Concerned About Dual Users? Then You May Want to Take NRT Products Off the Market

One of the major arguments that the major national health organizations make against the use of e-cigarettes for smoking cessation is that many smokers become "dual users" (i.e., people who use both e-cigarettes and real cigarettes). For example, the American Heart Association makes the following argument: "E-cigarette promoters claim the devices can help people quit smoking. But much more evidence is needed to determine if they are an effective way to quit. Research suggests that users are more likely to continue smoking along with vaping, which is referred to as “dual use." 

According to this argument, if a nicotine-containing smoking cessation product results in more smokers using both products than switching exclusively to the less harmful product, then that product is not "an effective way to quit."

The Rest of the Story

Recent data out of England reveal that 56.4% of smokers who use NRT products continue to smoke. In other words, 56.4% of NRT users in England are "dual users." By the American Heart Association's logic, it should be concluded that NRT is not "an effective way to quit" because smokers who try NRT are more likely to become dual users than to switch completely to NRT. However, we don't see the American Heart Association calling for bans or severe restrictions on NRT, not even flavored NRT.

The same report (called the Smoking Toolkit Study) revealed that in contrast to NRT, smokers who try e-cigarettes are more likely than not able to become sole users of e-cigarettes. In contrast to the 56% of smokers trying NRT who become dual users, only 36% of smokers who try e-cigarettes become dual users. By the American Heart Association's logic, they should conclude that e-cigarettes are an effective way to quit. However, we don't see the American Heart Association demanding that e-cigarettes remain on the market to help smokers quit.

So what explains the American Heart Association's stance on e-cigarettes vs. NRT as smoking cessation methods?

The first thing I always check when trying to explain logical discrepancies like this is money. An examination of funding received by the American Heart Association in 2020-2021 reveals that they received $40.7 million from pharmaceutical and biotech companies. Specifically, they received the following amount of money from individual companies within Big Pharma:

Alexion Pharmaceuticals: $1.3 million

Alnylam Pharmaceuticals: $0.75 million

Astra Zeneca: $6.3 million

Bayer Healthcare: $1.8 million

Boehringer Ingelheim Pharmaceuticals: $4.8 million (with a pledge of $4.8 million to be paid in future)

Janssen: $0.4 million

Jazz Pharmaceuticals: $0.25 million

Johnson & Johnson: $0.14 million

Kaneka Pharma America, LLC: $0.15 million

Merck: $0.15 million

Novartis: $1.7 million (with a pledge of $18.1 million to be paid in future years)

NovoNordisk: $1.6 million

Pfizer: $0.8 million

Sanofi: $1.7 million

This totals $21.8 million, with an additional pledge of $22.9 million, for a total of $44.7 million.

I'll be quite honest. If I or my company were receiving $44.7 million a year from Big Pharma, I, too, would not recommend that any of their products be taken off the market.

Why Isn't the American Lung Association Calling for the Removal of Flavored NRT Nicotine Gum from the Market?

In its statement responding to the FDA's approval of Zyn nicotine pouches for marketing in the United States, the American Lung Association blasted the FDA and called for the removal of all flavored nicotine products from the market. This includes flavored nicotine gum but not flavored NRT nicotine gum.  

The ALA argued that flavored nicotine products appeal to youth and could cause addiction, and therefore should be removed from the market. However, the ALA was only referring to products the FDA classifies as "tobacco products," which does not include NRT nicotine gum. 

What justification is there for the American Lung Association to want flavored non-NRT nicotine gum to be removed from the market but not flavored NRT nicotine gum? Why the distinction?

There are 4 possible justifications:

First, if non-NRT nicotine gum came in flavors that could attract youth while NRT nicotine did not.

Second, if non-NRT nicotine gum were more hazardous than NRT nicotine gum. The main concern here is the potential presence of carcinogens, specifically tobacco-specific nitrosamines.

Third, if non-NRT nicotine gum was used by a substantially greater proportion of youths compared to NRT nicotine gum.

Fourth, if non-NRT nicotine gum contained much higher levels of nicotine than NRT nicotine gum and was therefore more addictive.

Let's examine each of these.

