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He et al cite (ref 43 in their paper) our meta-analysis of the association between e-cigarette use and smoking cessation [1} to support the statement, "[e-cigarettes] have demonstrated potential in recent years in helping smoking cessation." Quite the contrary, the abstract of this paper concludes, "As consumer products, in observational studies, e-cigarettes were not associated with increased smoking cessation in the adult population."
A subsequent meta-analysis [2] concluded the same thing.
Both these meta-analyses include the other paper (ref 44 in their paper) He et al cite to support their statement that e-cigarettes assist smoking cessation [3].
The authors need to accurately represent the literature and stop promoting the myth that e-cigarettes as consumer products increase cigarette smoking cessation. They also need to correct their paper to avoid perpetuating the literature.
REFERENCES
1. Wang RJ, Bhadriraju S, Glantz SA. E-cigarette use and adult cigarette smoking cessation: a meta-analysis. Am J Public Health 2021;111:230–46. doi:10.2105/AJPH.2020.305999
2. Hedman L, Galanti MR, Ryk L, et al. Electronic cigarette use and smoking cessation in cohort studies and randomized trials: a systematic review and meta-analysis.
Tob Prev Cessat 2021;7:62.
3. Zhuang Y-L, Cummins SE, Sun JY, et al . Long-term E-cigarette use and smoking cessation: a longitudinal study w...
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He et al cite (ref 43 in their paper) our meta-analysis of the association between e-cigarette use and smoking cessation [1} to support the statement, "[e-cigarettes] have demonstrated potential in recent years in helping smoking cessation." Quite the contrary, the abstract of this paper concludes, "As consumer products, in observational studies, e-cigarettes were not associated with increased smoking cessation in the adult population."
A subsequent meta-analysis [2] concluded the same thing.
Both these meta-analyses include the other paper (ref 44 in their paper) He et al cite to support their statement that e-cigarettes assist smoking cessation [3].
The authors need to accurately represent the literature and stop promoting the myth that e-cigarettes as consumer products increase cigarette smoking cessation. They also need to correct their paper to avoid perpetuating the literature.
REFERENCES
1. Wang RJ, Bhadriraju S, Glantz SA. E-cigarette use and adult cigarette smoking cessation: a meta-analysis. Am J Public Health 2021;111:230–46. doi:10.2105/AJPH.2020.305999
2. Hedman L, Galanti MR, Ryk L, et al. Electronic cigarette use and smoking cessation in cohort studies and randomized trials: a systematic review and meta-analysis.
Tob Prev Cessat 2021;7:62.
3. Zhuang Y-L, Cummins SE, Sun JY, et al . Long-term E-cigarette use and smoking cessation: a longitudinal study with US population. Tob Control 2016;25:i90–5. doi:10.1136/tobaccocontrol-2016-053096
Regarding the first two questions, the analyses were based on the public use data from both the PATH Study and the MCS, with links to their archives, and the PATH study sample was drawn from the original cohort, the replenishment cohort, and the shadow cohorts (see 1st and 2nd paragraphs of Methods Section). Regarding the remaining questions, please note that our stated goal was to make the MCS and PATH analytical samples as comparable as possible when testing our hypotheses using both cohorts (3rd paragraph of Methods section). As we note in the limitations section (5th paragraph of Discussion section), the MCS had relatively limited items on e-cigarette use and tobacco smoking compared to PATH. The MCS did not assess other combustible tobacco product consumption in early adolescence, nor did MCS measure the sequencing of early adolescent tobacco and e-cigarette use (noted in the limitation section). Also, MCS youth answered survey questions about ever using e-cigarettes from 2015 to 2016 (3rd paragraph of Methods section), which gave us limited variability to test for a wave x e-cigarette interaction in both datasets.
I respectfully request answers to the following questions:
1. Was public use or restricted PATH data used. This is important, since Table 2 contains a cell, n=7, that is not generally approved by NAHDAP.
2. Was the PATH cohort drawn from Waves 1 and 4, with follow-ups to age 17 years as needed from the other waves?
3. There were significant differences in youth smoking-vaping between Wave 1 (2013-14) and Wave 4 (2016-18) that might have affected the results. Was each wave analyzed separately as well as together?
4. The analysis included a variable relating to “parent(s) smoking of cigarettes, cigars, or pipes.” Did the analysis include other combustible tobacco product consumption by the subjects themselves?
5. Did the authors account for age at first smoking or vaping (public use, < 12 years and 12-14 years) or which product(s) had been used first?
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Pichon-Riviere et al concluded that the four tobacco control interventions analyzed could successfully avert deaths and disability and significantly ease the tobacco-attributable economic burden, but are not enough, as smoking remains a leading cause of health and economic burden in Latin America (1). According to the Global Burden of Disease Project (2), regardless of the relative decrease in tobacco prevalence in the last decades, age-standardized rates of deaths and DALYs for smoking-attributable diseases remain high in Latin America, a region hard hit by the epidemic (3). Unfortunately, in most of the countries in Latin America, there are other problems related to the main strategy to reduce tobacco consumption (i.e., taxation falls short of WHO recommendations) for example cigarettes remain affordable mainly due to the commercialization of illegal tobacco products and smuggled cigarettes, an important distractor for public health authorities, as the real number of users is hidden, access for younger people is easier and health risks are surely higher (4).
