lung disease would want smokers to know that if they quit by switching to nicotine pouches, they will lower their risk for lung cancer and chronic lung disease. But for some reason, the American Lung Association is actually lobbying to get the FDA to forbid Swedish Match from telling consumers the truth.

Why the American Lung Association would want smokers to incorrectly think that switching from cigarettes to Zyn pouches would have no impact on their health is beyond me. This is a great public disservice. It could potentially result in deaths that could otherwise have been prevented. After all, if reversing this FDA decision results in smokers not believing there is any health advantage to switching to nicotine pouches, then why should they bother switching? Might as well get the full enjoyment of your Marlboro's if the tobacco-free, combustion-free, alternative is no safer.

Here is just one of the many testimonials that the FDA received from smokers who basically saved their lives by switching to Zyn: 

"I was a smoker for ten years and a smokeless tobacco user (snuff) since 1983. I found myself unable to quit tobacco for more than a few weeks at best. I switched to Zyn a year ago, and it has been game changing. To be blunt, I still get my nicotine, but not the cancer. It's fairly ludicrous to point at the risk of teenagers "getting hooked" on Zyn as a risk factor. Literally throwing out a valuable baby with the proverbial bathwater. This product is absolutely life-changer for the long-term nicotine junkie like myself." 

The reason given by the American Lung Association for demanding that the FDA prohibit Swedish Match from telling the consumers the truth is that "we must protect our children from a lifelong addiction to nicotine." I agree with that goal. But we should do this by lying to them? And by lying to adult smokers as well?

In public health, we have a code of ethics. And that code makes it clear that honesty and transparency are important core values. The first principle of health communication should be to tell the truth. The ends do not justify the means: it is not ethical for us to achieve a public health aim by lying to the public.  

The New Jersey Policy Institute summarized it well in its comment to the FDA, stating that: "many consumers lack a clear understanding of the differences in risk across nicotine products. When adults are not provided with clear, evidence-based information, they often assume that all nicotine products carry comparable harms. That misperception can discourage individuals who are actively trying to choose products that expose them to fewer toxicants than cigarettes." 

I would argue that the authorized modified risk statement is actually understated because there is no evidence that Zyn causes lung cancer or chronic lung disease in the first place. But clearly, merely claiming that Zyn use is safer than smoking, which involves the direct inhalation of tens of thousands of chemicals including 60 proven carcinogens, is a no-brainer based on scientific evidence. 

The FDA concluded that Zyn poses no significant risk of lung cancer, while "the risk of dying from lung cancer is 25 times higher among adults who smoke combusted cigarettes than those who do not smoke." Similarly, the FDA concluded that Zyn poses no significant risk of chronic obstructive lung disease, while "combusted cigarette smoking is associated with 22-25 times the risk of dying from COPD as having never smoked." You can see that the approved statement is actually an understatement because it merely suggests that Zyn reduces the risk of lung cancer and lung disease but does not provide any quantitative information so that consumers can appreciate the magnitude of these risk differences.

Furthermore, the authorized statement explicitly refers to quitting smoking by switching to Zyn. It starts: "Using Zyn instead of cigarettes... ." Why would public health groups object to a statement that essentially notes that the purpose of Zyn is to aid in smoking cessation? Ironically, by asking FDA to take away the only honest way that Swedish Match can market Zyn (i.e., telling smokers that switching to Zyn reduces health risks), the American Lung Association and other tobacco control groups that are also "appalled" are leaving the company no marketing path other than making nicotine pouch use look glamorous or appealing. The MRTP process is actually an effective way for FDA to control the marketing of these products. At the same time, it provides a pathway for companies to tell the truth about the purpose of these products, rather than having to mislead people into thinking that the purpose of these products is to make them look cool and appealing.

Tobacco control groups should consider the comments of Dr. Karl Fagerstrom, perhaps the world expert on nicotine addiction:   

"In my experience, most people who smoke do not view their dependence as a condition requiring medical intervention, and many cannot afford the time or cost associated with obtaining prescriptions or counseling. As a result, most smokers quit either unaided or with the help of alternative nicotine products such as e-cigarettes, nicotine pouches, snus, or heated tobacco. In Sweden and Norway, snus has become the most widely used nicotine product and has historically been the most frequently used aid to quit smoking. Today, nicotine pouches increasingly play this role and are on the verge of becoming the most commonly used nicotine product category in Sweden. In the United States, early data suggest that nicotine pouches are displacing traditional smokeless tobacco products. Researchers have described a “market disruption in the oral tobacco and nicotine category,” with notable declines in smokeless tobacco sales between 2018 and 2024 coinciding with the rapid growth of nicotine pouches. Importantly, this transition has occurred with very limited uptake among youth. With appropriate communication—including clear messaging that nicotine pouches present substantially lower health risks than smoking—these products could help reduce harm not only for users of smokeless tobacco but also for people who smoke. Authorizing nicotine pouches with modified risk claims could also help correct widespread misperceptions about the relative risks of different tobacco and nicotine products in the United States."

In closing, I find it appalling that the American Lung Association finds it appalling that the FDA is allowing Swedish Match to tell consumers the truth about the relative health risks of Zyn compared to combustible cigarettes. Reversing this decision would essentially force the company to lie to the public (a lie of omission) and to hide the single most important fact about the product that consumers need to know. Why in the world would we want Swedish Match to market Zyn as just another dangerous tobacco product for recreational use rather than encourage smokers to switch to Zyn to save their lives? 

 

Why is the American Cancer Society Holding a Gala Sponsored by Manufacturers of a Product that Causes 20,000 Cancer Deaths Each Year?

Imagine if the American Cancer Society (ACS) was holding a fancy gala sponsored by the nation's leading cigarette companies. They would be roundly criticized for accepting money and providing free publicity for companies responsible for approximately 200,000 cancer deaths in the United States each year - the #1 cause of cancer. It would be clear that holding such an event would be inconsistent with the mission of the organization, which is to prevent cancer, not to promote cancer-causing products.