1. Flavors

This is not a distinguishing factor between non-NRT nicotine gum and NRT nicotine gum because NRT nicotine gum comes in at least the following flavors:

Cinnamon

Fruit

Fruit Freeze and Mint Freeze

Fruit Chill

Ice Mint

Mint, Spearmint, and White Ice Mint

2. Tobacco-Specific Nitrosamines

There is little evidence that non-NRT nicotine gum contains substantially higher levels of tobacco-specific nitrosamines than NRT nicotine gum. Existing studies show that both contain either non-detectable or trace levels and so nicotine gum should not pose any significant carcinogenic risk.

3. Prevalence of Youth Use

According to 2024 data from the FDA, the prevalence of use of all oral nicotine products not including nicotine pouches (lozenges, sticks, and gums) was 1.2%. Thus, the prevalence of non-NRT nicotine gum use among adolescents appears to be around 1%.

Unfortunately, data on use of NRT nicotine gum among adolescents is difficult to find. The only estimate I could find was that every day use of NRT nicotine gum in one sample of students was approximately 1%.

It does not appear that there is a substantial difference here, and I have not seen any data to support the contention that there is a substantial difference.

4. Amount of Nicotine

NRT nicotine gum typically contains either 2mg or 4mg of nicotine. Most non-nicotine NRT gum appears to contain either 2mg or 4mg of nicotine, although I was able to find one brand that contained 8mg of nicotine. 

The Rest of the Story

If the American Lung Association truly believes that any flavored nicotine product that may appeal to youths and pose a risk of addiction should be removed from the market, then why are they not calling for all flavored nicotine gum to be removed from the market?

One logical reason could be that the American Lung Association doesn't want to remove from the market a product that is helping many smokers to quit. However, if that is the case, then it is a strong argument for keeping other nicotine gum products on the market as well, since there are many smokers who are using these products in an attempt to quit. 

It's not clear to me that the primary motivation here is to help smokers. If that were the case, then the ALA would certainly want to balance the benefit of flavored nicotine products in helping adult smokers quit with the potential harms to youth. This is exactly what the FDA did in its consideration of Zyn, and its finding was that the balance is clearly in favor of its benefits. It appears that the ALA and many other tobacco control organizations are not even considering the potential benefits of non-tobacco nicotine products in helping millions of smokers to quit. Instead, they have a sole focus on the use of any flavored nicotine product by youth. Well, any flavored nicotine product that is not manufactured by a pharmaceutical company. 

I have been struggling to understand why the ALA wants to selectively ban all flavored nicotine gum except for those made by Big Pharma. The only answer that I have come up with is this:

I believe that the American Lung Association and many other tobacco control groups simply cannot tolerate the fact that someone might be using nicotine and getting pleasure from it without suffering severe health effects and thus not being punished for their bad decision. After all, these groups are not calling on states to ban the sale of real cigarettes. Apparently, it is OK for adults to use cigarettes recreationally because they are going to be punished for their poor decision. But as soon as someone is using a relatively safe nicotine product, it must immediately be removed from the market.

From a broader perspective, why are so many health groups calling for a ban on any flavored nicotine product that may appeal to youths, but not calling for a ban on the sale of flavored alcohol? To be sure, flavored alcohol products are causing much more harm to the lives of adolescents than electronic cigarettes or nicotine pouches. And unlike these much safer products, flavored alcohol use has been shown to be a gateway to problem drinking behaviors. 

I'm afraid that the tobacco control movement's nearly sole focus on what is probably the safest form of youth substance use is diverting attention from much more hazardous forms of youth substance use like alcohol. When is the last time you heard the American Cancer Society call for a ban on flavored alcohol products, which are used by many more youths than nicotine pouches and which actually do cause cancer?

I'm not calling for a ban on flavored alcohol but if it's not reasonable to ban flavored alcohol then it's much less reasonable to ban flavored reduced risk nicotine products.

Fake News: American Lung Association Implies that Zyn Nicotine Pouches Contain Tobacco and Can Cause Cancer

The American Lung Association has issued a statement in response to the FDA's authorization of Zyn nicotine pouches in which it blasts the FDA for approving this product and asserts that it is a "gift to Big Tobacco." The statement also implies that Zyn contains tobacco and can cause cancer.