In addition, as in not all countries among our region there are available pharmacological alternatives to help current smokers, cessation strategies may be adapted for novel products, and treatment recommendations for tobacco use disorder should be made within the context of a harm reduction framework wherein alternative product use may be the desired outcome (5). Also, nicotine e‐cigare...
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Pichon-Riviere et al concluded that the four tobacco control interventions analyzed could successfully avert deaths and disability and significantly ease the tobacco-attributable economic burden, but are not enough, as smoking remains a leading cause of health and economic burden in Latin America (1). According to the Global Burden of Disease Project (2), regardless of the relative decrease in tobacco prevalence in the last decades, age-standardized rates of deaths and DALYs for smoking-attributable diseases remain high in Latin America, a region hard hit by the epidemic (3). Unfortunately, in most of the countries in Latin America, there are other problems related to the main strategy to reduce tobacco consumption (i.e., taxation falls short of WHO recommendations) for example cigarettes remain affordable mainly due to the commercialization of illegal tobacco products and smuggled cigarettes, an important distractor for public health authorities, as the real number of users is hidden, access for younger people is easier and health risks are surely higher (4).
In addition, as in not all countries among our region there are available pharmacological alternatives to help current smokers, cessation strategies may be adapted for novel products, and treatment recommendations for tobacco use disorder should be made within the context of a harm reduction framework wherein alternative product use may be the desired outcome (5). Also, nicotine e‐cigarettes probably do help people to stop smoking for at least six months. They probably work better than nicotine replacement therapy and nicotine‐free e‐cigarettes. They may work better than no support, or behavioral support alone, and they may not be associated with serious unwanted effects (6).
As member of the Latin-American Network for Tobacco Harm Reduction (www.reldat.org) we are actively working on reach the decision-makers to let them better understand the “harm reduction” concept for tobacco consumption, as it applies for other medical conditions.
1. Pichon-Riviere A, Bardach A, Rodríguez Cairoli F, et al. Tob Control Epub ahead of print: Health, economic and social burden of tobacco in Latin America and the expected gains of fully implementing taxes, plain packaging, advertising bans and smoke-free environments control measures: a modelling study. doi:10.1136/tc-2022-057618
2. He H, Pan Z, Wu J, et al. Health effects of tobacco at the global, regional, and national levels: results from the 2019 global burden of disease study. Nicotine & Tobacco Research 2022;24:864–70.
3. GBD. Tobacco collaborators. spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990-2019: a systematic analysis from the global burden of disease study 2019. Lancet 2021;397:2337–60.
4. Ortiz-Prado E, Teran E, Cevallos-Sierra G, Villacres T, Alcivar C, Vasconez E. Anti-tobacco policy and the smuggled cigarettes, a hidden problem in Ecuador. J Public Health Emerg 2022;6:10.
5. Palmer AM, Toll BA, Carpenter MJ, et al. Reappraising Choice in Addiction: Novel Conceptualizations and Treatments for Tobacco Use Disorder. Nicotine Tob Res 2022;24(1):3-9
6. Hartmann-Boyce J, McRobbie H, Butler AR, Lindson N, Bullen C, Begh R, Theodoulou A, Notley C, Rigotti NA, Turner T, Fanshawe TR, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews 2021, Issue 9. Art. No.: CD010216. DOI: 10.1002/14651858.CD010216.pub6. Accessed 10 May 2022.
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I read with interest the article "Global tobacco advertising, promotion, and sponsorship regulation: what’s old, what’s new, and where to next?[1]" published in Tobacco Control. As a psychiatrist specializing in addiction treatment at Taoyuan Psychiatric Center in Taiwan, I wish to share our institution's experience in implementing a successful smoke-free hospital program, which may serve as a model for other psychiatric centers.
Since 2014, Taoyuan Psychiatric Center has made significant progress in promoting a smoke-free environment through a comprehensive tobacco control program. Our program's objectives include creating a smoke-free hospital, increasing smoking cessation services for outpatients and inpatients, and improving patient smoking status documentation. Furthermore, we prioritize smoking cessation counseling for adolescents, pregnant women, and their families.
In psychiatric settings, smoking cessation is crucial as tobacco use can influence the blood concentration of psychotropic medications, potentially destabilizing psychiatric symptoms. Assisting patients in quitting smoking not only lowers the risk of tobacco-related diseases but also contributes to stabilizing their psychiatric conditions.
Our program encompasses various initiatives, including staff training, community tobacco harm prevention promotion, provision of second-generation smoking cessation treatments for outpatients and inpatien...
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I read with interest the article "Global tobacco advertising, promotion, and sponsorship regulation: what’s old, what’s new, and where to next?[1]" published in Tobacco Control. As a psychiatrist specializing in addiction treatment at Taoyuan Psychiatric Center in Taiwan, I wish to share our institution's experience in implementing a successful smoke-free hospital program, which may serve as a model for other psychiatric centers.
