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Ruth Malone's pursuit of common ground in the tobacco control and broader public health communities is most welcome. As I emphasize in a new commentary that has received wide circulation (https://drive.google.com/file/d/1C1nk1XEZ8WhnOXtCGTqHdeqomc9HOuko/view), we must collectively climb out of our bunkers, come to the table and genuinely work together. Everyone, on all sides of the concurrent debates over tobacco harm reduction and protecting youth must stop skirting the truth when it feels inconvenient and open our minds and ears to all of the science that is before us, while discouraging and abandoning studies and pronouncements that are demonstrably biased or inadequate. We must move beyond the adversarial nature of the debate and transparently acknowledge areas of ambiguity or concern.
Combating the smoking epidemic is a social justice issue, as too little attention is now being given in many places, including the U.S., to prioritizing the importance of promoting adult smoking cessation and, for those adults addicted to smoking who cannot or are unwilling to quit nicotine -- many of whom are socially marginalized, poor, less educated, experience serious mental health conditions, or are members of the military or veterans -- helping them switch to less-hazardous, noncombustible forms of nicotine.
Regardless of ideology and policy preferences, we...
NOT PEER REVIEWED
Ruth Malone's pursuit of common ground in the tobacco control and broader public health communities is most welcome. As I emphasize in a new commentary that has received wide circulation (https://drive.google.com/file/d/1C1nk1XEZ8WhnOXtCGTqHdeqomc9HOuko/view), we must collectively climb out of our bunkers, come to the table and genuinely work together. Everyone, on all sides of the concurrent debates over tobacco harm reduction and protecting youth must stop skirting the truth when it feels inconvenient and open our minds and ears to all of the science that is before us, while discouraging and abandoning studies and pronouncements that are demonstrably biased or inadequate. We must move beyond the adversarial nature of the debate and transparently acknowledge areas of ambiguity or concern.
Combating the smoking epidemic is a social justice issue, as too little attention is now being given in many places, including the U.S., to prioritizing the importance of promoting adult smoking cessation and, for those adults addicted to smoking who cannot or are unwilling to quit nicotine -- many of whom are socially marginalized, poor, less educated, experience serious mental health conditions, or are members of the military or veterans -- helping them switch to less-hazardous, noncombustible forms of nicotine.
Regardless of ideology and policy preferences, we must at the very least tell the public as well as health care practitioners the truth about nicotine. That means that all of the major national and international messengers in this area -- NGOs and government, alike -- should do everything possible to educate the world about the continuum of risk of nicotine products, as clearly described by the U.S. Food and Drug Administration in its comprehensive plan released in July 2017, and not sweepingly demonize nicotine, which devastatingly causes widespread dependence on cigarettes but itself does not cause the illnesses suffered by the users of tobacco and is, in fact, a drug approved by the FDA as being safe and effective when used for smoking cessation.
We won’t come together if we don’t come together with openness, honesty and integrity. The time for that is now.
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I appreciated the editorial by Ruth Malone on finding "common ground" on the topic of product regulation and more broadly the role of tobacco control. I would certainly agree that the current climate in smoking harm reduction has become toxic and emotional, non-scientific, and counterproductive to achieving the public health goal of reducing premature deaths caused by using smoked tobacco (i.e., mainly cigarettes). I also agree that the cigarette companies are likely using this as a wedge to advance their own financial interests - what else would you expect? I don't think anyone interested in public health is suggesting that we dismiss the past bad actions of the cigarette manufacturers, nor accept the claims of manufacturers of alternative nicotine products. Rather, we need to heed the lessons of the past so as not to make the same mistakes going forward. The United States, the Tobacco Control Act created a framework that should incentivize manufacturers to move away from profiting from the sale of cigarettes that causes so much harm to consumers. Promoting dialogue summits would allow for participants to engage in a civil manner, educate one another about challenges and opportunities and agree to specific measurable goals and objectives. Bringing stakeholders together will not resolve all differences but it will allow serious and responsible stakeholders the opportunity to bring ideas forward and find areas of common ground...