The American Lung Association stated as follows:

"Let’s be clear: Zyn is a tobacco product, and no tobacco product is safe. A 2022 study of 44 nicotine pouch products found that 26 of the samples contained cancer-causing chemicals and several other chemicals such as: ammonia, chromium, formaldehyde, nickel, pH adjusters and nicotine salt. ... It is now up to state and local governments to act to end the sale of flavored tobacco products if we are to end the tobacco use epidemic, once and for all."

The statement concludes with a link to a previous statement which, as I discussed earlier, falsely claims that using Zyn is no safer than cigarette smoking. 

The Rest of the Story

In this statement, the American Lung Association has doubled down on its suggestion that Zyn is unsafe because it contains carcinogens. This assertion relies upon a 2022 study which the ALA notes that "26 of the samples contained cancer-causing chemicals." It is referring to the detection of tobacco-specific nitrosamines (which are carcinogens) in 26 of the 44 products studied.

There are two serious problems with the ALA's assertion:

1. The American Lung Association is hiding from the public the levels of nitrosamines that were detected in nicotine pouches. It turns out that the study detected only trace levels and that these levels are substantially lower than those present in nicotine gum!

2. The American Lung Association is also hiding from the public the fact that Zyn has indeed been tested for tobacco-specific nitrosamines and none were detected. The FDA concluded that: "The new products do not contain measurable quantities of carcinogenic TSNAs, including NNN and NNK, or the carcinogenic polycyclic aromatic hydrocarbon B[a]P."

The ALA's implying that Zyn contains tobacco-specific nitrosamines because of a study that tested other nicotine pouch brands is irrresponsible because it would have taken only one click for them to read the FDA's report and find out that no tobacco-specific nitrosamines were detectable in any of the Zyn products that were authorized. This is guilt by association. The 2022 study actually has no relevance to the evaluation of Zyn's safety, especially when one can easily read the FDA's report and find out that Zyn is probably the safest nicotine product on the market in terms of carcinogen levels (even safer than nicotine gum in this regard). 

The American Lung Association's assertion that Zyn should be banned if we want to end the "tobacco use epidemic" implies that the use of Zyn is tobacco use. Nothing could be further from the truth because Zyn contains no tobacco! Someone who uses Zyn is not using tobacco. 

In fact, apparently unbeknownst to the ALA, the entire point of using Zyn is that it doesn't contain tobacco. And as the FDA reports: "The applicant also provided evidence from a study showing that a substantial proportion of adults who use cigarette and/or smokeless tobacco products completely switched to the newly authorized nicotine pouch products."

The rest of the story is that the truth is apparently not good enough for the American Lung Association to make a convincing argument that Zyn poses great dangers to the public's health. They can only scare the public into believing this by lying to them: implying that Zyn contains tobacco and that it contains carcinogens, neither of which is true. When an organization has to resort to making false or misleading statements to support its position, that is a sign that the actual truth is not sufficient to to do so.

Rather than being a "gift to Big Tobacco," the authorization of Zyn products could be the beginning of a death knell for actual tobacco products in the United States. Traditional Big Tobacco (cigarettes and smokeless tobacco) are greatly threatened by the authorization of electronic cigarettes and products like Zyn. This is not a gift to Big Tobacco. It is a gift to public health. It is a gift to smokers and smokeless tobacco users who want to improve their health by switching to a safer nicotine product. And it is a gift to anyone who wants to see the end of tobacco-related morbidity and mortality in this country.

American Lung Association Says that Quitting Smoking is Not Quitting Smoking, Unless You Do It Their Way

In an inane statement, the American Lung Association asserted that if you quit smoking by switching to nicotine pouches, you have not quit smoking. 

After noting that 10% of smokers who use nicotine pouches are able to switch completely (that is, quit smoking), the American Lung Association states: "This is not quitting, this is merely switching to another tobacco/nicotine product sold by the tobacco industry to sustain lifelong customers."

