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Thank you for the opportunity to clarify and correct some of the recent statements about our research article, ‘Exploring the Twitter activity around the eighth meeting of the Conference of the Parties to the WHO Framework Convention on Tobacco Control’.
Mr Sarangapani, Director of the Association of Vapers India (AVI), is incorrect in claiming that our article makes “false allegations” and “unsubstantiated claims”, and that it frames AVI as a tobacco industry (TI) front group. We categorise his organisation as a ‘next generation product (NGP) advocate’ and we state that AVI is a member of the International Network of Nicotine Consumer Organisations (INNCO). We also report that INNCO has received funding from the Foundation for a Smoke-Free World (FSFW),[1] which is an organisation that continues to be funded solely by Philip Morris International.[2] Thus, AVI is a member of an organisation that receives indirect funds from Philip Morris International, via the FSFW. Those statements are factual and substantiated; readers can locate further details and references to the FSFW’s grantees and tax returns via our Tobacco Tactics pages, as referenced in our article. In his letter, Mr Sarangapani points out that the Founder-Director of AVI is the current President of INNCO’s Governing Board; however, our research article makes no mention of that fact. We clearly state that: “We found no evidence that the individuals affiliated with INNCO or its mem...
NOT PEER REVIEWED
Thank you for the opportunity to clarify and correct some of the recent statements about our research article, ‘Exploring the Twitter activity around the eighth meeting of the Conference of the Parties to the WHO Framework Convention on Tobacco Control’.
Mr Sarangapani, Director of the Association of Vapers India (AVI), is incorrect in claiming that our article makes “false allegations” and “unsubstantiated claims”, and that it frames AVI as a tobacco industry (TI) front group. We categorise his organisation as a ‘next generation product (NGP) advocate’ and we state that AVI is a member of the International Network of Nicotine Consumer Organisations (INNCO). We also report that INNCO has received funding from the Foundation for a Smoke-Free World (FSFW),[1] which is an organisation that continues to be funded solely by Philip Morris International.[2] Thus, AVI is a member of an organisation that receives indirect funds from Philip Morris International, via the FSFW. Those statements are factual and substantiated; readers can locate further details and references to the FSFW’s grantees and tax returns via our Tobacco Tactics pages, as referenced in our article. In his letter, Mr Sarangapani points out that the Founder-Director of AVI is the current President of INNCO’s Governing Board; however, our research article makes no mention of that fact. We clearly state that: “We found no evidence that the individuals affiliated with INNCO or its member organisations were themselves funded by FSFW or by the TI directly” (p4). I acknowledge that on page 5 of the article, we have referred to AVI by their Twitter handle (vapeindia), as opposed to the organisation’s full name.
Mr Cullip’s interpretation of our article as a “smear” against vaping consumer advocates is an inaccurate representation of our research. As set out in our research objectives (p2), we examined the main themes and sentiment of tweets about WHO FCTC COP8, identified and classified the most active tweeters, explored how people who tweeted about COP8 engaged with one another and, lastly, explored the presence of TI links among the most active tweeters. Our article makes no statements that denigrate vapers’ opinions. Rather, we conclude there was an extensive online presence by Philip Morris International (PMI) executives, and by organisations and individuals funded directly and indirectly by PMI (e.g. Consumer Choice Center, Foundation for a Smoke-Free World, INNCO, Knowledge-Action-Change). We conclude that our findings are consistent with PMI’s 2014 corporate affairs strategy, which was leaked as part of an exposé by Reuters.[3] Far from being a “mythical tobacco industry plot” as Mr Cullip claims, PMI’s corporate affairs strategy described engaging tobacco harm reduction advocates to “amplify and leverage the debate on harm reduction” around events such as the WHO FCTC COP.[3]
Dr Gilchrist’s letter contains several inaccurate assertions. Our research does not “malign” either the individuals or the organisations that participated in the Twitter debate during COP8. We do not use the term “front group” in relation to any of the organisations supporting tobacco harm reduction referred to in our article. Nor do we imply that “any person or organisation who publicly supports tobacco harm reduction are paid to do so by the industry”. Our research article presents a factual account of the most common topics and sentiment of tweets that used #COP8FCTC, the categories of individuals and organisations tweeting, and their networks and patterns of engagement with one another. Around one-fifth of the most active tweeters were either tobacco companies, third-party organisations that have received direct tobacco industry funding, or employees of those organisations. We refer (accurately) to those tweeters as ‘tobacco industry actors’; we provide a detailed definition of our inclusion criteria and provide references to evidence tobacco industry funding. The only specific criticism Dr Gilchrist makes about our study is that we did not explore links between the most active tweeters and non-tobacco industry sources of funding. Given the irreconcilable conflict between the tobacco industry’s interests and tobacco control policy interests, and given tobacco companies’ repeated attempts to influence policy via third parties and intermediaries,[4] our focus on documenting tobacco industry involvement in FCTC debates is justified. Unlike tobacco companies, public health advocacy groups do not stand to generate or lose billions of dollars in profit as a result of decisions made at WHO FCTC COP. Neither do they have a history of obfuscating their funding sources.
Professor Stimson’s letter incorrectly states that we claim tobacco industry money is behind all the activity on Twitter by harm reduction advocates; in fact, on page 4 we state: “…for 23 of the 50 NGP [next generation product] advocates, we found no publicly available evidence of any link with the TI”. Professor Stimson is correct that we state: “…vaping consumer advocacy groups that receive TI funding are emerging and attempting to influence the WHO.” He insinuates this claim is unsubstantiated, yet we provide clear evidence that factasia.org and INNCO, each of whom describe themselves as a vaping consumer advocacy organisation, receive funding from PMI (directly and indirectly, respectively).[1,5] We do not claim TI links with national vaping advocacy groups and, as already noted, we state: “We found no evidence that the individuals affiliated with INNCO or its members organisations were themselves funded by FSFW or by the TI directly” (p4). As Professor Stimson points out, our article includes a paragraph where we report that a member of INNCO, ProVapeo Mexico, encouraged vapers to tweet during COP8. Professor Stimson interprets our research as “picking on” that organisation, yet we make no criticism of ProVapeo Mexico’s activities. Our article documents only the facts about the number of tweets using #COP8FCTC that appear to have been posted as a result of ProVapeo Mexico’s appeal.