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I appreciated the editorial by Ruth Malone on finding "common ground" on the topic of product regulation and more broadly the role of tobacco control. I would certainly agree that the current climate in smoking harm reduction has become toxic and emotional, non-scientific, and counterproductive to achieving the public health goal of reducing premature deaths caused by using smoked tobacco (i.e., mainly cigarettes). I also agree that the cigarette companies are likely using this as a wedge to advance their own financial interests - what else would you expect? I don't think anyone interested in public health is suggesting that we dismiss the past bad actions of the cigarette manufacturers, nor accept the claims of manufacturers of alternative nicotine products. Rather, we need to heed the lessons of the past so as not to make the same mistakes going forward. The United States, the Tobacco Control Act created a framework that should incentivize manufacturers to move away from profiting from the sale of cigarettes that causes so much harm to consumers. Promoting dialogue summits would allow for participants to engage in a civil manner, educate one another about challenges and opportunities and agree to specific measurable goals and objectives. Bringing stakeholders together will not resolve all differences but it will allow serious and responsible stakeholders the opportunity to bring ideas forward and find areas of common ground that can more rapidly advance population health. As an example, issues and concerns related to adolescent use of tobacco and nicotine products should be a major topic of concern, not only by the public health and tobacco control communities but by federal, state, and local policy makers and regulators, parents and teachers, responsible retailers and distributers, and many of those associated with the manufacturing businesses. While many stakeholders share common ground in this area, the polarizing and media driven approach that has been taken over the last several years has caused what has become a war of rhetoric, with a lot of finger pointing and a failure to bring interested parties together to discuss how to collectively deal with the issue and find workable solutions to protect youth while allowing smokers to have access to cleaner alternative nicotine products. It is often said that it should be good science that drives the implementation of sound policies. However, I fear that is not happening today. Finding "common ground" will be impossible so long as there remains an unwillingness to support civil dialogue on issues of smoking harm reduction. I hope that public health/ medial organizations like WHO, ACS, FDA, CDC and others will do more to facilitating real and open dialogue on how to accelerate a reduction of smoking caused disease and death than has been the case over the past decade.
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Professor Malone’s call for a better understanding of the context of the tobacco epidemic is timely. For tobacco as for sugar and alcohol, the extent of population harm is linked to the historic growth of an oligopoly which has used economies of scale, aggressive sales tactics and ingredient modification to transform commodities into highly-processed, convenient and affordable artefacts1-3. At a time when the pandemic has brought the role of governments in protecting the public into greater focus, the implementation of market restrictions which we know to be effective in reducing demand (higher tax, minimum price, minimum pack size)4 should receive a new impetus.
Professor Malone’s call to unite opponents and proponents of ‘newer and novel nicotine and tobacco products’ (NNNTPs) around opposition to the tobacco industry should be heeded. Imperial Brands’s recent decision to turn back to ‘neglected’ cigarettes after being ‘overly focused’ on alternative nicotine products shows that profits, not smokers’ lives, will always be the tobacco companies’ priority5. The enormous influence exercised by the tobacco industry over governments worldwide is perhaps the most pressing tobacco control issue today, with countries including the US continuing to score highly on the Global Index of Tobacco Industry Interference6.
As to whether NNNTPs represent a ‘breakthrough’, it is not so much the products themselves that are disruptive, but rather the...
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Professor Malone’s call for a better understanding of the context of the tobacco epidemic is timely. For tobacco as for sugar and alcohol, the extent of population harm is linked to the historic growth of an oligopoly which has used economies of scale, aggressive sales tactics and ingredient modification to transform commodities into highly-processed, convenient and affordable artefacts1-3. At a time when the pandemic has brought the role of governments in protecting the public into greater focus, the implementation of market restrictions which we know to be effective in reducing demand (higher tax, minimum price, minimum pack size)4 should receive a new impetus.
Professor Malone’s call to unite opponents and proponents of ‘newer and novel nicotine and tobacco products’ (NNNTPs) around opposition to the tobacco industry should be heeded. Imperial Brands’s recent decision to turn back to ‘neglected’ cigarettes after being ‘overly focused’ on alternative nicotine products shows that profits, not smokers’ lives, will always be the tobacco companies’ priority5. The enormous influence exercised by the tobacco industry over governments worldwide is perhaps the most pressing tobacco control issue today, with countries including the US continuing to score highly on the Global Index of Tobacco Industry Interference6.
As to whether NNNTPs represent a ‘breakthrough’, it is not so much the products themselves that are disruptive, but rather the fact that the most popular product i.e. the electronic cigarette did not originate with the tobacco industry, and that independent, non-tobacco companies have carved out a significant, perhaps even the largest slice of the market 7. The independent sector is routinely underreported because it is made up of a multitude of small to medium-sized companies rather than a few big players8, and because of market analysts’ outdated reliance on sales data from tobacco retail outlets rather than specialist shops. As Professor Malone says, the world is changing; the need to implement the provisions of the Framework Convention on Tobacco Control is as pressing as ever, but to fight tobacco harm in the new nicotine landscape, we need to move on from a simplistic conflation of tobacco and NNNTP industries. More sophisticated research is required to discern and illuminate the various strategies being employed by both tobacco and non-tobacco industry players in promoting combusted, smokeless or new nicotine products in different national markets, and to tease out the implications for population health and regulatory regimes.