Sadly, the American Cancer Society is doing the same thing for companies that make another product: alcohol. This one is the #2 cause of cancer in the United States and causes 20,000 cancer deaths each year. While there is a quantitative difference (20,000 cancer deaths vs. 200,000), there is little qualitative difference between these actions. The American Cancer Society is essentially allowing itself to be used as a pawn in the marketing strategy of the alcohol companies. By tying alcohol companies to the cause of preventing cancer, the ACS is helping to obscure the well-recognized relationship between alcohol and cancer, which is a huge public relations favor for these companies.

In a landmark article in today's STAT News, Isabella Cueto and Lev Facher have exposed the pernicious role that alcohol companies have played in preventing the adoption of policies to reduce alcohol-related deaths and the role that the American Cancer Society is playing in helping the companies accomplish this. 

According to the exposé: 

"Len Lichtenfeld had a long-overdue apology to make. He was haunted in late 2024 by an exchange with a New York Times reporter almost a decade earlier, during which Lichtenfeld defended the American Cancer Society’s official stance that a drink or two a day was safe, even for cancer prevention. There was mounting evidence to the contrary, which he knew from epidemiologists on staff, but didn’t mention." 

"Lichtenfeld left something else out, too: Behind the scenes, the American Cancer Society was raking in millions of dollars from the alcohol industry through an annual New York City gala, the details of which are reported here for the first time."

"Lichtenfeld, an oncologist who was then deputy chief medical officer at ACS, told STAT he felt indirect pressure to keep those donors happy. “It stayed with me, because I knew it was a conflicted situation,” he said."

So the American Cancer Society admitted that it was influenced by alcohol company donations to hide from the public the fact that moderate drinking is a cause of cancer and that even low-dose alcohol can cause breast cancer. The American Cancer Society essentially admitted to selling out the public's health and undermining its own mission in order to rake in millions of dollars from the alcohol industry.

The Rest of the Story

Unfortunately, the story doesn't end there. STAT News has reported that the alcohol industry-sponsored gala will continue and is scheduled for October of this year:

"As alcohol’s many health risks come to light, the contradiction at these kinds of events becomes more apparent. The American Cancer Society’s opulent Wine and Spirits Industry’s Gala, which is set to happen again in October, is a vivid example. The event is among the cancer nonprofit’s most glamorous, taking place in the iconic Rainbow Room overlooking Manhattan. Last year, from the heights of 30 Rockefeller Plaza, representatives from wine and liquor firms dined on braised beef shank, imbibed pineapple margaritas, and shared bottles of cabernet as they bid on a live auction. Flyers on high-top tables during dessert read: “Regular cancer screening can save your life." 

I am quoted in the article as stating:

"That is shocking, actually. For the American Cancer Society to be doing it is particularly appalling because they’re specifically charged with, or claim to be, trying to prevent cancer."

You aren't preventing cancer if you provide a platform for manufacturers of a product that causes cancer to sponsor your event and market their products, while at the same time pretending to be committed to preventing cancer. This public relations gift that the ACS is granting to Big Alcohol is worth far more than whatever amount the alcohol companies are paying to provide free alcohol.  

Disturbingly, the ACS apparently tried to downplay its involvement, telling STAT News that: "The extent of ACS’s involvement in the alcohol gala is some administrative support provided by staff." 

What a load of crap! The American Cancer Society's name and logo are all over the event web site and it is eminently clear that this is an ACS event that honors the wine and spirits "industries." This is more than just serving wine and spirits at the event; it is actually honoring the alcohol industry itself.

Instead of trying to pull the wool over our eyes, the ACS should just admit, like its former medical director did, that they are selling themselves, and their cancer prevention mission, out to Big Alcohol money.

The event website boasts that: "The Wine + Spirits Industry’s Gala has raised more than $22 million to support the American Cancer Society’s mission to end cancer as we know it, for everyone." 

Well perhaps not for everyone. The ACS is selling out the 20,000 people who will die from alcohol-related cancer this year.

Another Sham E-Cigarette Study is Retracted; Can We Trust Any of this Literature?

If you missed it, an article published in 2023 in the Journal of Investigative Medicine sent shock waves among researchers and policy makers by concluding that e-cigarette use causes chronic lung disease (both asthma and COPD). The study was cited in an influential meta-analysis concluding the same and was the basis of an advertising campaign in California touting the lung disease risks associated with e-cigarette use. 

The investigators based their conclusion on a cross-sectional study of the prevalence of e-cigarette use, smoking, dual use, and nonsmoking among a sample of 178,300 adults interviewed as part of the 2015-2016 and 2017-2018 National Health and Nutrition Examination Survey (NHANES) survey. 

According to the study authors: "The survey examines a nationally representative sample of about 5000 persons each year."  

The Rest of the Story

You don't have to know any more about the study than what I wrote above in order to figure out that it was a complete sham. And it doesn't take any knowledge of epidemiology or biostatistics. All it takes is some simple math.

The study combined four years of NHANES data. According to the authors themselves, the NHANES sample size is approximately 5,000 per year. So with four years of data, you would have a total of about 20,000 respondents in your overall sample. However, the authors claim to have a sample size of 178,300 adults. That doesn't add up.

Now, if we go to the NHANES web site, it turns out that the total number of people interviewed in the 2015-2016 and 2017-2018 cycles was 31,538. So there could not have been 178,300 respondents in the sample. 

This alone should get you to question the results of the study. If the authors cannot even get the sample size correct within an error margin of 140,000, does it give you any confidence that the results can be trusted?

But that's just the beginning of the sham. 

