American Medical Association Claims that E-Cigarettes Can Cause Several Types of Cancer

The American Medical Association (AMA) yesterday claimed that electronic cigarettes cause not just one type of cancer, but multiple types. 

Here is their statement: "Overwhelming evidence demonstrates that multiple types of cancer are linked to tobacco products, including e-cigarettes, and that the longer someone uses these products the greater their health risks become."

I'm at a loss for the multiple types of cancer that are caused by electronic cigarettes. I'm thinking that the AMA may be referring to lung cancer but multiple means more than one, so what is the other cancer type to which they are referring? 

The Rest of the Story

First, to set the record straight, there is no credible evidence that electronic cigarettes cause any type of cancer, much less multiple types. Not a single study has shown that absent tobacco use, e-cigarettes increase cancer risk of any kind. The levels of carcinogenic biomarkers in people who use e-cigarettes are much lower than among people who smoke and are even lower than that seen among users of snus and smokeless tobacco. In fact, they are similar to levels observed among people who use NRT gum. I'm not aware that the AMA is warning about the cancer risk of NRT gum. So there is not strong plausibility to the idea that e-cigarettes significantly increase cancer risk.

Second, there are no epidemiological studies that have clearly demonstrated a link between electronic cigarette use and increased risk for cancer. 

Even if we just provide a gimme and allow the AMA to claim that e-cigarettes cause lung cancer without challenge, where is their evidence that e-cigarettes cause at least one other type of cancer?

The rest of the story is that the evidence for banning flavored e-cigarettes from the market is so weak that organizations have to lie and deceive the public in order to support these bans.

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.