1. Mintz SW. Sweetness and power. New York: Viking; 1985.
2. Schudson M. The Emergence of New Consumer Patterns: the case of the cigarette. In: Miller D, ed. Consumption: critical concepts in the social sciences: Routledge; 2001: 475-501.
3. Benson P. Commentary: Biopolitical injustice and contemporary capitalism. American Ethnologist 2012; 39(3): 488-90.
4. World Health Organization. WHO Framework Convention on Tobacco Control. Geneva: WHO 2004.
5. Nilsson P. Imperial Brands turns focus back to tobacco. Financial Times. 2021 27 January 2021.
6. Assunta M. Global Tobacco Industry Interference Index 2020. Bangkok, Thailand: Global Center for Good Governance in Tobacco Control (GGTC), 2020.
7. Brown R. Scaring the Giants: Vaping Category Report 2020. The Grocer. 2020 14 February 2020.
8. Levy DT, Lindblom EN, Sweanor DT, et al. An Economic Analysis of the Pre-Deeming US Market for Nicotine Vaping Products. Tobacco Regulatory Science 2019; 5(2): 169-81.
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We thank Tobacco Control for the opportunity to respond to the comment above. Our study was obviously not looking into the harms of secondhand aerosol from e-cigarettes (SHA). Our paper departs from previous compelling research on the harms of SHA and assesses the prevalence and duration of such exposure among e-cigarette non-users, i.e., bystanders who are potentially exposed to the aerosols emitted by e-cigarette users.
Firstly, it is clear that we conducted the study on the basis of knowledge that bystanders were involuntarily exposed to potentially hazardous SHA in many places. We have clearly mentioned the growing evidence that supports our assertion about the potential harms of SHA in the Introduction and Discussion sections of the paper. SHA contains many toxicants, including nicotine, particulate matter and carcinogens (e.g., volatile organic compounds, polycyclic aromatic hydrocarbons, formaldehyde, acetaldehyde and tobacco specific nitrosamines-TSNAs). As mentioned, this evidence comes from previous scientific research (please, foresee the references 11 to 14 of our paper). Of special interest, fine particulate matter (PM2.5) concentration increased during e-cigarette use sessions with human volunteers in settings such as a room[1–3], during vapers’ conventions[4,5], and in vape shops and their neighbouring businesses[6]. Some TSNAs, such as N-nitrosonornicotine and nicotine-derived nitrosamine ketone, which are carcinogenic[7], hav...
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We thank Tobacco Control for the opportunity to respond to the comment above. Our study was obviously not looking into the harms of secondhand aerosol from e-cigarettes (SHA). Our paper departs from previous compelling research on the harms of SHA and assesses the prevalence and duration of such exposure among e-cigarette non-users, i.e., bystanders who are potentially exposed to the aerosols emitted by e-cigarette users.
Firstly, it is clear that we conducted the study on the basis of knowledge that bystanders were involuntarily exposed to potentially hazardous SHA in many places. We have clearly mentioned the growing evidence that supports our assertion about the potential harms of SHA in the Introduction and Discussion sections of the paper. SHA contains many toxicants, including nicotine, particulate matter and carcinogens (e.g., volatile organic compounds, polycyclic aromatic hydrocarbons, formaldehyde, acetaldehyde and tobacco specific nitrosamines-TSNAs). As mentioned, this evidence comes from previous scientific research (please, foresee the references 11 to 14 of our paper). Of special interest, fine particulate matter (PM2.5) concentration increased during e-cigarette use sessions with human volunteers in settings such as a room[1–3], during vapers’ conventions[4,5], and in vape shops and their neighbouring businesses[6]. Some TSNAs, such as N-nitrosonornicotine and nicotine-derived nitrosamine ketone, which are carcinogenic[7], have been identified in e-cigarette aerosol (reference 12 of our paper). Airborne nicotine concentration was found to increase after e-cigarette use in an experimental study in a room[1], in an observational study conducted in users’ and non-users’ homes (reference 13 of our paper), and in a study of vapers’ conventions[8]. Also, nicotine in SHA was found to be systematically absorbed by bystanders at levels comparable to secondhand tobacco smoke (references 10 and 42 of our paper), which is worrisome. Additionally, SHA may cause reduced lung function and asthma exacerbations among non-users exposed to it (references 15 and 16). Unfortunately, we are unable to review the study conducted by the California Department of Public Health that was mentioned in the comment, as the source is a blogsite without any specific reference to the scientific publication. Personal blogsites tend to be subjective and are dominantly used to express the bloggers’ personal views, even when these blogsites are maintained by academics. It is worth mentioning, our work was published in a peer-reviewed journal, developed by a team of researchers devoted to public health, and, importantly, who have no conflict of interests.