The study claimed that it compared the prevalence of COPD and asthma among a sample of e-cigarette users, smokers, dual users, and nonsmokers (two separate analyses). But it turns out that they used the following definitions:

"Smoking: The current smoking status of the participants was assessed by the following questions:
SMQ020: ‘‘Smoked at least 100 cigarettes in life,’’ SMQ040: ‘‘Do you now smoke cigarettes?’’

"E-cigarette: The e-cigarette use was assessed by the question; SMQ900 ‘‘Have {you/SP} EVER used an
e-cigarette?"   

Since smoking was defined as current smoking, the study apparently considered ex-smokers to be nonsmokers. In addition, it apparently classified as an e-cigarette user anyone who had ever used an e-cigarette. So if a 80 pack-year smoker tried an e-cigarette once, they would be classified as an e-cigarette user. Obviously, this is problematic because if that person gets COPD, it is certainly due to the smoking rather than the vaping. But the analysis is considering this as a death due to dual use. And if that individual was able to quit smoking, then they would be classified as a pure e-cigarette user. Clearly, that is going to artificially inflate the estimated risk for COPD among e-cigarette users.

This, too, would be enough to discount the study results. But it doesn't end there.

According to the data presented in Table 2 in the paper, the crude odds ratio for COPD associated with exclusive vaping is 0.18. This, in and of itself, would actually suggest that vaping is protective for COPD. But the paper presents an adjusted odds ratio of 11.3 for the risk of COPD among vapers compared to smokers. This is essentially impossible. It indicates that there is a major problem with the data being reported or the data being analyzed. The study results are meaningless.

We don't need to go any further, but it bears mentioning that even if the study did find an increased prevalence of COPD among e-cigarette users, it would most likely be due to the fact that when a smoker is diagnosed with COPD, that it likely to spur a quit attempt, possibly with e-cigarettes. So it would most likely be that the COPD is "causing" the vaping rather than that the vaping is causing the COPD.

Fortunately, the efforts of two of my colleagues were successful in getting the journal to retract the paper. 

Interestingly, another paper by some of the same authors, which concluded that vaping causes stroke, was also retracted recently. That study, which also used the 2015-2018 NHANES data, claimed to have a sample size of 266,058 respondents, which is 8 times higher than the actual total number of NHANES respondents. I don't know where the additional 234,520 respondents came from but it appears that many of these imposters also intruded themselves into the more recent study as well.

The reporting of inaccurate science, reported widely through the media and by tobacco control groups, has contributed to a widespread misunderstanding of the relative risks of vaping compared to smoking and to irrational policy decisions regarding the regulation of electronic cigarettes. In turn, this misunderstanding has harmed the public's health by deterring many smokers from quitting and has caused many ex-smokers to return to smoking. 

But the adverse implications of this go beyond that. Unfortunately, they cast doubt on the validity of the entire field of research claiming that e-cigarette use causes lung disease, stroke, and cancer. Even worse, these continuing retractions risk the loss of public trust for scientific research more broadly. 

A New Generation of Youth are NOT Getting Addicted to Nicotine Through Vaping

According to the Campaign for Tobacco-Free Kids, "E-cigarettes are hooking a new generation on nicotine – putting millions of kids at risk and threatening decades of progress in reducing youth tobacco use. It’s a nationwide crisis of youth addiction, fueled by thousands of kid-friendly flavors and massive doses of nicotine."

It's a great and truly alarming sound bite, but is it true?

An examination of data from the 2024 National Youth Tobacco Survey shows that the Campaign for Tobacco-Free Kids' claim is alarmist propaganda that is false and misleading as well as obscuring the real threats to public health posed by actual tobacco-containing products as well as the real risks associated with youth vaping itself.

The Rest of the Story

Let's look at how bad this "crisis" of youth addiction is. A good sign of addiction to nicotine in vapes is the daily use of e-cigarettes. The prevalence of daily vaping among middle and high school students in 2024 was just 1.4%. This means that youth vaping ranks equal to or below all of the following other forms of substance use which are arguably more dangerous:

Smoking: 1.4%; 

THC vaping: 4.2%

THC vaping or smoking: 4.9%

However, the Campaign for Tobacco-Free Kids is not saying anything about the problems of youth smoking or THC vaping.

In fact, if you exclude youths who are vaping THC and/or smoking, the prevalence of exclusive, daily e-cigarette vaping is only 0.5%.

By no means am I arguing that we don't need to address nicotine vaping among this 0.5% of youths. However, this can hardly be called an epidemic, there are clearly more dangerous substances being used by many more youth that need to be addressed, and in no way does this negate the drastic declines in youth smoking that have been achieved over the past several decades.

Moreover, even if vaping were sky-rocketing--like it did in 2019--it would still not be threatening our progress in reducing the use of tobacco among youth, as the Campaign for Tobacco-Free Kids claims. Why? Because nicotine vapes do not contain tobacco. Vaping is not a form of tobacco use, period. Even if every youth was vaping, it would not be a crisis of tobacco use. It would be a crisis of vaping.

Perhaps most importantly, the obsession that the Campaign for Tobacco-Free Kids has with hyperbolizing what is a real problem of youth vaping is damaging because it obscures attention from high risk behaviors that youth are engaging in but health groups are doing very little about: (1) smoking; and (2) THC vaping. This is not to mention the use of alcohol (10.4% past-month use among 10th graders in 2025) and other illicit drugs (11.3% past-month use among 10th graders in 2023). 

I understand the desire for groups like the Campaign for Tobacco-Free Kids to ignore the actual data and mislead the public in order to scare them into thinking that youth addiction to nicotine is running rampant because of tobacco company marketing of e-cigarettes to minors and that a new generation of youth is becoming addicted to tobacco. That strategy makes sense because it is alarming and will bring in donations. However, in public health, we should pride ourselves on being honest, transparent, and evidence-based. And the Campaign for Tobacco-Free Kids (along with many other tobacco control groups) is not doing any of these three. 