Since 2014, Taoyuan Psychiatric Center has made significant progress in promoting a smoke-free environment through a comprehensive tobacco control program. Our program's objectives include creating a smoke-free hospital, increasing smoking cessation services for outpatients and inpatients, and improving patient smoking status documentation. Furthermore, we prioritize smoking cessation counseling for adolescents, pregnant women, and their families.
In psychiatric settings, smoking cessation is crucial as tobacco use can influence the blood concentration of psychotropic medications, potentially destabilizing psychiatric symptoms. Assisting patients in quitting smoking not only lowers the risk of tobacco-related diseases but also contributes to stabilizing their psychiatric conditions.
Our program encompasses various initiatives, including staff training, community tobacco harm prevention promotion, provision of second-generation smoking cessation treatments for outpatients and inpatients with mental disorders, and organizing smoking cessation support groups and counseling. These efforts have led to a substantial increase in patients receiving smoking cessation services and a considerable decline in smoking rates among staff and patients.
In conclusion, Taoyuan Psychiatric Center's experience can serve as a valuable example for psychiatric institutions aiming to implement successful tobacco control programs. By addressing psychiatric patients' unique challenges, we can significantly impact their physical and mental well-being while contributing to global tobacco control efforts.
Sincerely,
Dr. LienChung Wei
Psychiatrist specializing in Addiction Treatment
Taoyuan Psychiatric Center, Taiwan
Reference:
[1] Freeman B, Watts C, Astuti PAS. Global tobacco advertising, promotion and sponsorship regulation: what’s old, what’s new and where to next? 2022;31(2):216-221.
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We acknowledge receipt of a private e-mail message from JLI regarding our paper (Yassine et al., 2022). Given the industry‘s long history of industry obfuscation, interference, and deception regarding research on tobacco products, we decided that the most transparent approach to the private e-mail that we received from an employee of a tobacco product manufacturer would be for us to report our results independently and respond to any public discussion of our work if and when it arose. Now that public discussion has arisen, we are pleased to respond to it.
We very recently analyzed the menthol and nicotine content of samples of liquid from six menthol flavor pods purchased in 2020. Three of these were liquids extracted from the pods in June 2021 for our paper and had been stored since in sealed amber glass containers at 5°C in the dark. The other three pods had been stored in their original sealed packages and were taken from the same batches as the pods analyzed in June 2021. These unopened packages were stored in the dark at room temperature over the intervening 18 months. The data from this small sample demonstrate a 24% reduction in menthol content over that period (12.01±0.46 vs 9.15±0.22 mg/ml), which helps to explain the results we reported (Yassine et al., 2022). We also found a 5% reduction in nicotine content (62.47±0.63 vs 59.52±0.49 mg/ml), as well as discoloration of the liquid in the pods that were stored at room temperatur...
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We acknowledge receipt of a private e-mail message from JLI regarding our paper (Yassine et al., 2022). Given the industry‘s long history of industry obfuscation, interference, and deception regarding research on tobacco products, we decided that the most transparent approach to the private e-mail that we received from an employee of a tobacco product manufacturer would be for us to report our results independently and respond to any public discussion of our work if and when it arose. Now that public discussion has arisen, we are pleased to respond to it.
We very recently analyzed the menthol and nicotine content of samples of liquid from six menthol flavor pods purchased in 2020. Three of these were liquids extracted from the pods in June 2021 for our paper and had been stored since in sealed amber glass containers at 5°C in the dark. The other three pods had been stored in their original sealed packages and were taken from the same batches as the pods analyzed in June 2021. These unopened packages were stored in the dark at room temperature over the intervening 18 months. The data from this small sample demonstrate a 24% reduction in menthol content over that period (12.01±0.46 vs 9.15±0.22 mg/ml), which helps to explain the results we reported (Yassine et al., 2022). We also found a 5% reduction in nicotine content (62.47±0.63 vs 59.52±0.49 mg/ml), as well as discoloration of the liquid in the pods that were stored at room temperature that suggests the possibility of other time-dependent changes in liquid constituents that we have not had an opportunity to evaluate comprehensively.
We acknowledge that the differences in menthol concentrations in JUUL products that were purchased across a three-year period, reported in Yassine et al., 2022, are consistent with changes in product composition that can occur during storage. A correction to the manuscript is now being published.
Our findings highlight that tobacco product manufacturers should be required to release to the public and the scientific community everything they know about their products, including product ingredients, abuse liability, potential adverse health consequences, and time- and temperature-dependent degradation of quality. For example, much of this information may be available in Premarket Tobacco Product Applications submitted to the Food and Drug Administration’s Center for Tobacco Products, and thus could be shared easily on each company’s website. This vital information should be available to all. In the meantime, our original article (Yassine et al., 2022), the industry response (Gillman, 2022), and this reply provide needed archival documentation for the scientific record.