In response to Julie Woessner’s letter, at no point does our article state that INNCO is a tobacco front group. As I note above, our article documents substantial activity on Twitter during COP8 both by PMI, and by organisations (and people affiliated with those organisations) that have received money from PMI either directly, or indirectly via the FSFW. We believe this activity is consistent with proposed actions laid out in PMI’s leaked 2014 corporate affairs strategy, which included plans to: “Establish the concept of harm reduction as legitimate public policy in tobacco regulation”, “Identify and engage non-traditional 3rd party stakeholders/allies (e-cigarette manufacturers and retailers, adult consumers of RRP products, tobacco harm reduction advocates…” and “Amplify and leverage the debate on harm reduction around global events (eg, COP6)”.[3] We believe our findings raise important questions about PMI’s claims of transformation, as the activity we have documented appears part of a long-standing corporate affairs plan. Our article presents the facts that some harm reduction-related organisations receive PMI (or FSFW) funds. We do not cast those funded organisations as “nefarious”.
Our research aims to increase transparency in tobacco control policy-making. Making known any links between tobacco companies and individuals and organisations that participate in tobacco control policy debates, even if those links are indirect and occur through intermediaries, is in the public interest and consistent with the principles of WHO FCTC Article 5.3.[6] Vapers who belong to INNCO-affiliated organisations are also entitled to know the network (or “umbrella organization”) to which their organisation belongs receives tobacco industry funding via the FSFW. It is encouraging therefore to observe that following our publication, INNCO appears to have added a statement declaring its FSFW funding onto its homepage (that development appears to have occurred between 1 and 16 November 2020).[7,8]
We are transparent about our research funders. The researchers working on this paper were funded by Bloomberg Philanthropies through the STOP initiative, and by Cancer Research UK; neither funder, nor any of the STOP partners, had any role in the research conceptualisation, study design, data collection, analysis, decision to publish, or preparation of the manuscript.
Lindsay Robertson, MPH, PhD
Conflict of Interest: None declared
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I am writing as co-founder of Pro-Vapeo Mexico, a non-profit consumer association affiliated with the International Network of Nicotine Consumer Organisations (INNCO), explicitly mentioned in the article “Exploring the Twitter activity around the eighth meeting of the Conference of the Parties to the WHO Framework Convention on Tobacco Control”. The authors of this article explicitly recognize that “We found no evidence that the individuals affiliated with INNCO or its member organizations were themselves funded by FSFW [Foundation for a Smoke Free World] or by the TI [Tobacco Industry] directly”. While this statement is correct, it still leaves missing information that we believe it is necessary and useful, for the benefit of your readers, to fully clarify: not only has Pro Vapeo Mexico never received any funding (direct or indirect) from any industry sector (tobacco, e-cigarettes or pharmaceutical) or from INNCO or the FSFW, we are a fully independent NGO whose activities are not (and have never been) directed by the TI or the FSFW or INNCO. Our affiliation with INNCO stems from its role as an umbrella organization grouping consumer associations worldwide united in advocating for Tobacco Harm Reduction, a strategy to improve global health by providing adult smokers the option to consume nicotine without having to inhale toxic cigarette smoke.
Regrettably, the authors of the above-mentioned article claim that our twitter activity in the...
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I am writing as co-founder of Pro-Vapeo Mexico, a non-profit consumer association affiliated with the International Network of Nicotine Consumer Organisations (INNCO), explicitly mentioned in the article “Exploring the Twitter activity around the eighth meeting of the Conference of the Parties to the WHO Framework Convention on Tobacco Control”. The authors of this article explicitly recognize that “We found no evidence that the individuals affiliated with INNCO or its member organizations were themselves funded by FSFW [Foundation for a Smoke Free World] or by the TI [Tobacco Industry] directly”. While this statement is correct, it still leaves missing information that we believe it is necessary and useful, for the benefit of your readers, to fully clarify: not only has Pro Vapeo Mexico never received any funding (direct or indirect) from any industry sector (tobacco, e-cigarettes or pharmaceutical) or from INNCO or the FSFW, we are a fully independent NGO whose activities are not (and have never been) directed by the TI or the FSFW or INNCO. Our affiliation with INNCO stems from its role as an umbrella organization grouping consumer associations worldwide united in advocating for Tobacco Harm Reduction, a strategy to improve global health by providing adult smokers the option to consume nicotine without having to inhale toxic cigarette smoke.
Regrettably, the authors of the above-mentioned article claim that our twitter activity in the period 9-18 October 2018 -somehow- proves our alleged participation in a lobbying effort coordinated by the TI to disrupt the COP-8 WHO-FCTC meeting taking place at the time. This is ludicrous. Our tweets do not prove this claim, but instead reveal our effort to mobilize our community of consumers to claim our right to attend and participate in that COP WHO-FCTC meeting as a legitimate part of the civil society. We were only protesting against the unjustified exclusion from this event of INNCO and its affiliated consumer associations under the false contention that we formed a TI front. In fact, we intend to keep protesting until our right to attend and participate in COP WHO-FCTC meetings as part of the civil society is fulfilled.
When doing scientific research, following the scientific method, you have a hypothesis (question) that you are going to investigate - in this case: Does xxx consumer organisation have any direct ties to tobacco companies that influence their advocacy?
After you have chosen your method, you then gather your evidence, make an objective analysis and state your findings and make a conclusion.
Your method SHOULD be thorough and your research should be objective in order to maintain the integrity of your research (and yourself). The evidence will either prove/disprove your original hypothesis.
Instead, the authors have chosen to not only demonise the participation of consumers in the narrative of their own health, one has lobbied false claims about tobacco industry connections that do not exist.
It is very concerning that the authors find it necessary to disenfranchise the very people who are fighting for their right to make informed choices about their health. It defies logic, and the principles of fairness and decency.
It perhaps would have been more helpful to all concerned if the authors had done due diligence beyond looking at a website that does not have verified information, to cast aspersions on consumer advocacy organisations.
It definitely would be more productive to welcome the voices of the people for whom felt impassioned enough to get involved in consumer advocacy to help smokers not only hav...
When doing scientific research, following the scientific method, you have a hypothesis (question) that you are going to investigate - in this case: Does xxx consumer organisation have any direct ties to tobacco companies that influence their advocacy?
After you have chosen your method, you then gather your evidence, make an objective analysis and state your findings and make a conclusion.
Your method SHOULD be thorough and your research should be objective in order to maintain the integrity of your research (and yourself). The evidence will either prove/disprove your original hypothesis.
Instead, the authors have chosen to not only demonise the participation of consumers in the narrative of their own health, one has lobbied false claims about tobacco industry connections that do not exist.
It is very concerning that the authors find it necessary to disenfranchise the very people who are fighting for their right to make informed choices about their health. It defies logic, and the principles of fairness and decency.
It perhaps would have been more helpful to all concerned if the authors had done due diligence beyond looking at a website that does not have verified information, to cast aspersions on consumer advocacy organisations.