Tobacco Control Groups are Misleading Legislators in Their Efforts to Block Smokers from Access to Life-Saving Products

Last night I testified at a hearing of the Rhode Island Senate Finance Committee on a bill (S2844) that would allow the sale of flavored e-cigarettes in specialty vape shops that are only open to adults age 21+ and that conduct age verification (beyond checking an ID). The bill would also allocate 10% of the state revenue from such sales to be used for smoking cessation programs.

You can watch the hearing here (my testimony is at -24:30). You can find the written testimony that was submitted to the committee here.  

Below is my testimony, followed by some observations about the hearing.

Testimony on S2844

I am Dr. Michael Siegel, a professor of public health and community medicine at Tufts University School of Medicine. 40 years ago – almost to this day – I, as a senior at Brown University, stood one floor above where we are today and testified before the Senate HEW committee in favor of a bill (S2643) to ban smoking in all workplaces in Rhode Island. We faced off against two Big Tobacco stalwarts – Kelly Sheridan (a tobacco institute lobbyist) and former Governor Dennis Roberts, a Big Tobacco sympathizer. We won, kicked Big Tobacco’s butts out of the state, and the legislature was on its way to becoming a national leader in the effort to make smoking history.

Thank you for the opportunity to testify today, 40 years later, as a tobacco researcher who has dedicated my career to trying to save lives from smoking-related diseases.

You can imagine my shock when I drove down to Rhode Island today to find out that the state legislature has given Big Tobacco a huge victory. After all my work fighting to make smoking history in Rhode Island, the legislature has taken an enormous step backwards.

HOW? By putting a huge barrier in front of Rhode Island smokers who want to quit to save their lives. The legislature did this by banning the single most effective strategy to quit smoking: flavored vapes. What a favor to Big Tobacco! Allow all of their products to remain on the shelves in every gas station and convenience store while putting flavored e-cigarettes on the black market, only available to those who are willing to conspire to break state law.

This is why I stand in favor of legislation that would allow the sale of flavored e-cigarettes in stores that exclusively sell tobacco products and restrict access to individuals aged 21 and older. This is a commonsense policy that balances public health concerns with the reality of adult smokers' needs.

Let’s be clear: the state legislature’s current approach to banning nearly all electronic cigarettes, while continuing to allow the unrestricted sale of real tobacco cigarettes in convenience stores and gas stations, is not just inconsistent—it’s downright hypocritical. We are talking about a product—real cigarettes—that has killed millions of Americans and remains easily accessible to anyone who walks into a corner store. Meanwhile, flavored e-cigarettes, a far less harmful alternative for adult smokers, are pushed into the shadows, making it harder for people to make a healthier choice.

For many adults who rely on flavored e-cigarettes as a tool to quit, this ban is a direct threat to their progress. They are left with two choices: relapse back to smoking or turn to the black market.

We must recognize that banning flavored e-cigarettes doesn’t solve the problem—it merely drives it underground. Instead of pushing people toward less-regulated and more dangerous options, we should give them the ability to make a safer choice.

I urge you to support this legislation, not just for fairness but for public health. Let’s stop punishing adult smokers who are trying to make a positive change and give them a chance to stay away from cigarettes. Let’s restore Rhode Island as a national leader in smoking prevention, not smoking facilitation. Thank you.

The Rest of the Story

Some Observations about the Hearing

The primary opponents of this bill were the American Lung Association, American Heart Association, American Cancer Society, Campaign for Tobacco-Free Kids, Rhode Island Academy of Pediatrics, and the Rhode Island Department of Health. When I refer to the bill's "opponents" below, I am referring to these organizations.

1. I never thought that I would be on the other side of the issue from these organizations, with which I worked for many years. 

It was extremely uncomfortable for me to be in a position where I was speaking on the opposing side of these organizations with which I worked for many years. In fact, when I was a lobbyist in Rhode Island (during my senior year at Brown University) promoting a ban on smoking in all workplaces, I worked closely with the Rhode Island chapters of the American Cancer Society, American Heart Association, and the American Lung Association, along with the Rhode Island Department of Health (where I was an intern). It was very strange and uncomfortable to now be on the opposite side, where I was supporting an effort to enhance smoking cessation while these groups were trying to block the most effect off-ramp for smoking cessation that currently exists.

Based on the National Health Interview Survey, approximately five million Americans have quit smoking completely using e-cigarettes. Among young adults, flavored e-cigarettes are the single most used method for assisted smoking cessation and the single most effective method for assisted smoking cessation. Why these groups would want to block this off-ramp for millions of smokers is beyond my comprehension. It makes no sense. 

Ironically, these groups defeated their own testimony by repeatedly emphasizing to the Committee how easy it is for youth to access flavored vapes in Rhode Island. That is actually a strong argument in support of this bill because flavored vapes have been banned in Rhode Island for more than a year, If it is still easy for youth to access these products, then clearly the ban is not particularly effective. And if that's the case, then smokers are being harmed for no good reason. One of the bill opponents testified that they had spoken to a group of youths the night before and 11 out of 11 said that it's no problem for them to obtain flavored vapes. Essentially, the opponents admitted that the flavored e-cigarette ban is not very effective and that if youth really want to vape they'll find a way to access the product. 

2. These groups no longer seem to be interested in making smoking history. They are throwing smokers under the bus to promote their organizational agenda of trying to end the recreational use of nicotine for any purpose.

The opposition groups continued to emphasize throughout the hearing that there needs to be off-ramps for smokers yet they are blocking the single most effective and highly used off-ramp for Rhode Island smokers. I submitted written testimony summarizing the evidence from clinical trials that pitted e-cigarettes against NRT or Chantix for smoking cessation. The results from all of these clinical trials are consistent: e-cigarettes are more effective than any "FDA-approved" medication for smoking cessation. Why would these groups -- who argue that providing off-ramps for smokers is essential -- want to keep the single most effective off-ramp off the market? None of the organizations that opposed this legislation was able to provide a compelling answer to that question. In fact, they simply ignored that question completely.