The Rest of the Story

I criticized the American Lung Association yesterday for lying to the public by asserting that cigarette smoking is no more hazardous than using a nicotine pouch. After reading the statement again, I now realize that there is a second lie: the assertion that if you quit smoking by switching to Zyn, you have not quit smoking.

The truth or falsehood of this statement hardly needs a scientific analysis because it is false on its face. What the American Lung Association is essentially saying is: "Quitting smoking is not quitting smoking." This is like claiming that 1 is not equal to 1.

What I think the American Lung Association is really saying is: "Quitting smoking doesn't count as quitting smoking unless you do it our proscribed way." Apparently, switching from tobacco cigarettes to another product that contains no tobacco and involves no combustion does not count as stopping using tobacco cigarettes unless that product is free of nicotine. And not produced by a tobacco company.

What the American Lung Association is revealing here is that its primary concern is apparently not the health of smokers or trying to prevent smokers from dying. Their concern is that people not use nicotine and that people not purchase any product manufactured by a tobacco company. Unless of course that product is cigarettes. After all, the American Lung Association is discouraging smokers from quitting using a much safer product like Zyn. Apparently, they would rather that a smoker continue to smoke than to switch to a product that will likely save their life. Is it really better that smokers die rather than use a safer nicotine product?

The rest of the story is that this is no longer public health. This is an ideological crusade against nicotine use. Not because of adverse health effects of nicotine but simply because the American Lung Association apparently cannot tolerate the possibility that someone might be using a nicotine product in a way that greatly benefits their health.

The zealotry and ideology in the tobacco control movement has become so strong that protecting the public's health and saving lives are no longer the primary concern. The primary concern is upholding a Puritanical crusade against the use of nicotine, regardless of the actual health effects or consequences. Saving your life is not worth it if it means continuing to use nicotine. Better that you should die so that you suffer the consequences from your decision to use nicotine.

I really believe that tobacco control organizations are troubled by the fact that someone could use nicotine without paying a price (with their health or lives). The crusade against nicotine is so strong that anyone who uses nicotine in any form must be punished; they must suffer health consequences. It clearly pains the American Lung Association to think that someone might be using a nicotine product but experience an improvement in their health and greatly reducing the chances that they will be mortally punished for what is apparently viewed as a sin.

American Lung Association Claims that Nicotine Pouches are No Safer than Cigarettes

In light of the FDA's approval yesterday of a pre-market tobacco product application (PMTA) for Zyn nicotine pouches, I did some internet searches to see what tobacco control and health groups are telling the public about the health risks of nicotine pouches compared to cigarettes. The fact that the FDA approved this product indicates that the agency determined that nicotine pouches are much safer than cigarettes. This is one determination the FDA must make before it can approve any PMTA. 

The FDA explicitly stated its conclusion that Zyn nicotine pouches are safer than cigarettes: "Among several key considerations, the agency’s evaluation showed that, due to substantially lower amounts of harmful constituents than cigarettes and most smokeless tobacco products, such as moist snuff and snus, the authorized products pose lower risk of cancer and other serious health conditions than such products. The applicant also provided evidence from a study showing that a substantial proportion of adults who use cigarette and/or smokeless tobacco products completely switched to the newly authorized nicotine pouch products."

Because nicotine pouches contain no tobacco, do not involve combustion, and do not even involve heating, they do not produce either smoke or vapor. Therefore, they are probably one of the safest forms, if not the safest form, of nicotine intake. Obviously, there is no comparison between the safety of nicotine pouch use compared to that of cigarette smoking. Nicotine pouch use is unequivocally much safer than smoking.

However, that fact did not stop the American Lung Association from publicly claiming that nicotine pouches are no safer than cigarettes, which is another way of saying that cigarette smoking is no more hazardous than using a nicotine pouch - a preposterous and damaging statement on its face.

Here is exactly what the American Lung Association claims:

"Because of their smokeless, odorless features, many people believe that these nicotine pouches are a safer alternative to cigarettes. But don’t be fooled. A 2022 study of 44 nicotine pouch products found that 26 of the samples contained cancer-causing chemicals and several other chemicals such as: ammonia, chromium, formaldehyde, nickel, pH adjusters, and nicotine salt."