It definitely would be more productive to welcome the voices of the people for whom felt impassioned enough to get involved in consumer advocacy to help smokers not only have the choices they need switch to less harmful alternative, but to be informed consumers of safer nicotine products.
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It is disappointing to see the BMJ publishing a research paper which smears consumer advocates for tobacco harm reduction by attempting to link consumer activity on social media with the tobacco industry. One can only conclude that the goal was to devalue the opinions of former smokers who have found safer nicotine products to have been beneficial to their lives.
I write as chair of the UK New Nicotine Alliance and as it is highly likely that tweets from our supporters have been included in this research, so we welcome the right to reply to the article.
The attempt to paint consumers as part of some mythical tobacco industry plot is offensive to individuals and organisations promoting tobacco harm reduction. We and our supporters, along with many other vapers, are systematically excluded from the FCTC conferences and yet have a strong stake in the outcomes of the meeting. Social media is one of the few opportunities we have to get our views across. Consumers of safer nicotine products have been acutely aware of an increasing warfare against the products which have helped them to stop smoking.
In 2018, there were clear threats being expressed by the WHO FCTC in advance of COP8 towards products that vaping consumers value highly for helping them to quit smoking. Many vapers travelled to Geneva in 2018 at their own expense, but as ‘members of the public’ were excluded from the meeting.
The article by Robertson et al was funded b...
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It is disappointing to see the BMJ publishing a research paper which smears consumer advocates for tobacco harm reduction by attempting to link consumer activity on social media with the tobacco industry. One can only conclude that the goal was to devalue the opinions of former smokers who have found safer nicotine products to have been beneficial to their lives.
I write as chair of the UK New Nicotine Alliance and as it is highly likely that tweets from our supporters have been included in this research, so we welcome the right to reply to the article.
The attempt to paint consumers as part of some mythical tobacco industry plot is offensive to individuals and organisations promoting tobacco harm reduction. We and our supporters, along with many other vapers, are systematically excluded from the FCTC conferences and yet have a strong stake in the outcomes of the meeting. Social media is one of the few opportunities we have to get our views across. Consumers of safer nicotine products have been acutely aware of an increasing warfare against the products which have helped them to stop smoking.
In 2018, there were clear threats being expressed by the WHO FCTC in advance of COP8 towards products that vaping consumers value highly for helping them to quit smoking. Many vapers travelled to Geneva in 2018 at their own expense, but as ‘members of the public’ were excluded from the meeting.
The article by Robertson et al was funded by Bloomberg Philanthropies: an organisation set up to distribute funds from an American multi-billionaire with antipathy to tobacco harm reduction.
In reality the article shows how successful THR consumer advocates are in dominating the Twittersphere around COP, and rightly so, because it is they are who are most affected by the outcome of COP meetings. Instead of attempting to denigrate these opinions, an altruistic approach would be to welcome the fact that consumers are engaging with the process and studying how consumer experience can help enhance public health outcomes. Sadly, this has not been considered by the authors of this report.
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Freedom of speech is a fundamental right in a free society. There is no justification to either interfere with the right of stakeholders to participate in the public debate regarding tobacco harm reduction policy, or to malign those that exercise that right. Given that the outcome of these policy discussions will affect the lives of more than one billion people on the planet who smoke, everyone must be free to advance arguments for and against any policy, and each argument must be scrutinized and evaluated on its evidence base and merits. Unfortunately, the recent paper in Tobacco Control—Exploring the Twitter activity around the eighth meeting of the Conference of the Parties to the WHO Framework Convention on Tobacco Control—missed the opportunity to do this.
Instead of engaging in a discussion on the key issues and arguments put forth in the public discussion around the eighth meeting of the Conference of the Parties (COP8), the authors employ diversionary ad hominem tactics. They mischaracterize Philip Morris International’s (PMI’s) legitimate participation in the public debate on the role that products with the potential to reduce the risk of harm compared to smoking can play in global public health policy. Using phrases like ‘tobacco industry actors’ and ‘front groups’ the authors falsely imply that any person or organization who publicly supports tobacco harm reduction are paid to do so by the tobacco industry, and specifically PMI....
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Freedom of speech is a fundamental right in a free society. There is no justification to either interfere with the right of stakeholders to participate in the public debate regarding tobacco harm reduction policy, or to malign those that exercise that right. Given that the outcome of these policy discussions will affect the lives of more than one billion people on the planet who smoke, everyone must be free to advance arguments for and against any policy, and each argument must be scrutinized and evaluated on its evidence base and merits. Unfortunately, the recent paper in Tobacco Control—Exploring the Twitter activity around the eighth meeting of the Conference of the Parties to the WHO Framework Convention on Tobacco Control—missed the opportunity to do this.
Instead of engaging in a discussion on the key issues and arguments put forth in the public discussion around the eighth meeting of the Conference of the Parties (COP8), the authors employ diversionary ad hominem tactics. They mischaracterize Philip Morris International’s (PMI’s) legitimate participation in the public debate on the role that products with the potential to reduce the risk of harm compared to smoking can play in global public health policy. Using phrases like ‘tobacco industry actors’ and ‘front groups’ the authors falsely imply that any person or organization who publicly supports tobacco harm reduction are paid to do so by the tobacco industry, and specifically PMI.
We fundamentally disagree with the authors’ approach. However, if they wish to pursue it in a robust way, we invite them to address an obvious inconsistency, and lack of rigor, in their present publication: the failure to explore the funding or linkages of individuals or organizations they deemed not to have tobacco industry links. By excluding this analysis, the authors have ignored the potential bias of almost one third of the Twitter accounts that they say engaged in the debate around COP8, including many who have links to their own funders (Bloomberg Philanthropies’ STOP: Stopping Tobacco Organizations and Products), and who have their own agendas (1-4) . Completing this analysis would be a useful way to shift from ad hominem attacks and move forward to a robust, science-based debate about tobacco harm reduction in the context of the next Conference of the Parties (COP9).
The importance of tobacco harm reduction policy to hundreds of millions of the world’s population means that it deserves a reasoned, fact-based dialogue between all parties, with science and consumers at the centre of discussion. It is legitimate to disagree, but ad hominem attacks have nothing to do with the argument at hand and simply serve to undermine progress. Dismissing views that differ from one’s own, or—worse still—attempting to intimidate dissenters into silence, will not move the debate forward. Emotions should not be allowed to dictate what and who does and does not get heard—truth and accuracy should be the only considerations.