3. The hypocrisy of these groups is overwhelming.

All of these groups want to ban the sale of virtually all e-cigarettes but are perfectly OK with deadly cigarettes being readily available at every corner store, convenience store, and gas station throughout Rhode Island. The groups are not even asking to restrict the sale of cigarettes to tobacco-only stores that are only open to adults ages 21+. It makes no public health sense to make it literally impossible to legally purchase "fake" cigarettes that contain no tobacco but to make sure that deadly tobacco cigarettes are readily available around every corner. 

I have long argued that all nicotine-containing products should only be available at vape/tobacco shops with age 21+ restrictions and age verification. Instead of forcing cigarettes to compete head-to-head with a much safer product, these groups are giving cigarette companies a huge advantage in the marketplace by banning the sale of their chief competition.

4. Despite 17 years of experience and conclusive research on the effectiveness of e-cigarettes for smoking cessation and the decreased risk of e-cigarettes compared to smoking, these groups are not willing to update their prior convictions, which they've held since 2009.

When electronic cigarettes came on the market in 2007, I thought they were just another Big Tobacco ploy to addict the next generation of youth by marketing a product as being safer than cigarettes when it really wasn't any safer. I thought this was another "light" cigarettes fiasco. My position was essentially the same as that of the opposition groups that spoke last night. However, when the research came out showing that e-cigarettes were not another "light" cigarette fiasco, when I learned that Big Tobacco had nothing to do with the introduction these products into the market (they were not in the act until 2011), and when I talked to hundreds of vapers who explained how nothing on the market was effective in helping them quit until they tried vaping, I changed my mind. My views change as the research evidence changes. These groups seem to be permanently stuck in 2009.

5. These opposition groups continue to paint the picture that Big Tobacco is preying on youth when the reality is that most youth are not using e-cigarettes made by tobacco companies.

I continually heard the mantra that it is Big Tobacco which is peddling e-cigarettes to minors and enticing them with flavors like cherry, gummy bear, and cotton candy. This has been the rhetoric of the Campaign for Tobacco-Free Kids for years. It is wrong and it is damaging because this misunderstanding is preventing us from intervening effectively in the effort to reduce youth use of e-cigarettes. According to my analysis of data from the 2026 National Youth Tobacco Survey, only 12% of youth vapers are using brands manufactured by tobacco companies. An overwhelming 88% are using brands that are technically sold on the black market as they have not received a marketing authorization order from the FDA. 

The reality is that even if the tobacco companies stopped selling all e-cigarettes today, it would hardly put a dent in the public health problem of youth vaping. The appropriate solution is not to ban e-cigarettes so that the only vapes that youth get their hands on are unregulated black market products. The appropriate solution is to actually regulate these products so that we can control their safety, ingredients, and marketing practices. The prohibition approach that these groups have promoted has essentially turned the e-cigarette market into a primarily illicit market. Ironically, the policies these groups have promoted has prevented the regulation of e-cigarettes and instead, ensured that the overwhelming majority of e-cigarettes on the market are unregulated.

6. Worst of all, these groups are apparently OK with using misinformation and deception to promote their position.

For example, the American Lung Association, American Heart Association, American Cancer Society, and Campaign for Tobacco-Free Kids stated that: "Flavored tobacco products are reversing decades of progress in reducing tobacco use among youth and worsening the persistent disparities regarding addiction among communities of color." This is untrue. Flavored tobacco products are not reversing decades of progress in reducing tobacco use. Tobacco use among youth is the lowest it has been in decades and has declined even more rapidly since e-cigarettes have been on the market. In the 2026 National Youth Tobacco Survey, the prevalence of youth smoking was only 1.4%. 

Moreover, e-cigarettes are not disproportionately addicting communities of color. The prevalence of daily vaping (an indication of likely addiction) among non-Hispanic White adolescents in 2026 was 1.8%, compared to 1.3% for non-Hispanic Black adolescents and 0.9% for Hispanic adolescents. 

As another example, these organizations state: "There is overwhelming evidence that mint, menthol and other candy and fruit flavors are luring children and adolescents and fueling tobacco and nicotine addiction in the next generation." While these flavors could potentially be leading to nicotine addiction they are not leading to tobacco addiction. These products contain no tobacco so youth who are addicted to vapes are not experiencing tobacco addiction. Moreover, there is no evidence that e-cigarettes are a gateway to smoking (the opposite is true) so flavored vapes are not leading to tobacco addiction via that route either.

In addition, these groups state: "Among students who use electronic cigarettes, the vast majority (87.6%) use flavored products, including fruit, candy and mint. The tobacco industry knows these flavors appeal to youth and the data show that this sinister strategy works to attract and addict them." This statement is not just misleading, it is downright false. The tobacco industry is not marketing fruit, candy, or mint e-cigarette flavors. The only flavored e-cigarette products that they are marketing are menthol. I would ask these organizations to list all of the fruit, candy, and mint-flavored e-cigarettes being sold by tobacco companies. It would be a blank list.

The Rhode Island Department of Health also misled the Committee when it claimed that: "Most tobacco use, including vaping, starts and is established in adolescence." The problem with this statement is that vaping is not a form of tobacco use. There is no tobacco in the product. It is not fair to mislead the legislature like this.

While it is disappointing for me to see my colleagues in the tobacco control movement take positions that I believe are detrimental to the public's health, they certainly have the right to offer a different opinion. However, it is not acceptable for them to mislead the legislature or to misrepresent the facts in order to support their positions. 