References
Yassine A, El Hage R, El-Hellani A, Salman R, Talih S, Eissenberg T, Shihadeh A, Saliba N. Did JUUL alter the content of menthol pods in response to US FDA flavour enforcement policy? Tob Control. 2022 Nov;31(Suppl 3):s234-s237. doi: 10.1136/tc-2022-057506. PMID: 36328458; PMCID: PMC9641543.
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Authors previewed this study on March 16, 2022, at the Annual Meeting of the Society for Research on Nicotine and Tobacco[1]. Prompted by this presentation, on April 5, 2022, I emailed Drs. Talih, Eissenberg, and Shihadeh with product-specific information and questions that raised substantial doubt in the authors’ claims about JUUL products, specifically the purported modification of Menthol JUULpods.
Due to word limits here, we have posted a full copy of my email to the authors on PubPeer[2]. This email predated by almost a month the authors’ submission to the journal. Below please find an excerpt from this correspondence:
“In your presentation, you conclude that Juul Labs has in some way altered or otherwise modified its e-liquid formulations, but these claims are incorrect. Juul Labs has not altered or modified these e-liquid formulations since they were introduced into the market before August 2016 (i.e., FDA’s deeming date). We have supporting documentation, including batch records and certificates of analysis to confirm this.
“Setting aside any issues with methodologies or environmental conditions in the study, there are a number of possible explanations for the variations you found. For example, one potential explanation for the differences in tested products is the loss of menthol over time. It is well-documented in scientific literature[3] that menthol may migrate from areas of high concentration to low concentration,...
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Authors previewed this study on March 16, 2022, at the Annual Meeting of the Society for Research on Nicotine and Tobacco[1]. Prompted by this presentation, on April 5, 2022, I emailed Drs. Talih, Eissenberg, and Shihadeh with product-specific information and questions that raised substantial doubt in the authors’ claims about JUUL products, specifically the purported modification of Menthol JUULpods.
Due to word limits here, we have posted a full copy of my email to the authors on PubPeer[2]. This email predated by almost a month the authors’ submission to the journal. Below please find an excerpt from this correspondence:
“In your presentation, you conclude that Juul Labs has in some way altered or otherwise modified its e-liquid formulations, but these claims are incorrect. Juul Labs has not altered or modified these e-liquid formulations since they were introduced into the market before August 2016 (i.e., FDA’s deeming date). We have supporting documentation, including batch records and certificates of analysis to confirm this.
“Setting aside any issues with methodologies or environmental conditions in the study, there are a number of possible explanations for the variations you found. For example, one potential explanation for the differences in tested products is the loss of menthol over time. It is well-documented in scientific literature[3] that menthol may migrate from areas of high concentration to low concentration, and therefore flavor levels may decrease over time.” [4][5][6][7]
I never received a reply to this email from the publication’s authors and the manuscript does not recognize the issues that were raised, nor does it provide sufficient information to address the most likely flaw in the authors’ interpretation: that likely the loss of menthol during product storage played a vital and determinative role in the lower menthol amount observed in the aged JUULpods purchased in 2017 and 2018.
We request that Tobacco Control require the authors to provide detailed information regarding the timing of their analyses and ideally responses to all of the issues raised in our email to them. We would furthermore appreciate the opportunity to share with Tobacco Control the documentation I referenced in my initial email to study authors - including batch records and certificates of analysis - that demonstrate that we made no changes to our products’ formulations.
Assuming this further engagement demonstrates to the editors that the authors’ assertions that Juul Labs altered its products are unfounded, we ask that this article be retracted.
Dr. Gene Gillman
Vice President, Regulatory Chemistry
Juul Labs
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I would like to make three comments by way of a brief post-publication review.
1. The impacts of vaping tax on smoking have been completely overlooked
For a study of e-cigarette taxation to have any public health relevance, it must consider the impact of e-cigarette prices on *cigarette* demand. Cigarettes and e-cigarettes are economic substitutes. The demand for one responds to changes in the price of the other, an idea well understood in economics and quantified through the concept of cross-elasticity. The paper appears to pay no regard to the impact of vaping taxes on cigarette demand, Yet such effects might easily overwhelm any benefits from reduced e-cigarette use - in fact, impact on demand for other tobacco products and the development of informal markets are by far the most important impacts of a vaping tax. By way of example, a 2020 paper by Pesko et al. [1] concluded:
"Our results suggest that a proposed national e-cigarette tax of $1.65 per milliliter of vaping liquid would raise the proportion of adults who smoke cigarettes daily by approximately 1 percentage point, translating to 2.5 million extra adult daily smokers compared to the counterfactual of not having the tax."
2. The case for reducing adult vaping by taxation has not been made
The authors have based their paper on an unexamined assumption that it is a justifiable goal of policy to lower rates of adult e-cigarette use. Why should...
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I would like to make three comments by way of a brief post-publication review.