For more than a decade, PMI has been at the forefront of researching, developing and scientifically assessing products that have the potential to reduce the risk of harm compared to smoking for adults who would otherwise continue to smoke. We are convinced that such products can contribute to improving public health. We are confident in the robustness of our scientific findings and the arguments in favor of tobacco harm reduction. We are proud of our scientists who have developed products that have the potential to reduce the risks of harm compared to smoking for those adults who do not quit. These products are precisely the ones which can make the policy of tobacco harm reduction work. We are open to discuss our strategies, actions and achievements with everyone who has a role to play in shaping public policy to reach better outcomes for men and women who smoke. If the authors of the recent paper—or anyone else—would like to engage in a factual discussion on the issues that really matter, we are ready and willing to debate with them.
(1) https://www.who.int/tobacco/about/partners/bloomberg/en/ (accessed 20 Nov 2020)
(2) https://www.fctc.org/about-us/ (accessed 23 Nov 2020)
(3) https://untobaccocontrol.org/kh/article-53/bloomberg-philanthropies-sele... (accessed 23 Nov 2020)
(4) https://www.tobaccofreekids.org/what-we-do/global/bloomberg (accessed 20 Nov 2020)
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It’s surprising finding oneself involuntarily part of a research study. Given no chance to contribute, perhaps I can offer privileged insight into the processes the authors seek to describe.
Analysis of tweets around the COP8 meeting show that nicotine consumer advocates were the most active, followed by public health advocates and the tobacco industry. My company – Knowledge Action Change – also tweeted, at the Geneva launch of our tobacco harm reduction report. [1] Tweeting by tobacco harm reduction advocates out-shadowed “official” FCTC messaging (and if the authors had searched #FCTCCOP8 and #COP8 as well as #COP8FCTC, they would have uncovered more).
The article asserts that tobacco industry money is behind this activity. But it is beyond this study’s narrow methodological reach to illuminate why nicotine consumer advocates tweet. My discussions with nicotine consumer advocates – the majority of whom are volunteers - demonstrate passionate interest in the policymaking that influences their lives. Having found safer alternatives to smoking, they fear that inappropriate regulation including bans will see their options disappear. They are frustrated that they are ignored by tobacco control policymakers, regulators and researchers. Barred from COP8 along with the public and press, consumer organisations are also barred from the NGO coalition Framework Convention Alliance. No other field of health policy excludes the affected. Consu...
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It’s surprising finding oneself involuntarily part of a research study. Given no chance to contribute, perhaps I can offer privileged insight into the processes the authors seek to describe.
Analysis of tweets around the COP8 meeting show that nicotine consumer advocates were the most active, followed by public health advocates and the tobacco industry. My company – Knowledge Action Change – also tweeted, at the Geneva launch of our tobacco harm reduction report. [1] Tweeting by tobacco harm reduction advocates out-shadowed “official” FCTC messaging (and if the authors had searched #FCTCCOP8 and #COP8 as well as #COP8FCTC, they would have uncovered more).
The article asserts that tobacco industry money is behind this activity. But it is beyond this study’s narrow methodological reach to illuminate why nicotine consumer advocates tweet. My discussions with nicotine consumer advocates – the majority of whom are volunteers - demonstrate passionate interest in the policymaking that influences their lives. Having found safer alternatives to smoking, they fear that inappropriate regulation including bans will see their options disappear. They are frustrated that they are ignored by tobacco control policymakers, regulators and researchers. Barred from COP8 along with the public and press, consumer organisations are also barred from the NGO coalition Framework Convention Alliance. No other field of health policy excludes the affected. Consumers use social media to speak out, asking others to do likewise. Picking on a tiny unfunded Mexican organisation for encouraging peers to tweet misunderstands how social media works: the FCA itself recently exhorted members to tweet in the week of the postponed COP9.
Prior assumptions about tobacco industry interference dominate this article (as with much of the Bath group’s work). The authors assert that ‘vaping consumer advocacy groups’ receive industry funding, but provide no evidence for this for any national or local group cited. Net result – the article both smears and further disempowers a disenfranchised population.
Do the authors apply their ‘theory of external influence’ to their own work? The Bath group shares over $20m from the anti-nicotine and anti-tobacco harm reduction Bloomberg Philanthropies. [2] Philanthro-capitalism comes with its own strings attached. [3]
Perhaps more productive would be social science insights into the views of consumer advocates and the narratives that both drive and divide a field in which all parties ostensibly share a common outcome - an end to smoking.
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We appreciate the authors’ concern about industry “astroturfing.” We believe astroturf activities undermine the genuine consumer movement that INNCO and its members represent. But the conclusions that the authors draw from their research are attenuated and inaccurate. In particular, we object strenuously to the authors’ conclusion that because INNCO has received funding from the Foundation for a Smoke-Free World (the Foundation), we are a tobacco front group.
INNCO was formed in 2016, a year before the Foundation was established. All of INNCO’s members are autonomous, independent consumer organisations, and with rare exception are run by volunteers on a shoe-string budget. These organisations joined forces to create INNCO, and they nominate and elect INNCO’s Governing Board members, who serve without compensation.
INNCO only accepts funding from sources where our independence as an organisation run by and for consumers is assured. INNCO operated for more than two years with only volunteer efforts and no funding. (Funding from the Foundation was received in December of 2018, which is after the period this paper covers.)
As the authors note, INNCO was formed in large part to ensure the consumer voice is heard on international platforms. However, we question the authors’ intent in casting our desire to engage as legitimate stakeholders as nefarious.
While the authors have cited numerous references on the motivations of t...
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We appreciate the authors’ concern about industry “astroturfing.” We believe astroturf activities undermine the genuine consumer movement that INNCO and its members represent. But the conclusions that the authors draw from their research are attenuated and inaccurate. In particular, we object strenuously to the authors’ conclusion that because INNCO has received funding from the Foundation for a Smoke-Free World (the Foundation), we are a tobacco front group.
INNCO was formed in 2016, a year before the Foundation was established. All of INNCO’s members are autonomous, independent consumer organisations, and with rare exception are run by volunteers on a shoe-string budget. These organisations joined forces to create INNCO, and they nominate and elect INNCO’s Governing Board members, who serve without compensation.
INNCO only accepts funding from sources where our independence as an organisation run by and for consumers is assured. INNCO operated for more than two years with only volunteer efforts and no funding. (Funding from the Foundation was received in December of 2018, which is after the period this paper covers.)
As the authors note, INNCO was formed in large part to ensure the consumer voice is heard on international platforms. However, we question the authors’ intent in casting our desire to engage as legitimate stakeholders as nefarious.
While the authors have cited numerous references on the motivations of the tobacco industry, they appear to not understand the tobacco harm reduction consumer space, relying solely on the previous work of their own organisation to draw inferences. Consumer advocates are passionate about alternatives that have helped them wean off smoking, and are committed to ensuring continued access for these potentially life-saving products.