Study Claiming that Vaping Causes Lung Cancer Fails to Document that a Single Case Occurred After the Person Started Vaping

An article published recently in the journal Frontiers in Oncology concluded that vaping causes lung cancer among young adults (age <50) based on the finding that lung cancer risk among dual users of cigarettes and e-cigarettes was higher than the risk among exclusive smokers. This was a case-control study of young adults in which the investigators used electronic medical records to identify patients with lung cancer and a matching set of patients without cancer and then compared the odds of having lung cancer among the dual users to the odds of having lung cancer among the smokers. 

The study found that the odds of having lung cancer among the dual users was 2.8 times higher than among the exclusive smokers. Based on this finding, the authors concluded that "vaping and smoking together accelerate lung cancer risk among young people, particularly in the development of pulmonary adenocarcinoma."

The Rest of the Story

To evaluate the study's conclusion, we need to review some basic epidemiology. In a case-control study, the odds ratio measures the odds of disease (in this case, lung cancer) among the exposed (in this case, dual users) to the odds of disease among the unexposed (in this case, smokers). Dual use is the exposure and it is being compared to exclusive smoking. 

OK, now a key thing to understand about the case-control design is that the ratio of the odds of disease among the exposed to the odds of disease among the unexposed is the same as the ratio of the odds of exposure among the diseased to the odds of exposure among the controls.  

To repeat that in terms of this study, the relevant odds ratio comparing the lung cancer risk of dual users to that of smokers is equivalent to:

The odds of dual use among smokers with lung cancer divided by the odds of dual use among smokers without lung cancer. We'll come back to this in a second.

Now, critically, in a case-control study, one has to go back in time in order to measure the exposure because if exposure and disease are measured concurrently, there is no assurance that the exposure preceded the disease, which is a key criterion for drawing a causal conclusion. If a case-control study measures exposure at the current time (concurrently) rather than retrospectively, it risks severe reverse causality, where the outcome influences the exposure rather than vice versa. This design is unsuitable for establishing causation, as it cannot confirm if the exposure occurred before the disease.

Importantly, in this study, it appears that smoking and vaping status was measured concurrently with the disease. The paper fails to state that the investigators went back in time to determine the historical trajectory of an individual's smoking and vaping status. It appears that they just drew the information from the record of the particular visit in the record database rather than searching historical records to determine smoking and vaping status in the past. For this reason, it cannot be documented that dual use preceded the lung cancer. It is very possible that dual use came after the lung cancer. And in fact, that is the most plausible explanation for the study results.

Let's go back to this point: The relevant odds ratio comparing the lung cancer risk of dual users to that of smokers is equivalent to the odds of dual use among smokers with lung cancer divided by the odds of dual use among smokers without lung cancer. The study found that the odds of dual use among lung cancer patients who smoked is 2.8 times higher than the odds of dual use among controls who smoked. So essentially, the authors are concluding that vaping causes lung cancer because when smokers are admitted to the hospital with lung cancer, they are more likely to be vaping than smokers who are admitted to the hospital but don't have any type of cancer.

Clearly, the most likely explanation for this finding is that getting lung cancer serves as a highly motivating event to trigger an attempt to quit smoking. And since e-cigarettes are a commonly used smoking cessation strategy, many of those diagnosed patients likely used e-cigarettes in an attempt to quit smoking.

Thus, it is not at all a surprise to find that the odds of dual use among smokers diagnosed with lung cancer is about 3 times higher than the odds of dual use among smokers who are not diagnosed with cancer. All that this suggests is that smokers who are diagnosed with lung cancer are more likely to be motivated to try e-cigarettes in attempt to quit than smokers who are not diagnosed with cancer.

I don't understand why the authors drew a causal conclusion from a case-control study that measured exposure concurrently with the outcome. This is a situation where reverse causation is the most plausible explanation for the study findings. 

Moreover, the authors do not even mention this possibility in the skimpy limitations section. In fact, the limitations "section" is just a single sentence: "One study limitation was that due to the nature of the electronic medical record data, we could not quantify vaping and smoking as detailed as we had planned, nor the timing of vaping relative to smoking. ... Another limitation was the lack of information on potential effect modifiers such as exposure to secondhand smoke, air pollution, and genetic predisposition to lung cancer." Well if they acknowledge that they had no idea of the timing of vaping relative to smoking then how can they possibly draw a causal conclusion?

Even worse, the paper takes the opportunity to use this single flawed conclusion to condemn harm reduction. Although they acknowledged that they had no idea of the timing of the decision of these smokers to try e-cigarettes, and although they have no idea how long the patients vaped before their lung cancer diagnosis, the authors argue that: "Our results are in marked contrast to the 'harm reduction' approach that deems vaping to be less harmful than cigarette smoking, instead showing that exposure to aerosolized e-liquid may in fact promote lung carcinogenesis, especially when combined with smoking."  

So now they go even further in their conclusion than their study would allow them even if reverse causation was not a problem. Here, they conclude that vaping is no less harmful than smoking. It certainly has the appearance that there is investigator bias involved with that bold (and false) statement. They are literally making a plea to alter the entire strategy for smoking cessation throughout the country based solely on the finding that when smokers are diagnosed with lung cancer, they then are more likely to use e-cigarettes than smokers who are not diagnosed with cancer.

Perhaps the clincher here is that the authors, in the abstract and introduction to the paper, make a false statement -- three times -- revealing a massive misunderstanding of the nature of e-liquids. They state: "the inhalation of heated aerosolized vaping oil has now replaced cigarette smoking as the major source of nicotine among young people." Then, they state: "Notably, the inhalation of heated aerosolized vaping oil is currently the major source of nicotine among young people." Shortly thereafter, they state: "While the inhalation of aerosolized nicotine-containing vaping oil is known to expose the lungs to carcinogens, only a few studies have examined the potential role of vaping as a lung cancer risk factor."