The Rest of the Story

The basis of the American Lung Association's claim that nicotine pouch use is no safer than smoking is this 2022 study which indeed detected tobacco-specific nitrosamines (carcinogens) in 26 of 44 nicotine pouches studied. However, what the American Lung Association is not informing the public is that the levels of nitrosamines detected in nicotine pouches were extremely low -- essentially trace levels -- and that these levels are two orders of magnitude lower than the nitrosamine levels in some brands of nicotine gum, which the American Lung Association heavily endorses.

The level of nitrosamines detected in nicotine pouches that did have detectable levels typically were in the 0.5ng to 3ng range. The absolute highest level detected in any of the pouches was 13ng. 

In contrast, nicotine gum has been found to contain levels of tobacco-specific nitrosamines as high as 380ng per gram of gum. Conservatively assuming that a piece of nicotine gum weighs one gram, the nitrosamine content of this brand of nicotine gum is 380ng. 

Since the highest nitrosamine level detected in nicotine pouches was 13ng, this means that the level of these carcinogens in this nicotine gum brand is 29 times higher than the nicotine pouch with the highest level of nitrosamines. Most of the nicotine pouches had no detectable nitrosamines, and most of the pouches that did have nitrosamines detectable had levels of no more than 3ng. This means that nicotine gum may have carcinogen levels that are as much as 127 times higher than most nicotine pouches with detectable nitrosamine levels. Of course, the level of nitrosamines in nicotine gum is infinitely higher than its level in 18 of the nicotine pouches tested.

Clearly, the American Lung Association is outright lying to the American public. There is no evidence to support its claim that smoking is no more hazardous than using a nicotine pouch. And there is abundant evidence that smoking is much more hazardous than using a nicotine pouch. Moreover, the study which the American Lung Association cites to back up its claim actually demonstrates that nicotine pouches have far lower levels of tobacco-specific nitrosamines than nicotine gum!

This would be an almost laughable misrepresentation of the truth were it not for the fact that the American Lung Association's false information may very plausibly deter smokers who might otherwise switch to nicotine pouches from quitting smoking.

This is a huge favor to the cigarette industry. Nicotine pouches--because of their drastically lower health risks than cigarettes--pose an existential threat to the cigarette industry. But not if the American Lung Association has its way. 

The rest of the story is that the American Lung Association is lying to the public and they are doing so in a way that is helping to protect the profits of cigarette companies, deter smokers from quitting, and boosting sales of deadly cigarettes, which means more lung disease. 

Yes, the American Lung Association's irresponsible reporting of the relative health effects of nicotine pouches compared to cigarettes may well result in increasing lung disease in the population.

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

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

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

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

The Rest of the Story

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

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

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

Why San Francisco helping to increase profits for cigarette companies?

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

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

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

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

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

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

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

2-Naphthylamine (proven human carcinogen): 85%

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

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

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

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

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

ortho-toluidine (proven human carcinogen): 65%

 

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

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

The Rest of the Story

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

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

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

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

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

The Rest of the Story

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

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

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

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

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

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

Surgeon General Calls for Cancer Warning Labels on Alcohol

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

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

Among the Surgeon General's recommendations are:

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

The Rest of the Story

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

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

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

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

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

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

The Rest of the Story

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

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

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

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

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

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

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

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

Most Egregious Statement About Electronic Cigarettes for 2024

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

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

The Rest of the Story

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

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

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

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

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

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

The claims come in two varieties. 

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

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

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

 

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

The Rest of the Story

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Rest of the Story

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

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

Partial List of "Quit Our Way or Die" Organizations

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

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

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

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

Final Thoughts

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

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

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

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

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

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

The Rest of the Story

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

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

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

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

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

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

There's More to the Story

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

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

So let's examine this claim:

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

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

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

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

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

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

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

There's Even More to the Story

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

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

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

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

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

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

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

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

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

The Rest of the Story

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

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

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

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

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

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

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

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

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

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

But how wrong I was.

The Rest of the Story

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

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

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

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

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

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

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