Consumers are aligned with FCTC’s goals of mitigating tobacco-related death and disease, although our approach differs in that we reject prohibitionism and stigmatisation in favour of pragmatic, humane and ultimately more effective policies that recognise human rights and the agency of users to become proactive participants in improving their health. INNCO thus brings a unique, ear-to-the-ground perspective to tobacco control efforts, and should be welcomed as FCTC observers.
By encouraging governments, policymakers and others to view consumers and consumer groups as fronts for the tobacco industry, the authors deplatform and disenfranchise an already unfairly marginalised group. We urge the authors to consider the ethical implications of nudging decisionmakers to dismiss the consumer voice. This disregard of the most profoundly affected stakeholders occurs in no other health or policy arena.
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We object to the framing of Association of Vapers India (AVI), erroneously referred to as ‘Vape India’ in the paper, as a tobacco industry front group, without providing any basis for the claim except our membership of International Network of Nicotine Consumer Organisations (INNCO).
AVI was organised in August 2016, when consumers of low-risk alternatives came together to arrest the tide of state bans in India, which were being lobbied for by the Bloomberg Philanthropies network the authors belong to.[1] Though one of our directors is the current president of INNCO’s governing board, elected through a member vote in the 2020 General Assembly, he is serving in unpaid, honorary capacity.
AVI has not received funding from INNCO, nor from the Foundation for Smoke-free World (FSFW), and neither from the tobacco industry. Our work is financed through voluntary contributions, and like INNCO, the affairs are conducted by a governing board comprising unpaid consumer volunteers.
It is scurrilous to cast AVI as a tobacco industry group or anything other than a consumer-led movement that is seeking access to harm reduction avenues for India’s nearly 270 million tobacco users, among whom cancers are rising[2] even as most have meagre means to deal with the health consequences, which makes harm prevention a vital mitigation strategy. We are product agnostic and advocate access to lower-risk alternatives for both smokers and smokeless tobacco...
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We object to the framing of Association of Vapers India (AVI), erroneously referred to as ‘Vape India’ in the paper, as a tobacco industry front group, without providing any basis for the claim except our membership of International Network of Nicotine Consumer Organisations (INNCO).
AVI was organised in August 2016, when consumers of low-risk alternatives came together to arrest the tide of state bans in India, which were being lobbied for by the Bloomberg Philanthropies network the authors belong to.[1] Though one of our directors is the current president of INNCO’s governing board, elected through a member vote in the 2020 General Assembly, he is serving in unpaid, honorary capacity.
AVI has not received funding from INNCO, nor from the Foundation for Smoke-free World (FSFW), and neither from the tobacco industry. Our work is financed through voluntary contributions, and like INNCO, the affairs are conducted by a governing board comprising unpaid consumer volunteers.
It is scurrilous to cast AVI as a tobacco industry group or anything other than a consumer-led movement that is seeking access to harm reduction avenues for India’s nearly 270 million tobacco users, among whom cancers are rising[2] even as most have meagre means to deal with the health consequences, which makes harm prevention a vital mitigation strategy. We are product agnostic and advocate access to lower-risk alternatives for both smokers and smokeless tobacco users, adhering to harm reduction and human rights principles laid out in UN drug policies and in Article 1(d) of the FCTC charter.
We find these accusations especially mischievous in light of our Indian government owning a major 28% stake in the country’s cigarette monopoly and gaining directly from the e-cigarette ban,[3] despite which it was invited to chair COP8 proceedings, whereas consumer advocates, including from AVI, who were there to seek deliberations on their right to access lower-risk alternatives, and whom the FCTC policies affect most severely, were ousted after the plenary session on the pretext of preventing industry influence, left to protest outside the venue and use social media to make ourselves heard.
We strongly oppose this unfair application of Article 5.3 of FCTC which covets tobacco-trading governments but forcefully excludes consumers and attempts to delegitimize them under the garb of the same provision.
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Recent work from Ilies et al. (1) is very informative toward understanding the degree to which heated tobacco products might confer less health risk than combusted cigarettes. This publication extends well beyond the existing HTP emissions evidence base, much of which was not conducted by independent groups. The authors should be commended for leveraging strong methodology, and for their comprehensive evaluation of toxicants generated by these products.
While the methodology and results of this publication appear sound, there are a number of inaccurate claims that warrant criticism in the second paragraph of the Introduction section:
• The second paragraph discusses nicotine vaping products (e-cigarettes), however citation #2 (Centers for Disease Control and Prevention (CDC). Use of cigarettes and other tobacco products among students aged 13-15 years--worldwide, 1999-2005. MMWR Morb Mortal Wkly Rep 2006;55:553) utilize data from 1999 through 2005, which mostly spans a time frame prior to the invention of the first e-cigarette in 2004 (2), and certainly spans a timeframe prior to their widespread marketing in the United States. The citation follows the sentence “However, the death toll provoked by their [e-cigarettes] consumption has increased significantly, reaching 650,000 annually, and it is likely to rise over the coming year…” This citation is clearly inapplicable to the unfounded claim being made about deaths attributable to e-ci...
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Recent work from Ilies et al. (1) is very informative toward understanding the degree to which heated tobacco products might confer less health risk than combusted cigarettes. This publication extends well beyond the existing HTP emissions evidence base, much of which was not conducted by independent groups. The authors should be commended for leveraging strong methodology, and for their comprehensive evaluation of toxicants generated by these products.
While the methodology and results of this publication appear sound, there are a number of inaccurate claims that warrant criticism in the second paragraph of the Introduction section:
• The second paragraph discusses nicotine vaping products (e-cigarettes), however citation #2 (Centers for Disease Control and Prevention (CDC). Use of cigarettes and other tobacco products among students aged 13-15 years--worldwide, 1999-2005. MMWR Morb Mortal Wkly Rep 2006;55:553) utilize data from 1999 through 2005, which mostly spans a time frame prior to the invention of the first e-cigarette in 2004 (2), and certainly spans a timeframe prior to their widespread marketing in the United States. The citation follows the sentence “However, the death toll provoked by their [e-cigarettes] consumption has increased significantly, reaching 650,000 annually, and it is likely to rise over the coming year…” This citation is clearly inapplicable to the unfounded claim being made about deaths attributable to e-cigarette use.
• Citation #3 also supports claims about e-cigarette use, however the cited paper (Sinha DN, Kumar A, Bhartiya D, et al. Smokeless tobacco use among adolescents in global perspective. Nicotine Tob Res 2017;19:1395–6) references non-combusted tobacco products in general, as opposed to the many publications which have looked explicitly at e-cigarette use in a more comprehensive fashion. After reading the Sinha et al. research letter, I am not sure that e-cigarettes were considered at all.