E-liquids do not contain oils. Vaping oils are used in THC vapes, not nicotine vapes (e-cigarettes). Vaping oils are not used to deliver nicotine. They are used to deliver THC, CBD, or essential oils. To be clear, the use of vaping oils can be quite dangerous. If vitamin E acetate is used to increase the viscosity of the oil, vaping it can cause severe lung damage and even death. Even without vitamin E acetate, vaping oils can cause lipoid pneumonia, which can result in permanent lung injury. The excipients in e-cigarettes are alcohols: propylene glycol and glycerin. They are not oils. 

I'm not concerned that a particular study has a flawed conclusion. However, what is very concerning is that anti-vaping groups are using this shoddy research to support their false claims that vaping is just as dangerous as smoking. This is causing real public health harm because it dissuades smokers from quitting, may cause some ex-smokers to return to smoking, and leads to public policies that result in blocking a major off-ramp for smokers looking to quit. 

Findings from the 2025 National Youth Tobacco Survey that Anti-Nicotine Groups Don't Want You to Know

Earlier this week, the FDA released the data from its 2025 National Youth Tobacco Survey. This is a public use dataset so it is freely available to all. My own analysis of these data revealed some important findings that I want to share. To the best of my knowledge, the questions I investigated in my analysis are questions that no health agency or anti-nicotine organization has ever examined. When you see the results, you will understand why.

First, I want to put forth the conceptual thinking that led me to ask these particular questions. It is based on adolescent risk-taking theory, which posits that adolescent risk-taking is not necessarily a sign of brain dysfunction, but rather a normal, necessary, and adaptive part of development. According to the UCLA Center for the Developing Adolescent: "It’s not only normal for adolescents to take risks and try new things, it’s an essential part of learning during these years. Being able and willing to take risks is a part of our natural tendency to explore new things in adolescence—in ways that help us discover who we are, expand our skills, and ultimately leave the safe nest of home." 

Moreover, independence and rebellion are the core values of adolescence. Risk-taking is a way of expressing autonomy and rebelling against adult authority. It is also a way of coping with the stresses of adolescent life. Given what is going on in the world today, it is not surprising that youth are facing unprecedented challenges to their mental health. Most are going to engage in some form of risky behavior in order to cope. The problem with authoritarian thinking in the tobacco control movement is that we have committed ourselves to the goal of eliminating all nicotine-related risk among youth rather than attempting to employ a harm reduction approach and ensure that the risks youth do take are relatively safe, at least in comparison what they could otherwise be doing.

The general theory in the tobacco control movement is that youth vape because Big Tobacco is evil and has tricked them into thinking that vapes are safer than cigarettes, has enticed them with gummy bear and cotton candy flavors, and used targeting marketing in an attempt to addict a new generation to a behavior that is a gateway to smoking and most likely, a lifetime of tobacco use. This argument is flawed for many reasons -- not the least of which is that it is untruthful -- but beyond that there is strong evidence that vaping went viral largely because of social media influencers combined with the addictive nature of nicotine. Remember that even without an addictive component, "six-seven" took off in 2025 and fidget spinners became a viral toy craze in 2017. 

The bottom line is that adolescents engage in risk-taking behavior and that youth who take one type of risk are also more likely to take other risks. For example, we know that youth who use marijuana are also more likely to smoke. So the question I posed is: Could it be that youth who use e-cigarettes are also more likely to smoke or to vape other even more risky substances, like THC, CBD, or synthetic marijuana like K2 or spice? 

The Rest of the Story

Based on my analysis of the 2025 National Youth Tobacco Survey, the prevalence of current e-cigarette use (defined as use within the past 30 days) among middle and high school students was 5.2%, drastically down from a peak of 20.0% in 2019. Among these youth current e-cigarette users, about half (51.0%) also were current smokers and/or current users of THC, CBD, or synthetic marijuana vapes. Among heavy e-cigarette users (defined as use on at least 20 of the past 30 days), a large majority (63.5%) also were current smokers and/or current users of THC, CBD, or synthetic marijuana vapes.

What this means is that for nearly two-thirds of youth heavy e-cigarette users, the biggest risk they face is not the e-cigarettes but either smoking or using black market marijuana vapes. 

The reason tobacco control groups don't want you to know this is that it exposes their culpability in the EVALI outbreak, which resulted in nearly 3,000 hospitalizations and 68 deaths. These groups were insistent upon blaming the outbreak on e-cigarettes. They promoted bans on e-cigarettes and continually insisted that the problem was e-cigarettes but failed to tell youth the truth: black market THC products tainted with vitamin E acetate are the cause and you need to stop using these product today!

The failure to warn youth about the dangers of black market THC products was very much responsible for many hospitalizations and perhaps deaths. The health groups did such a poor job of communicating this essential fact that only 11% of youth knew that EVALI was caused by marijuana vaping.

These data paint a very different picture of the youth vaping "epidemic." The large majority of youth who use e-cigarettes regularly are engaging in multiple risk taking behaviors, including ones that are far more dangerous than nicotine vaping. The use of black market THC vapes or synthetic marijuana vapes could literally be life-threatening or at least pose a significant risk of immediate health harm severe enough to require hospitalization. Even though vitamin E acetate is no longer a common component of THC vapes, the use of any black market vaping product carries the risk of tainting with synthetic cannabinoids or other drugs, a risk that is not present with the use of nicotine-containing e-cigarettes that originated in a retail store. These drugs can cause heart attacks, strokes, and seizures. Black market THC vape pens may also contain synthetic opioids whose use could be fatal. 

Based on my analysis, an alarming 15.2% of youth daily e-cigarette users are also vaping synthetic marijuana. While anti-vaping groups are trying to ban e-cigarettes, most are not even informing youth about this risk and seem to be more concerned about a youth ripping a cherry vape than having hallucinations, seizures, or being hospitalized because of black market drug use.

Yes, youth e-cigarette use is a public health problem. However, our insistence on a prohibition-based approach rather than focusing on harm reduction is putting youth at great risk, not less.

