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?

End of Year Thoughts: Why are So Many Anti-Tobacco Groups Attacking a Product with Few Acute Risks, But Saying Nothing About Truly Risky Tobacco Products?

Why are so many anti-tobacco groups attacking electronic cigarettes (and to some degree nicotine pouches) but saying little about the risks of much more dangerous behaviors such as smoking? This is the $64,000 question, although I will only add my 2 cents here. But it is something that I have been thinking about for a long time (specifically, 16 years).

After a decade and a half of thought, I've gone through and discarded a slew of hypotheses and although I think there is some truth to many of them, there is only one that I find can consistently explain the shocking, irrational, unscientific, hysterical, and damaging behavior of so many anti-tobacco organizations.

First, why do I explain the behavior of so many of these groups as shocking, irrational, unscientific, hysterical, and damaging?

Shocking: It is shocking to me that an organization like the American Lung Association (with which I worked closely for several decades as both an employee and volunteer) is telling the public that quitting smoking by switching to vaping is not quitting smoking. That statement doesn't even make sense grammatically. It's false on its very face. You can't say "quitting smoking by doing X isn't quitting smoking." Unless that X is smoking! In this case, the X is not smoking, but vaping. They're not even qualifying the statement by asserting that if you don't switch completely to e-cigarettes, then you haven't quit smoking. They're actually saying - and I believe they actually mean - that if you quit smoking you have not quit smoking (if you did it in a way that they disapprove).

Irrational: It is irrational to discourage people who are addicted to smoking from switching to a much safer form of nicotine intake that has helped millions of people quit completely. Groups like the American Cancer Society are actively discouraging smokers from quitting using e-cigarettes, despite their proven effectiveness.

Unscientific: There is abundant scientific evidence that switching to vaping is the single most effective method for quitting smoking (other than cold turkey quitting for those who are highly motivated or triggered). The smoking cessation rate associated with the use of e-cigarettes is consistently about twice as high as that for nicotine replacement therapy, yet NRT is considered the "gold standard" for smoking cessation treatment.

Hysterical: By hysterical, I don't mean that the claims that many of these groups are making are funny. I mean that they are completely ungrounded in science and greatly exaggerated. In other words, that they are a form of hysteria which is helping to spread false information. For example, the claim that vaping causes popcorn lung is hysteria: there is not a shred of evidence to support that claim. Smoking itself is not associated with popcorn lung. It is, quite frankly, a hysterical claim in its lack of scientific grounding.

Damaging: As a result of all of the above, these organizations are essentially recommending against smoking cessation for smokers who desire to quit using e-cigarettes. They are actually providing medical advice to smokers indicating that they might as well continue to smoke rather than switch to e-cigarettes and some are even suggesting that switching to e-cigarettes is more dangerous than just continuing to smoke, arguing that dual use of smoking and e-cigarettes somehow greatly increases health damage despite dramatically lower tobacco smoke consumption. The campaigns of deception have resulted in demonstrable public health damage, as national surveys confirm that the majority of both youth and adults in the U.S. do not appreciate that smoking is any more hazardous than exclusive e-cigarette use. Undoubtedly, this has discouraged many smokers from quitting and has probably even led some ex-smokers to return to cigarette smoking.

The Rest of the Story

The conclusion I have come to is that the primary reason that so many of these groups are attacking these forms of nicotine use that have few acute risks is precisely because they have so few acute risks. In other words, deep down there is something about the relative lack of health dangers of these behaviors that bothers them and that they cannot accept. Ironically, these products pose such a risk to these groups because they don't pose a tremendous risk to youth and actually help adults who smoke. It finally occurred to me that the reason why these groups are attacking the very nicotine products at the lowest end of the risk continuum is because they are at the lowest end of the risk continuum. This is threatening to the idea that drug use should be harmful. 

And more specifically, it is threatening to the idea that people who use a recreational, addictive drug should be punished for that decision rather than rewarded for it. It is difficult for these groups to accept the fact that: 

(1) millions of adults are using a recreational drug involving addictive nicotine in a healthy way -- namely, in a way that actually improves their health; and

(2) hundreds of thousands of youth are using a recreational drug involving addictive nicotine without putting themselves at great risk of substantial health harm. 