• Citation #4 (US Department of Commerce CB. National cancer Institute and centers for disease control and prevention Co-Sponsored tobacco use supplement to the current population survey 2007) does not provide a direct link to any supporting data/publication. It appears the authors are generally referring to the 2006-2007 Tobacco Use Supplement to the Current Population Survey (CPS-TUS), which was conducted in April 2006, August 2006, and January 2007 (3). The first report of an e-cigarette being imported to the United States is from August 2006 (https://rulings.cbp.gov/ruling/M85579), and the 2006-2007 CPS-TUS did not include any survey items related to e-cigarettes. As such, there is no data from the 2006-2007 CPS-TUS that supports the claim “[e-cigarettes] are highly addictive and can cause serious health problems”.
• The claim “More than 30 carcinogenic compounds in high concentrations were identified, leading to severe health hazards such as oral, pharyngeal, oesophageal and pancreatic cancers” is unfounded, as there is no longitudinal data linking e-cigarettes and cancer to date, nor am I aware of evidence that over 30 carcinogenic compounds in “high concentrations” have been identified in any studies of e-cigarette emissions. Additionally, the provided citation (citation #5: Hatsukami D, Zeller M, Gupta P, et al. Smokeless tobacco and public health: a global perspective 2014) does not talk about e-cigarettes even once.
• Citation #6 (Gupta R, Gupta S, Sharma S, et al. Risk of coronary heart disease among smokeless tobacco users: results of systematic review and meta-analysis of global data. Nicotine and Tobacco Research 2019;21:25–31) also does not pertain to e-cigarettes at all, and the accompanying claim “Cardiovascular death risks and stillbirths were also shown to increase up to four times, signalling real concerns regarding human health safety” is baseless with respect to the epidemiological literature on e-cigarettes.
While these concerns do not directly impact the study results or conclusions, e-cigarettes have become a polarizing topic in the tobacco control community and beyond. As such, claims about e-cigarettes must be made with the utmost care, based on rigorous scientific evidence and sound, balanced interpretations of relevant findings. This publication will be read and cited many times over as heated tobacco products continue to proliferate in tobacco markets across the globe, making it that much more important to address these misleading, and at times, blatantly false claims.
References:
1. Ilies BD, Moosakutty SP, Kharbatia NM, et al. Identification of volatile constituents released from IQOS heat-not-burn tobacco HeatSticks
using a direct sampling method. Tobacco Control. Published Online First: 26 May 2020. doi: 10.1136/tobaccocontrol-2019-055521
2. Henningfield JE & Zaatari GS. Electronic nicotine delivery systems: emerging science foundation for policy. Tobacco Control
2010;19:89e90. doi:10.1136/tc.2009.035279
3. US Department of Commerce, Census Bureau (2006-2007). National Cancer Institute and Food and Drug Administration co-sponsored
Tobacco Use Supplement to the Current Population Survey. 2006-2007. https://cancercontrol.cancer.gov/brp/tcrb/tus-cps/
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The meta-analysis by Khouja et al. confirms the strong association in young people between e-cigarette use and subsequent smoking.[1] The critical issue is whether the relationship is causal. If there is a causal relationship, there are several factors which diminish its impact.
Firstly, most of the studies used ‘ever smoking’ as the outcome. Ever smoking is a poor marker for smoking-related harm as most smoking by vapers who later smoke is experimental and infrequent and few progress to established smoking (100+ lifetime cigarettes). Shahab et al. found that only 2.7% of youth who tried e-cigarettes first progressed to established smoking. Only established smoking is linked to significant smoking-related death and disease.[2]
Secondly, the absolute number of non-smokers who progress from vaping to smoking is small as smoking precedes vaping in the vast majority of cases (70-85%).[3] If there is a gateway from vaping to smoking, this only affects a minority of young vapers.
Thirdly, the authors use Bradford Hill’s dose-response and specificity criteria to assess whether the association between vaping and subsequent smoking is likely to be causal.
They acknowledge that the dose-response criterion is mostly based on nicotine dependence, indicating that that nicotine dependent vapers are more likely to progress to smoking. However, nicotine dependence in non-smoking vapers is rare, less than 4% in the 2018 National Youth T...
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The meta-analysis by Khouja et al. confirms the strong association in young people between e-cigarette use and subsequent smoking.[1] The critical issue is whether the relationship is causal. If there is a causal relationship, there are several factors which diminish its impact.
Firstly, most of the studies used ‘ever smoking’ as the outcome. Ever smoking is a poor marker for smoking-related harm as most smoking by vapers who later smoke is experimental and infrequent and few progress to established smoking (100+ lifetime cigarettes). Shahab et al. found that only 2.7% of youth who tried e-cigarettes first progressed to established smoking. Only established smoking is linked to significant smoking-related death and disease.[2]
Secondly, the absolute number of non-smokers who progress from vaping to smoking is small as smoking precedes vaping in the vast majority of cases (70-85%).[3] If there is a gateway from vaping to smoking, this only affects a minority of young vapers.
Thirdly, the authors use Bradford Hill’s dose-response and specificity criteria to assess whether the association between vaping and subsequent smoking is likely to be causal.
They acknowledge that the dose-response criterion is mostly based on nicotine dependence, indicating that that nicotine dependent vapers are more likely to progress to smoking. However, nicotine dependence in non-smoking vapers is rare, less than 4% in the 2018 National Youth Tobacco Survey (NYTS).[4]
They point out that studies with ‘negative control outcomes’ would reduce specificity but do not cite any studies to demonstrate this. A number of studies have found that vaping also predicts other risky behaviors such as alcohol, marijuana and other substance use.[5,6] There is no biologically plausible mechanism for e-cigarette use being a causal factor for these other behaviours. We think that, like smoking, these associations are best explained by a common liability.[7]
Finally, the recent study by Shahab et al. using NYTS data found that nicotine vaping appears to be protective against future smoking.[2] Teens who vaped first were significantly less likely to subsequently become established smokers than 1) those who smoked first and 2) a matched group of non-vapers.
Their findings suggest that, if there is a gateway from vaping to smoking it is very small and is outweighed by a much larger effect of diverting youth away from cigarette smoking.