1. The impacts of vaping tax on smoking have been completely overlooked
For a study of e-cigarette taxation to have any public health relevance, it must consider the impact of e-cigarette prices on *cigarette* demand. Cigarettes and e-cigarettes are economic substitutes. The demand for one responds to changes in the price of the other, an idea well understood in economics and quantified through the concept of cross-elasticity. The paper appears to pay no regard to the impact of vaping taxes on cigarette demand, Yet such effects might easily overwhelm any benefits from reduced e-cigarette use - in fact, impact on demand for other tobacco products and the development of informal markets are by far the most important impacts of a vaping tax. By way of example, a 2020 paper by Pesko et al. [1] concluded:
"Our results suggest that a proposed national e-cigarette tax of $1.65 per milliliter of vaping liquid would raise the proportion of adults who smoke cigarettes daily by approximately 1 percentage point, translating to 2.5 million extra adult daily smokers compared to the counterfactual of not having the tax."
2. The case for reducing adult vaping by taxation has not been made
The authors have based their paper on an unexamined assumption that it is a justifiable goal of policy to lower rates of adult e-cigarette use. Why should this be a policy goal any more than reducing caffeine use or moderate alcohol use? The goal of public health policy is to address significant harms or self-destructive patterns of use, not to modify behaviours that the authors find distasteful. What are the harms that justify state intervention to reduce adult vaping with a tax? Further, they appear indifferent to welfare costs and the distributional impact of imposing a regressive tax burden on people who use vaping products. Tobacco control advocates should become more familiar with the idea that punitive policies impose harm on users, even though these users are supposed to be the intended beneficiaries. For example, a vaping tax harms families by drawing on the household budget of those who continue to vape.
3. The analysis to support the policy recommendations is wholly inadequate
The authors make over-confident policy recommendations without considering the full range of impacts of the measures they are proposing.
"Our findings suggest that adopting a vaping product excise tax policy may help reduce ENDS use and suppress the increase of ENDS use prevalence among young adults. Considering that there are still a number of US states that have not implemented vaping product excise tax policy, wider adoption of such policy across the nation would likely help mitigate ENDS use prevalence."
Without considering all the possible responses to the tax they support, they may easily be proposing tobacco control policies that do more harm than good. In fact, the most important public health impact of this policy is entirely excluded from the analysis. That is the effect of a vaping tax on smoking or other tobacco use. Given the two orders of magnitude difference in risk between smoking and vaping, only a tiny uptick in smoking would be needed to completely offset the benefits, if any, arising from reduced vaping
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I have a number of concerns with the paper as currently written.
1) The authors write: “Besides, none of the previous studies except Pesko et al (15) that examined the associations between vaping product excise tax adoption and ENDS use has accounted for the clustering of respondents within the same localities…” This is not accurate, as citation 19 also clusters standard errors at the locality level in all specifications.
2) The authors write: "A working paper reported reduced ENDS sales, but not ENDS use prevalence or behaviours, after implementation of a vaping product excise tax policy. (19)” This is not accurate, as the cited study uses the magnitude of e-cigarette tax values, rather than an indicator variable for tax implementation. States have adopted e-cigarette taxes of different magnitudes and a number of them (such as California) have changed the magnitudes of these taxes after adoption. All of this variation is used in citation 19, contrary to the current study’s description. It's also unclear from the sentence whether citation 19 studied use and found imprecise estimates, or did not study use. It's the latter and this should be clarified. It's also unclear why the authors did not use magnitude of e-cigarette taxes themselves in the current paper, as has been commonly done in the referenced literature.
3) Authors write they use a “nationally representative sample of US young adults.” I do not beli...
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I have a number of concerns with the paper as currently written.
1) The authors write: “Besides, none of the previous studies except Pesko et al (15) that examined the associations between vaping product excise tax adoption and ENDS use has accounted for the clustering of respondents within the same localities…” This is not accurate, as citation 19 also clusters standard errors at the locality level in all specifications.
2) The authors write: "A working paper reported reduced ENDS sales, but not ENDS use prevalence or behaviours, after implementation of a vaping product excise tax policy. (19)” This is not accurate, as the cited study uses the magnitude of e-cigarette tax values, rather than an indicator variable for tax implementation. States have adopted e-cigarette taxes of different magnitudes and a number of them (such as California) have changed the magnitudes of these taxes after adoption. All of this variation is used in citation 19, contrary to the current study’s description. It's also unclear from the sentence whether citation 19 studied use and found imprecise estimates, or did not study use. It's the latter and this should be clarified. It's also unclear why the authors did not use magnitude of e-cigarette taxes themselves in the current paper, as has been commonly done in the referenced literature.
3) Authors write they use a “nationally representative sample of US young adults.” I do not believe this is not accurate. The TUS-CPS sample itself may be nationally representative, but this representativeness may be lost when subgroups are explored.
4) The “vaping product excise tax policy” variable in Table 3 appears to be re-defined mid-table. Based on the discussion of the results, in column 1 it appears that this variable is an indicator equal to 1 only at the time when a state has an e-cigarette tax in place. In column 2 though, this indicator equals 1 when a state ever has an e-cigarette tax in place (even prior to it being in place). The use of the same row for a variable that changes across columns is unusual and can easily lead to the wrong interpretation.
We appreciate the comments from Bates and the opportunity for us to respond and clarify.