In other words, the huge threats here are that an adult can use nicotine as a recreational drug in a way that improves their health and that a youth can use nicotine as a recreational drug in a way that does not put them at a particularly high risk of suffering severe health damage.

Let's play this argument out a little more. 

A devil's advocate argument might be that it can't be the lack of risk that is the cause for alarm because these same anti-tobacco groups are OK with the low risks associated with pharmaceutical nicotine products -- such as nicotine patches or gum or drugs like varenicline or buproprion. If these groups are threatened by the fact that people might be using nicotine in a healthy way, then why wouldn't they also be attacking NRT?

But it's not the use of nicotine in a healthy way that is threatening to these groups -- it is the recreational use of nicotine that bothers them. For decades, we in tobacco control have demonized nicotine. Given its demonic status, how can we possibly condone, or even support and recommend, the recreational use of this drug for any purpose, even one that improves the health of an individual? We're not offended if it's prescribed by a doctor as a medication because then it's not recreational use. It's the recreational use aspect that makes it unacceptable.

It's unfortunate because in some ways, latching on to nicotine as a central evil of cigarettes was what helped greatly reduce cigarette smoking, promote effective regulations, destroy the reputation of the cigarette companies, and achieve major legislative and litigation battles. In many ways, it was former FDA Commissioner David Kessler's pronouncement of nicotine as a drug that ultimately led to passage of the Family Smoking Prevention and Tobacco Control Act of 2009. So recognizing and emphasizing the role of nicotine in smoking addiction played a major role in fighting the tobacco industry and in greatly reducing smoking rates.

The problem is that now, what was previously an appropriate obsession with the problem of nicotine addiction is threatening to destroy a golden opportunity to literally make smoking history, as we had previously indicated was our primary goal (e.g., the slogan of the Massachusetts anti-smoking campaign for many years was "Let's Make Smoking History.")

Ironically, it is the tobacco control movement that is now the greatest threat to making smoking history as the movement's continuing demonization of nicotine--divorced from any consideration of its actual health effects--is leading to misguided public recommendations, physician misinformation, public deception, and ill-conceived regulation and legislation that has combined to achieve the effect of doing everything possible to protect combustible tobacco use from being completely displaced by much safer forms of nicotine use that do not even involve tobacco (although the mainstream tobacco control groups continue to incorrectly call e-cigarettes and nicotine pouches "tobacco products" and "forms of tobacco use"). 

While the mainstream tobacco control movement has become obsessed with trying to destroy the safest forms of nicotine available, they are at the same time protecting the most dangerous form of nicotine available (cigarette smoking). And while groups like Parents Against Vaping E-Cigarettes would apparently like to see nicotine e-cigarettes banned, they don't utter a word about much more acute and severe threats to youth health like black market THC vapes, drug-spiked cannabis products, and alcohol use. Apparently, while they think that every single flavored e-cigarette product needs to be banned, they are OK with alcohol companies recruiting kids to dangerous drinking by indoctrinating them with flavored alcoholic beverages (which, unlike e-cigarettes, are a gateway to more dangerous forms of drug use). Ultimately, it's not doing any good for our nation's youth to teach them that ripping an occasional cherry vape is the greatest risk to their health.

The rest of the story is that the demonization of nicotine--while it previously played a critical role in the fight against smoking--is now impeding progress in what would otherwise be a golden opportunity to eliminate the use of combustible tobacco. This is largely a result of the inability of the tobacco control movement to change its old paradigms as the world changes: as new scientific evidence arises, as the market changes, as the actions of the tobacco industry change. 

I understand the difficulty of changing your paradigm. Look - I have acknowledged that between 2007 and 2009 (when I first heard about e-cigarettes), my position on these products was exactly what the position of the mainstream tobacco control groups are today: I thought this was a Big Tobacco ploy to addict a new generation of kids by marketing a product as being safer when it really wasn't. But I changed my views, and my paradigms, when I learned more about what was actually happening and what the science actually indicated. I challenged my pre-existing thinking, allowing myself to be swayed by new scientific evidence. I took the time to speak with the heads of many e-cigarette companies, to visit vape shops, to talk to hundreds of vapers, and to conduct my own research. And by 2009, my opinion had changed. 