References
1. Khouja JN, Suddell SF, Peters SE, et al. Is e-cigarette use in non-smoking young adults associated with later smoking? A systematic review and meta-analysis. Tobacco control 2020 doi: 10.1136/tobaccocontrol-2019-055433 [published Online First: 2020/03/12]
2. Shahab L, Beard E, Brown J. Association of initial e-cigarette and other tobacco product use with subsequent cigarette smoking in adolescents: a cross-sectional, matched control study. Tobacco control 2020 doi: 10.1136/tobaccocontrol-2019-055283
3. Berry KM, Reynolds LM, Collins JM, et al. E-cigarette initiation and associated changes in smoking cessation and reduction: the Population Assessment of Tobacco and Health Study, 2013-2015. Tobacco control 2018;28(1):42-49. doi: 10.1136/tobaccocontrol-2017-054108
4. West R, Brown J, Jarvis M. Epidemic of youth nicotine addiction? What does the National Youth Tobacco Survey reveal about high school ecigarette use in the USA? 2019 [Available from: https://www.qeios.com/read/article/391 accessed 24 February 2020.
5. Park E, Livingston JA, Wang W, et al. Adolescent E-cigarette use trajectories and subsequent alcohol and marijuana use. Addictive behaviors 2020;103:106213. doi: 10.1016/j.addbeh.2019.106213 [published Online First: 2019/12/22]
6. Rigsby DC, Keim SA, Adesman A. Electronic Vapor Product Usage and Substance Use Risk Behaviors Among U.S. High School Students. J Child Adolesc Psychopharmacol 2019;29(7):545-53. doi: 10.1089/cap.2019.0047 [published Online First: 2019/07/26]
7. Vanyukov MM, Tarter RE, Kirillova GP, et al. Common liability to addiction and "gateway hypothesis": theoretical, empirical and evolutionary perspective. Drug and alcohol dependence 2012;123 Suppl 1:S3-17. doi: 10.1016/j.drugalcdep.2011.12.018 [published Online First: 2012/01/21]
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Thank you for the opportunity to clarify and correct some of the recent statements about our research article, ‘Exploring the Twitter activity around the eighth meeting of the Conference of the Parties to the WHO Framework Convention on Tobacco Control’.
Mr Sarangapani, Director of the Association of Vapers India (AVI), is incorrect in claiming that our article makes “false allegations” and “unsubstantiated claims”, and that it frames AVI as a tobacco industry (TI) front group. We categorise his organisation as a ‘next generation product (NGP) advocate’ and we state that AVI is a member of the International Network of Nicotine Consumer Organisations (INNCO). We also report that INNCO has received funding from the Foundation for a Smoke-Free World (FSFW),[1] which is an organisation that continues to be funded solely by Philip Morris International.[2] Thus, AVI is a member of an organisation that receives indirect funds from Philip Morris International, via the FSFW. Those statements are factual and substantiated; readers can locate further details and references to the FSFW’s grantees and tax returns via our Tobacco Tactics pages, as referenced in our article. In his letter, Mr Sarangapani points out that the Founder-Director of AVI is the current President of INNCO’s Governing Board; however, our research article makes no mention of that fact. We clearly state that: “We found no evidence that the individuals affiliated with INNCO or its mem...
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I am writing as co-founder of Pro-Vapeo Mexico, a non-profit consumer association affiliated with the International Network of Nicotine Consumer Organisations (INNCO), explicitly mentioned in the article “Exploring the Twitter activity around the eighth meeting of the Conference of the Parties to the WHO Framework Convention on Tobacco Control”. The authors of this article explicitly recognize that “We found no evidence that the individuals affiliated with INNCO or its member organizations were themselves funded by FSFW [Foundation for a Smoke Free World] or by the TI [Tobacco Industry] directly”. While this statement is correct, it still leaves missing information that we believe it is necessary and useful, for the benefit of your readers, to fully clarify: not only has Pro Vapeo Mexico never received any funding (direct or indirect) from any industry sector (tobacco, e-cigarettes or pharmaceutical) or from INNCO or the FSFW, we are a fully independent NGO whose activities are not (and have never been) directed by the TI or the FSFW or INNCO. Our affiliation with INNCO stems from its role as an umbrella organization grouping consumer associations worldwide united in advocating for Tobacco Harm Reduction, a strategy to improve global health by providing adult smokers the option to consume nicotine without having to inhale toxic cigarette smoke.
Regrettably, the authors of the above-mentioned article claim that our twitter activity in the...
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When doing scientific research, following the scientific method, you have a hypothesis (question) that you are going to investigate - in this case: Does xxx consumer organisation have any direct ties to tobacco companies that influence their advocacy?
After you have chosen your method, you then gather your evidence, make an objective analysis and state your findings and make a conclusion.
Your method SHOULD be thorough and your research should be objective in order to maintain the integrity of your research (and yourself). The evidence will either prove/disprove your original hypothesis.
Instead, the authors have chosen to not only demonise the participation of consumers in the narrative of their own health, one has lobbied false claims about tobacco industry connections that do not exist.
It is very concerning that the authors find it necessary to disenfranchise the very people who are fighting for their right to make informed choices about their health. It defies logic, and the principles of fairness and decency.
It perhaps would have been more helpful to all concerned if the authors had done due diligence beyond looking at a website that does not have verified information, to cast aspersions on consumer advocacy organisations.
It definitely would be more productive to welcome the voices of the people for whom felt impassioned enough to get involved in consumer advocacy to help smokers not only hav...
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Show MoreIt is disappointing to see the BMJ publishing a research paper which smears consumer advocates for tobacco harm reduction by attempting to link consumer activity on social media with the tobacco industry. One can only conclude that the goal was to devalue the opinions of former smokers who have found safer nicotine products to have been beneficial to their lives.
I write as chair of the UK New Nicotine Alliance and as it is highly likely that tweets from our supporters have been included in this research, so we welcome the right to reply to the article.
The attempt to paint consumers as part of some mythical tobacco industry plot is offensive to individuals and organisations promoting tobacco harm reduction. We and our supporters, along with many other vapers, are systematically excluded from the FCTC conferences and yet have a strong stake in the outcomes of the meeting. Social media is one of the few opportunities we have to get our views across. Consumers of safer nicotine products have been acutely aware of an increasing warfare against the products which have helped them to stop smoking.
In 2018, there were clear threats being expressed by the WHO FCTC in advance of COP8 towards products that vaping consumers value highly for helping them to quit smoking. Many vapers travelled to Geneva in 2018 at their own expense, but as ‘members of the public’ were excluded from the meeting.
The article by Robertson et al was funded b...
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Show MoreFreedom of speech is a fundamental right in a free society. There is no justification to either interfere with the right of stakeholders to participate in the public debate regarding tobacco harm reduction policy, or to malign those that exercise that right. Given that the outcome of these policy discussions will affect the lives of more than one billion people on the planet who smoke, everyone must be free to advance arguments for and against any policy, and each argument must be scrutinized and evaluated on its evidence base and merits. Unfortunately, the recent paper in Tobacco Control—Exploring the Twitter activity around the eighth meeting of the Conference of the Parties to the WHO Framework Convention on Tobacco Control—missed the opportunity to do this.