First, Bates' argument heavily relies on the assumption that e-cigarettes and combustible cigarettes are substitutes, which is theoretically possible as some consider vaping as a harm reduction alternative to combustible cigarettes. Empirically, however, there have been mixed findings about whether e-cigarettes and combustible cigarettes are substitutes (or complements). Bates cited Pesko et al. (2020) that concludes e-cigarettes and combustible cigarettes are substitutes, whereas other studies have shown that they are complements. For example, Cotti et al. (2018) found that higher cigarette excise taxes, in fact, decrease sales of both e-cigarettes and combustible cigarettes, suggesting that they are complements. Such mixed results abate Bates' argument that taxing ENDS could lead to more use of combustible cigarettes.
Second, Bates might have ignored that our study focused on young adults aged 18-24 years rather than general adults when examining the effect of vaping product tax on e-cigarette use. Although Pesko et al. (2020) suggests that e-cigarettes and combustible cigarettes are substitutes, the findings are based on the general adult population (average age: 55 years) which may not be generalizable to the young adult population. In fact, one study conducted by Abouk and Adams (2017) indicates that e-cigarettes and combustible ci...
We appreciate the comments from Bates and the opportunity for us to respond and clarify.
First, Bates' argument heavily relies on the assumption that e-cigarettes and combustible cigarettes are substitutes, which is theoretically possible as some consider vaping as a harm reduction alternative to combustible cigarettes. Empirically, however, there have been mixed findings about whether e-cigarettes and combustible cigarettes are substitutes (or complements). Bates cited Pesko et al. (2020) that concludes e-cigarettes and combustible cigarettes are substitutes, whereas other studies have shown that they are complements. For example, Cotti et al. (2018) found that higher cigarette excise taxes, in fact, decrease sales of both e-cigarettes and combustible cigarettes, suggesting that they are complements. Such mixed results abate Bates' argument that taxing ENDS could lead to more use of combustible cigarettes.
Second, Bates might have ignored that our study focused on young adults aged 18-24 years rather than general adults when examining the effect of vaping product tax on e-cigarette use. Although Pesko et al. (2020) suggests that e-cigarettes and combustible cigarettes are substitutes, the findings are based on the general adult population (average age: 55 years) which may not be generalizable to the young adult population. In fact, one study conducted by Abouk and Adams (2017) indicates that e-cigarettes and combustible cigarettes are not substitutes for young people. Established cigarette smokers may use e-cigarettes as a cessation tool but it is less common in young adults. In addition, even if e-cigarettes and combustible cigarettes are substitutes to some degree, the direction of substitution as well as co-use versus subsequent use should not be overlooked. Studies have shown that e-cigarettes may serve as a gateway to future combustible cigarette smoking among young people. For example, a study conducted by Hair et al. (2021) shows that youth and young adults who reported ever e-cigarette use had significantly higher odds of ever cigarette use one year later. Therefore, e-cigarette use versus combustible cigarette smoking is not simply an issue of substitution in particular among young people.
Disclosure: We did not receive any funding from the tobacco industry.
References:
1. Abouk, R., & Adams, S. (2017). Bans on electronic cigarette sales to minors and smoking among high school students. Journal of Health Economics, 54, 17-24.
2. Cotti, C., Nesson, E., & Tefft, N. (2018). The relationship between cigarettes and electronic cigarettes: Evidence from household panel data. Journal of Health Economics, 61, 205-219.
3. Hair, E. C., Barton, A. A., Perks, S. N., Kreslake, J., Xiao, H., Pitzer, L., ... & Vallone, D. M. (2021). Association between e-cigarette use and future combustible cigarette use: Evidence from a prospective cohort of youth and young adults, 2017–2019. Addictive Behaviors, 112, 106593.
4. Pesko, M. F., Courtemanche, C. J., & Maclean, J. C. (2020). The effects of traditional cigarette and e-cigarette tax rates on adult tobacco product use. Journal of Risk and Uncertainty, 60(3), 229-258.
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He et al cite (ref 43 in their paper) our meta-analysis of the association between e-cigarette use and smoking cessation [1} to support the statement, "[e-cigarettes] have demonstrated potential in recent years in helping smoking cessation." Quite the contrary, the abstract of this paper concludes, "As consumer products, in observational studies, e-cigarettes were not associated with increased smoking cessation in the adult population."
A subsequent meta-analysis [2] concluded the same thing.
Both these meta-analyses include the other paper (ref 44 in their paper) He et al cite to support their statement that e-cigarettes assist smoking cessation [3].
The authors need to accurately represent the literature and stop promoting the myth that e-cigarettes as consumer products increase cigarette smoking cessation. They also need to correct their paper to avoid perpetuating the literature.
REFERENCES
1. Wang RJ, Bhadriraju S, Glantz SA. E-cigarette use and adult cigarette smoking cessation: a meta-analysis. Am J Public Health 2021;111:230–46. doi:10.2105/AJPH.2020.305999
2. Hedman L, Galanti MR, Ryk L, et al. Electronic cigarette use and smoking cessation in cohort studies and randomized trials: a systematic review and meta-analysis.