This was not a ploy by Big Tobacco because Big Tobacco was actually not involved (they didn't even enter the picture until 2011). The companies weren't lying in claiming that vapes were safer than cigarettes - they were safer. The goal of the product was not to addict a new generation of youth but to help adult smokers quit. And the product was effective. Large numbers of smokers who were not able to quit using any other method were finding vaping an effective quitting strategy.  And the safety and effectiveness of these products has only improved since 2009.

I can only hope that the new year will bring a fresh perspective and a more rational approach to the public health practice of tobacco control. 

World Health Organization Explicitly Rejects Harm Reduction in Tobacco Control, Endangering Millions of Lives Worldwide

The Conference of the Parties to the World Health Organization's (WHO) Framework Convention on Tobacco Control (FCTC) met recently to update their international strategies to (supposedly) reduce the international burden of tobacco-related morbidity and mortality. Today, the Tobacco Tactics team published an article in the journal Tobacco Control that summarizes the consensus approach to the issue of harm reduction in tobacco control.

Here is the summary:  

"COP11 included a specific agenda item on nicotine addiction in light of the tobacco industry’s narrative on ‘harm reduction’, during which Parties discussed proposed decisions. This year’s discussion demonstrated the strong interest among Parties in identifying the best approaches to protect future generations from both tobacco and nicotine addiction. In preparation for this discussion, the Convention Secretariat prepared a report,10 making it clear that there is no legitimate ‘tobacco harm reduction’ based on advancing the commercial and vested interests of the tobacco industry. In the context of the WHO FCTC, ‘harm reduction’ is ‘harm elimination, the intended outcome from the full implementation of the treaty’s existing, evidence-based measures."

The Rest of the Story

This is a shocking statement. It explicitly asserts that there is no legitimacy to the concept of harm reduction in tobacco control and it claims that tobacco harm reduction is only promoted by the tobacco industry and its sole purpose is to advance the commercial interests of the tobacco industry. It goes so far as to say that the only legitimate harm reduction regarding smokers is harm elimination, meaning that there is only benefit if a smoker becomes abstinent from nicotine, not if that smoker quits smoking using one of the most popular and effective methods in the world.

It is demonstrably false that harm reduction is only promoted by the tobacco industry. In fact, harm reduction is a central concept of public health and is promoted widely by tens of thousands of public health professionals, organizations, and agencies throughout the world. Harm reduction is a central approach in the field of drug addiction. It is also being promoted widely throughout the world by scientists and advocates who have no affiliation with Big Tobacco.

Moreover, the overwhelming majority of the companies selling e-cigarettes are not part of the tobacco industry. And the idea of e-cigarettes for harm reduction did not originate with Big Tobacco. These products came to market in 2005 and the tobacco industry did not get involved until 2011. 

It is also demonstrably false that harm reduction is solely being promoted to advance the interests of the tobacco industry. In fact, the more smokers switch to e-cigarettes, the lower the profits are for cigarette sales. While it is true that the cigarette companies that also produce e-cigarettes will obtain sales revenue from e-cigarettes, is that not a far better outcome than these companies gaining revenue from cigarette sales? 

The rejection of harm reduction by WHO endangers the lives of millions of smokers worldwide. The WHO is literally abandoning smokers and using them as sacrificial lambs in an effort to demonize safer alternatives to cigarettes because the FCTC leaders can't stand the idea that the use of a nicotine product could actually be beneficial to health (even though they have no problem with pharmaceutical companies reaping in billions of dollars based on the same concept - perhaps this is because the WHO Foundation receives millions from the pharmaceutical industry). 

While it is bad enough that tobacco control organizations and health agencies in the United States have shunned harm reduction in tobacco control, the fact that WHO has rejected harm reduction strategies to address the worldwide burden of smoking-related disease is truly a global public health disaster. 

 

Many Tobacco Control Organizations are Asserting that Quitting Smoking is Not Quitting Smoking if You Use E-Cigarettes to Quit

The American Lung Association has long been trumpeting the falsehood that quitting smoking by switching to electronic cigarettes isn't quitting smoking, a statement that is false on its face. The American Lung Association has been telling the public that "Switching Isn't Quitting." 