Instead of engaging in a discussion on the key issues and arguments put forth in the public discussion around the eighth meeting of the Conference of the Parties (COP8), the authors employ diversionary ad hominem tactics. They mischaracterize Philip Morris International’s (PMI’s) legitimate participation in the public debate on the role that products with the potential to reduce the risk of harm compared to smoking can play in global public health policy. Using phrases like ‘tobacco industry actors’ and ‘front groups’ the authors falsely imply that any person or organization who publicly supports tobacco harm reduction are paid to do so by the tobacco industry, and specifically PMI....
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It’s surprising finding oneself involuntarily part of a research study. Given no chance to contribute, perhaps I can offer privileged insight into the processes the authors seek to describe.
Analysis of tweets around the COP8 meeting show that nicotine consumer advocates were the most active, followed by public health advocates and the tobacco industry. My company – Knowledge Action Change – also tweeted, at the Geneva launch of our tobacco harm reduction report. [1] Tweeting by tobacco harm reduction advocates out-shadowed “official” FCTC messaging (and if the authors had searched #FCTCCOP8 and #COP8 as well as #COP8FCTC, they would have uncovered more).
The article asserts that tobacco industry money is behind this activity. But it is beyond this study’s narrow methodological reach to illuminate why nicotine consumer advocates tweet. My discussions with nicotine consumer advocates – the majority of whom are volunteers - demonstrate passionate interest in the policymaking that influences their lives. Having found safer alternatives to smoking, they fear that inappropriate regulation including bans will see their options disappear. They are frustrated that they are ignored by tobacco control policymakers, regulators and researchers. Barred from COP8 along with the public and press, consumer organisations are also barred from the NGO coalition Framework Convention Alliance. No other field of health policy excludes the affected. Consu...
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We appreciate the authors’ concern about industry “astroturfing.” We believe astroturf activities undermine the genuine consumer movement that INNCO and its members represent. But the conclusions that the authors draw from their research are attenuated and inaccurate. In particular, we object strenuously to the authors’ conclusion that because INNCO has received funding from the Foundation for a Smoke-Free World (the Foundation), we are a tobacco front group.
INNCO was formed in 2016, a year before the Foundation was established. All of INNCO’s members are autonomous, independent consumer organisations, and with rare exception are run by volunteers on a shoe-string budget. These organisations joined forces to create INNCO, and they nominate and elect INNCO’s Governing Board members, who serve without compensation.
INNCO only accepts funding from sources where our independence as an organisation run by and for consumers is assured. INNCO operated for more than two years with only volunteer efforts and no funding. (Funding from the Foundation was received in December of 2018, which is after the period this paper covers.)
As the authors note, INNCO was formed in large part to ensure the consumer voice is heard on international platforms. However, we question the authors’ intent in casting our desire to engage as legitimate stakeholders as nefarious.
While the authors have cited numerous references on the motivations of t...
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We object to the framing of Association of Vapers India (AVI), erroneously referred to as ‘Vape India’ in the paper, as a tobacco industry front group, without providing any basis for the claim except our membership of International Network of Nicotine Consumer Organisations (INNCO).
AVI was organised in August 2016, when consumers of low-risk alternatives came together to arrest the tide of state bans in India, which were being lobbied for by the Bloomberg Philanthropies network the authors belong to.[1] Though one of our directors is the current president of INNCO’s governing board, elected through a member vote in the 2020 General Assembly, he is serving in unpaid, honorary capacity.
AVI has not received funding from INNCO, nor from the Foundation for Smoke-free World (FSFW), and neither from the tobacco industry. Our work is financed through voluntary contributions, and like INNCO, the affairs are conducted by a governing board comprising unpaid consumer volunteers.
It is scurrilous to cast AVI as a tobacco industry group or anything other than a consumer-led movement that is seeking access to harm reduction avenues for India’s nearly 270 million tobacco users, among whom cancers are rising[2] even as most have meagre means to deal with the health consequences, which makes harm prevention a vital mitigation strategy. We are product agnostic and advocate access to lower-risk alternatives for both smokers and smokeless tobacco...
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Recent work from Ilies et al. (1) is very informative toward understanding the degree to which heated tobacco products might confer less health risk than combusted cigarettes. This publication extends well beyond the existing HTP emissions evidence base, much of which was not conducted by independent groups. The authors should be commended for leveraging strong methodology, and for their comprehensive evaluation of toxicants generated by these products.
While the methodology and results of this publication appear sound, there are a number of inaccurate claims that warrant criticism in the second paragraph of the Introduction section:
• The second paragraph discusses nicotine vaping products (e-cigarettes), however citation #2 (Centers for Disease Control and Prevention (CDC). Use of cigarettes and other tobacco products among students aged 13-15 years--worldwide, 1999-2005. MMWR Morb Mortal Wkly Rep 2006;55:553) utilize data from 1999 through 2005, which mostly spans a time frame prior to the invention of the first e-cigarette in 2004 (2), and certainly spans a timeframe prior to their widespread marketing in the United States. The citation follows the sentence “However, the death toll provoked by their [e-cigarettes] consumption has increased significantly, reaching 650,000 annually, and it is likely to rise over the coming year…” This citation is clearly inapplicable to the unfounded claim being made about deaths attributable to e-ci...
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The meta-analysis by Khouja et al. confirms the strong association in young people between e-cigarette use and subsequent smoking.[1] The critical issue is whether the relationship is causal. If there is a causal relationship, there are several factors which diminish its impact.
Firstly, most of the studies used ‘ever smoking’ as the outcome. Ever smoking is a poor marker for smoking-related harm as most smoking by vapers who later smoke is experimental and infrequent and few progress to established smoking (100+ lifetime cigarettes). Shahab et al. found that only 2.7% of youth who tried e-cigarettes first progressed to established smoking. Only established smoking is linked to significant smoking-related death and disease.[2]
Secondly, the absolute number of non-smokers who progress from vaping to smoking is small as smoking precedes vaping in the vast majority of cases (70-85%).[3] If there is a gateway from vaping to smoking, this only affects a minority of young vapers.
Thirdly, the authors use Bradford Hill’s dose-response and specificity criteria to assess whether the association between vaping and subsequent smoking is likely to be causal.
They acknowledge that the dose-response criterion is mostly based on nicotine dependence, indicating that that nicotine dependent vapers are more likely to progress to smoking. However, nicotine dependence in non-smoking vapers is rare, less than 4% in the 2018 National Youth T...
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