Tob Prev Cessat 2021;7:62.
3. Zhuang Y-L, Cummins SE, Sun JY, et al . Long-term E-cigarette use and smoking cessation: a longitudinal study w...
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Regarding the first two questions, the analyses were based on the public use data from both the PATH Study and the MCS, with links to their archives, and the PATH study sample was drawn from the original cohort, the replenishment cohort, and the shadow cohorts (see 1st and 2nd paragraphs of Methods Section). Regarding the remaining questions, please note that our stated goal was to make the MCS and PATH analytical samples as comparable as possible when testing our hypotheses using both cohorts (3rd paragraph of Methods section). As we note in the limitations section (5th paragraph of Discussion section), the MCS had relatively limited items on e-cigarette use and tobacco smoking compared to PATH. The MCS did not assess other combustible tobacco product consumption in early adolescence, nor did MCS measure the sequencing of early adolescent tobacco and e-cigarette use (noted in the limitation section). Also, MCS youth answered survey questions about ever using e-cigarettes from 2015 to 2016 (3rd paragraph of Methods section), which gave us limited variability to test for a wave x e-cigarette interaction in both datasets.
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I respectfully request answers to the following questions:
1. Was public use or restricted PATH data used. This is important, since Table 2 contains a cell, n=7, that is not generally approved by NAHDAP.
2. Was the PATH cohort drawn from Waves 1 and 4, with follow-ups to age 17 years as needed from the other waves?
3. There were significant differences in youth smoking-vaping between Wave 1 (2013-14) and Wave 4 (2016-18) that might have affected the results. Was each wave analyzed separately as well as together?
4. The analysis included a variable relating to “parent(s) smoking of cigarettes, cigars, or pipes.” Did the analysis include other combustible tobacco product consumption by the subjects themselves?
5. Did the authors account for age at first smoking or vaping (public use, < 12 years and 12-14 years) or which product(s) had been used first?
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Show MorePichon-Riviere et al concluded that the four tobacco control interventions analyzed could successfully avert deaths and disability and significantly ease the tobacco-attributable economic burden, but are not enough, as smoking remains a leading cause of health and economic burden in Latin America (1). According to the Global Burden of Disease Project (2), regardless of the relative decrease in tobacco prevalence in the last decades, age-standardized rates of deaths and DALYs for smoking-attributable diseases remain high in Latin America, a region hard hit by the epidemic (3). Unfortunately, in most of the countries in Latin America, there are other problems related to the main strategy to reduce tobacco consumption (i.e., taxation falls short of WHO recommendations) for example cigarettes remain affordable mainly due to the commercialization of illegal tobacco products and smuggled cigarettes, an important distractor for public health authorities, as the real number of users is hidden, access for younger people is easier and health risks are surely higher (4).
In addition, as in not all countries among our region there are available pharmacological alternatives to help current smokers, cessation strategies may be adapted for novel products, and treatment recommendations for tobacco use disorder should be made within the context of a harm reduction framework wherein alternative product use may be the desired outcome (5). Also, nicotine e‐cigare...
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I read with interest the article "Global tobacco advertising, promotion, and sponsorship regulation: what’s old, what’s new, and where to next?[1]" published in Tobacco Control. As a psychiatrist specializing in addiction treatment at Taoyuan Psychiatric Center in Taiwan, I wish to share our institution's experience in implementing a successful smoke-free hospital program, which may serve as a model for other psychiatric centers.
Since 2014, Taoyuan Psychiatric Center has made significant progress in promoting a smoke-free environment through a comprehensive tobacco control program. Our program's objectives include creating a smoke-free hospital, increasing smoking cessation services for outpatients and inpatients, and improving patient smoking status documentation. Furthermore, we prioritize smoking cessation counseling for adolescents, pregnant women, and their families.
In psychiatric settings, smoking cessation is crucial as tobacco use can influence the blood concentration of psychotropic medications, potentially destabilizing psychiatric symptoms. Assisting patients in quitting smoking not only lowers the risk of tobacco-related diseases but also contributes to stabilizing their psychiatric conditions.
Our program encompasses various initiatives, including staff training, community tobacco harm prevention promotion, provision of second-generation smoking cessation treatments for outpatients and inpatien...
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We acknowledge receipt of a private e-mail message from JLI regarding our paper (Yassine et al., 2022). Given the industry‘s long history of industry obfuscation, interference, and deception regarding research on tobacco products, we decided that the most transparent approach to the private e-mail that we received from an employee of a tobacco product manufacturer would be for us to report our results independently and respond to any public discussion of our work if and when it arose. Now that public discussion has arisen, we are pleased to respond to it.