Can you imagine a public health organization telling people trying to get off of heroin that "Switching (to methadone) Isn't Quitting"? 

The Rest of the Story

Unfortunately, it is not just the American Lung Association that has been spreading this nonsensical, false, and dangerous rhetoric. Here is a list of other tobacco control groups that have made the same assertion.

Tobacco Education Clearinghouse of California

El Dorado County Public Health

DePaul University Office of Student Affairs

Fresno County Department of Public Health

North Dakota Department of Health

Butte County Health Department

California Tobacco Free Colleges

Kick It California

American Lung Association of Rhode Island

Cuesta College Student Health Services

Fargo Cass Public Health

Healthy UC Davis

Southeast Asia Tobacco Control Alliance

Tobacco Free North Dakota

Shasta County Tobacco Education Coalition

Clearly, there is a major misinformation campaign going on within the tobacco control movement. Many of these groups are using false information to discourage smokers from quitting and entice ex-smokers to return to smoking.

American Lung Association Directs Youth to Complain about Seeing People Use Nicotine Pouches in Workplaces

A campaign being run by youth in Wisconsin who are part of a group called FACT is urging their fellow youth to complain to legislators about having to see people using nicotine pouches in workplaces. Youth are instructed to tell their legislators: "What tobacco products do you still see used in places covered by the smoke-free air law (workplaces like restaurants, hotels, and offices)? Vapes? Nicotine pouches? What bothers you about seeing these products in those places?"

I spent many years of my career lobbying for smoke-free workplace laws. But when I said "smoke-free" I meant "smoke-free." In other words, I was promoting the elimination of tobacco smoke in workplaces. My efforts were based on voluminous scientific evidence of the long-terms harms of tobacco smoke exposure for employees, especially those working in smoky bars and restaurants. 

I have to honestly say that I'm not crazy about banning vaping in public places because I'm not aware of solid evidence that it causes significant health effects but I can at least understand the rationale. People are being slightly exposed to chemicals in aerosol that they did not create. However, I fail to see the rationale behind banning the use of nicotine pouches in public places. The use of a nicotine pouch has absolutely no health effects for bystanders. It doesn't create any kind of smoke, vapor, aerosol, or any other exposure for people who are not actually using the product. So why would youth want to ban the use of this product? It just doesn't make any sense. 

Something else bothers me about the appeal being made by this FACT organization. The appeal does not give youth the option of not being bothered by the use of nicotine pouches in public places. It asks "what bothers you" about seeing nicotine pouches in these places, essentially implying to youth that there is no option other than to be bothered by the use of nicotine pouches.

This sends a bad message to youth. It sends the message that we should be banning individual behavior that has no harmful effect on anyone else. And that we should ban a behavior that actually may be life-saving for people, since many - if not most - adults who use nicotine pouches are doing so in an effort to quit smoking.

This is tantamount to telling kids that they should be bothered by seeing methadone clinics, naloxone distribution programs, or needle exchange programs. It asks youth to oppose life-saving harm reduction policies in the name of regulating people's lifestyle choices that affect nobody else except themselves.

It struck me that there has to be something else behind this organization because youth on their own would not promote such an idea that is totally contrary to public health and also contrary to the way most youth think.

The Rest of the Story

Well, the truth is that these youth are not acting independently. The organization is actually an initiative of the American Lung Association and is funded by the state health department!

According to the web site: "FACT is ably managed by the American Lung Association, funded by Wisconsin’s Commercial Tobacco Prevention & Treatment Program, and organized with the help of local health alliances." 

The American Lung Association is basically using youth to do their bidding. They are taking advantage of youth in order to try to push their own agenda of banning nicotine pouches. 

This is not the first time I have exposed tobacco control organizations using kids as a pawn in their efforts to support their own agenda in a way that is far from transparent. While anti-nicotine groups have the right to try to ban life-saving harm reduction products, they should not be manipulating youth into promoting these misguided policies for them. This is why I find what the American Lung Association is doing in Wisconsin so disturbing.