Smoke-Free Products Nearing 50% of the Nicotine Market Thanks to Tobacco and Vaping Companies But In Spite of the Actions of Most Tobacco Control Groups

A new report from the nation's leading tobacco market expert - Bonnie Herzog at Goldman Sachs - reveals that smoke-free nicotine products now account for 48% of the overall nicotine market and are projected to comprise 75% of the market within 10 years. Furthermore, the overwhelming majority of the smoke-free market is also tobacco-free, meaning that not only are combustible tobacco products on the decline but tobacco products themselves are on the decline. The major players in the smoke-free, tobacco-free nicotine market are e-cigarettes and nicotine pouches.

The Rest of the Story

Here's the sad part of the story. This transition from combustible cigarettes to smoke-free, tobacco-free electronic cigarettes and nicotine pouches is almost entirely due to innovations from tobacco and vaping companies, not because of the hard work of tobacco control and public health organizations. In fact, most tobacco control groups have tried to obstruct, rather than promote, this miraculous, live-saving transition. The rest of the story is that this public health miracle is due to innovations within the tobacco and vaping industries and it occurred in spite of, not because of the actions of tobacco control and health groups.

When Massachusetts initiated its landmark anti-smoking program in 1993, our slogan was "Let's Make Smoking History." At the time, I thought that was a goal that would never be achieved. Thirty-three years later, that dream is starting to come true. But the reason it's coming true is not because Massachusetts and other states have acted to promote a market transition away from combustible tobacco products. The sad truth is that the opposite is the case. Most tobacco control groups, health groups, and policy makers have done everything in their power to block this transition. Their attacks on e-cigarettes and now, nicotine pouches, have hindered rather than helped progress in reducing morbidity and mortality from smoking, which is still the leading preventable cause of death in the United States. 

While youth vaping is a public health problem, its negative impacts are dwarfed by the life-saving gains resulting from the decimation of the combustible tobacco market. Moreover, contrary to the actions of the mainstream tobacco control groups, we can address the problem of youth vaping without precluding adult access to the much safer, smoke-free, tobacco-free alternatives. We don't have to cut off our nose to spite our face. And in fact, current efforts to address youth vaping have harmed the public's health more than they have improved it. 

The current U.S. regulatory system for nicotine products is backwards. It prohibits or restricts the safest forms of nicotine while promoting the use of the most deadly form: cigarette smoking. And the reason for this backwards form of regulation is the advocacy done by the leading tobacco control groups, which did the cigarette companies a huge favor by trying to eliminate most or all e-cigarettes from the market while doing nothing to restrict the most harmful consumer product on the market.

The rest of the story is that the mainstream tobacco control groups have largely squandered an opportunity to promote what is potentially one of the most substantial and miraculous public health advances of our time: making smoking history.

Massachusetts Association of Health Boards Wants to Ban the Use of Flavored E-Cigarettes, by ANYONE

The Massachusetts Association of Health Boards (MAHB) has disseminated a model nicotine regulation policy that it is recommending be adopted by all boards of health in Massachusetts. The policy makes it illegal for anyone in the state to possess a flavored electronic cigarette. 

Existing state law prohibits the sale of flavored tobacco products but it does not prohibit people from using these products. For example, although youth cannot be sold flavored e-cigarettes, they are not punished (i.e., fined) if they take a hit from one. Many adults use flavored e-cigarettes to keep off of real cigarettes, and although flavored products can't legally be sold in the state, an adult is not punished if they are caught vaping a non-tobacco-flavored vape.

The model policy being promoted by MAHB calls for changing the law so that not only is the sale of flavored e-cigarettes banned, but the use of these products would be prohibited as well. The law prohibits any person from "possessing, holding, or keeping" a flavored e-cigarette. This of course means that you are not allowed to use an e-cigarette because you have to hold it to use it! (You would be prohibited from using it anyway because if you're vaping, then you obviously are "possessing" it).

The specific language of the model policy reads as follows (the revised text is shown in bold): "No retailer or person, as defined herein, shall possess, hold, keep, sell or distribute or cause to be possessed, held, kept, sold or distributed any flavored tobacco product, as defined herein, or any flavored tobacco product enhancer, as defined herein, (NOTE: If the municipality permits smoking bars add this phrase [except in smoking bars for on-site consumption only])."

Technically, this also makes it illegal to even hand over a flavored e-cigarette to someone because you are then "causing it to be possessed."

The Rest of the Story

I hope that local boards of health have enough sense not to implement this recommended policy. It has long been the philosophy in tobacco control that you don't punish the users of tobacco products but focus on the sellers who violate the law. Moreover, why would you punish people who are trying to save their lives through the use of flavored vaping products?

I don't know what the MAHB is trying to do here but it certainly has the appearance of wanting to punish smokers for making the wise health decision to switch to electronic cigarettes. Passage of such an ordinance would mean that every person who uses anything other than a tobacco-flavored e-cigarette would be violating the law. Ironically, smoking a Marlboro Red would be perfectly legal. 

This proposed ordinance also recommends that nicotine pouches either be restricted to less than 6mg of nicotine or that their sale be restricted to adult-only tobacco shops. There is no scientific rationale for setting the level at 6mg and doing so could potentially make the products less effective in getting smokers to quit. Moreover, banning the sale of nicotine pouches at convenience stores but allowing deadly cigarettes to be sold makes no sense. 

What is the motivation behind wanting to make sure that it is as easy as pie for any youth or adult for that matter to obtain deadly tobacco cigarettes at your nearest gas station or convenience store but restricting much safer nicotine pouches (no tobacco, no combustion) to select stores? Requiring all nicotine products to be sold in adult-only "tobacco" shops would be consistent with public health but why do such a favor for cigarette manufacturers at the expense of people's health and lives?