We very recently analyzed the menthol and nicotine content of samples of liquid from six menthol flavor pods purchased in 2020. Three of these were liquids extracted from the pods in June 2021 for our paper and had been stored since in sealed amber glass containers at 5°C in the dark. The other three pods had been stored in their original sealed packages and were taken from the same batches as the pods analyzed in June 2021. These unopened packages were stored in the dark at room temperature over the intervening 18 months. The data from this small sample demonstrate a 24% reduction in menthol content over that period (12.01±0.46 vs 9.15±0.22 mg/ml), which helps to explain the results we reported (Yassine et al., 2022). We also found a 5% reduction in nicotine content (62.47±0.63 vs 59.52±0.49 mg/ml), as well as discoloration of the liquid in the pods that were stored at room temperatur...
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Authors previewed this study on March 16, 2022, at the Annual Meeting of the Society for Research on Nicotine and Tobacco[1]. Prompted by this presentation, on April 5, 2022, I emailed Drs. Talih, Eissenberg, and Shihadeh with product-specific information and questions that raised substantial doubt in the authors’ claims about JUUL products, specifically the purported modification of Menthol JUULpods.
Due to word limits here, we have posted a full copy of my email to the authors on PubPeer[2]. This email predated by almost a month the authors’ submission to the journal. Below please find an excerpt from this correspondence:
“In your presentation, you conclude that Juul Labs has in some way altered or otherwise modified its e-liquid formulations, but these claims are incorrect. Juul Labs has not altered or modified these e-liquid formulations since they were introduced into the market before August 2016 (i.e., FDA’s deeming date). We have supporting documentation, including batch records and certificates of analysis to confirm this.
“Setting aside any issues with methodologies or environmental conditions in the study, there are a number of possible explanations for the variations you found. For example, one potential explanation for the differences in tested products is the loss of menthol over time. It is well-documented in scientific literature[3] that menthol may migrate from areas of high concentration to low concentration,...
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I would like to make three comments by way of a brief post-publication review.
1. The impacts of vaping tax on smoking have been completely overlooked
For a study of e-cigarette taxation to have any public health relevance, it must consider the impact of e-cigarette prices on *cigarette* demand. Cigarettes and e-cigarettes are economic substitutes. The demand for one responds to changes in the price of the other, an idea well understood in economics and quantified through the concept of cross-elasticity. The paper appears to pay no regard to the impact of vaping taxes on cigarette demand, Yet such effects might easily overwhelm any benefits from reduced e-cigarette use - in fact, impact on demand for other tobacco products and the development of informal markets are by far the most important impacts of a vaping tax. By way of example, a 2020 paper by Pesko et al. [1] concluded:
"Our results suggest that a proposed national e-cigarette tax of $1.65 per milliliter of vaping liquid would raise the proportion of adults who smoke cigarettes daily by approximately 1 percentage point, translating to 2.5 million extra adult daily smokers compared to the counterfactual of not having the tax."
2. The case for reducing adult vaping by taxation has not been made
The authors have based their paper on an unexamined assumption that it is a justifiable goal of policy to lower rates of adult e-cigarette use. Why should...
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I have a number of concerns with the paper as currently written.
1) The authors write: “Besides, none of the previous studies except Pesko et al (15) that examined the associations between vaping product excise tax adoption and ENDS use has accounted for the clustering of respondents within the same localities…” This is not accurate, as citation 19 also clusters standard errors at the locality level in all specifications.
2) The authors write: "A working paper reported reduced ENDS sales, but not ENDS use prevalence or behaviours, after implementation of a vaping product excise tax policy. (19)” This is not accurate, as the cited study uses the magnitude of e-cigarette tax values, rather than an indicator variable for tax implementation. States have adopted e-cigarette taxes of different magnitudes and a number of them (such as California) have changed the magnitudes of these taxes after adoption. All of this variation is used in citation 19, contrary to the current study’s description. It's also unclear from the sentence whether citation 19 studied use and found imprecise estimates, or did not study use. It's the latter and this should be clarified. It's also unclear why the authors did not use magnitude of e-cigarette taxes themselves in the current paper, as has been commonly done in the referenced literature.
3) Authors write they use a “nationally representative sample of US young adults.” I do not beli...
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We appreciate the comments from Bates and the opportunity for us to respond and clarify.
First, Bates' argument heavily relies on the assumption that e-cigarettes and combustible cigarettes are substitutes, which is theoretically possible as some consider vaping as a harm reduction alternative to combustible cigarettes. Empirically, however, there have been mixed findings about whether e-cigarettes and combustible cigarettes are substitutes (or complements). Bates cited Pesko et al. (2020) that concludes e-cigarettes and combustible cigarettes are substitutes, whereas other studies have shown that they are complements. For example, Cotti et al. (2018) found that higher cigarette excise taxes, in fact, decrease sales of both e-cigarettes and combustible cigarettes, suggesting that they are complements. Such mixed results abate Bates' argument that taxing ENDS could lead to more use of combustible cigarettes.
Second, Bates might have ignored that our study focused on young adults aged 18-24 years rather than general adults when examining the effect of vaping product tax on e-cigarette use. Although Pesko et al. (2020) suggests that e-cigarettes and combustible cigarettes are substitutes, the findings are based on the general adult population (average age: 55 years) which may not be generalizable to the young adult population. In fact, one study conducted by Abouk and Adams (2017) indicates that e-cigarettes and combustible ci...
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