Secondly, the evidence available at the time of the writing of our paper shows that e-cigarette use and seeing e-cigarette use may renormalise tobacco smoking, induce relapse to smoking among former smokers and trigger initiation of e-cigarette use among non-smokers, particularly young people, by decreasing the harm perception of e-cigarettes (references 17 to 21, and 57). This means the concern around SHA is not only about the air quality but also the social norm it might shape.
In conclusion, based on the evidence mentioned, we wanted to know to what extent e-cigarette exposure was perceived among the general population in European countries; consequently, our study estimates the prevalence of passive exposure to SHA from e-cigarettes. Perhaps the “fear” (we prefer to say “concern”) should exist for selling or using products that may harm the health of people who use them and bystanders who are involuntarily exposed to their aerosols. Based on our results, current evidence, and arguments previously discussed[9], we continue to believe that governments should include e-cigarettes use in smoke-free laws.
References mentioned in this response:
1 Schober W, Szendrei K, Matzen W, et al. Use of electronic cigarettes (e-cigarettes) impairs indoor air quality and increases FeNO levels of e-cigarette consumers. Int J Hyg Environ Health 2014;217:628–37. doi:10.1016/j.ijheh.2013.11.003
2 van Drooge BL, Marco E, Perez N, et al. Influence of electronic cigarette vaping on the composition of indoor organic pollutants, particles, and exhaled breath of bystanders. Environ Sci Pollut Res 2019;26:4654–66. doi:10.1007/s11356-018-3975-x
3 Volesky KD, Maki A, Scherf C, et al. The influence of three e-cigarette models on indoor fine and ultrafine particulate matter concentrations under real-world conditions. Environ Pollut 2018;243:882–9. doi:10.1016/j.envpol.2018.08.069
4 Chen R, Aherrera A, Isichei C, et al. Assessment of indoor air quality at an electronic cigarette (Vaping) convention. J Expo Sci Environ Epidemiol 2018;28:522–9. doi:10.1038/s41370-017-0005-x
5 Soule EK, Maloney SF, Spindle TR, et al. Electronic cigarette use and indoor air quality in a natural setting. Tob Control 2017;26:109–12. doi:10.1136/tobaccocontrol-2015-052772
6 Li L, Nguyen C, Lin Y, et al. Impacts of electronic cigarettes usage on air quality of vape shops and their nearby areas. Sci Total Environ 2021;760:143423. doi:10.1016/j.scitotenv.2020.143423
7 Hecht SS. Biochemistry, Biology, and Carcinogenicity of Tobacco-Specific N -Nitrosamines. Chem Res Toxicol 1998;11:559–603. doi:10.1021/tx980005y
8 Johnson JM, Naeher LP, Yu X, et al. A biomonitoring assessment of secondhand exposures to electronic cigarette emissions. Int J Hyg Environ Health 2019;222:816–23. doi:10.1016/j.ijheh.2019.04.013
9 Wilson N, Hoek J, Thomson G, et al. Should e-cigarette use be included in indoor smoking bans? Bull World Health Organ 2017;95:540–1. doi:10.2471/BLT.16.186536
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I wish to express my dismay with the clear and obvious intention to promote an agenda of fear. One might ask why you are not looking to see whether there actually are any harms from second hand aerosol as the study clearly acts upon a preface that this is the case. I would point you to the CDC's own testing of the air quality found here. Something smells a lot less like science and a lot more like virtue signalling funded by an agenda eager to skip the important part of knowing what you're dealing with before searching for potential victims. https://tobaccoanalysis.blogspot.com/2017/05/vape-shop-air-sampling-by-c...
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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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This is a well written original research about the burning issue of tobacco manufacturer lobbying. These manufacturing industries have developed strategies to undercut minimum price laws. By increasing tobacco taxes an effective policy has been designed to decrease tobacco use. In Pakistan currently, 209 million people smoke and about 83 billion cigarettes are smoked per year. As Pakistan has not ratified any anti-smoking policies, there should be great effort made to raise excise duties and taxes on tobacco companies to reduce the demand for cigarettes. In 2017 the local price of cigarettes was about 75 rupees of which half was excise duties [1].
With this expansion of taxes, there will be responses of reducing tobacco consumption, but the cigarette manufacturing industries developed specific promotions and lobbies to encourage their consumers to purchase lower taxed or lower priced tobacco products. It is the responsibility of health authorities to regulate the prices and promotion of such hazardous products [2]. According to WHO, “MPOWER” was the slogan in 2015, according to which M= monitor tobacco usage, P= Protect people from tobacco smoke, O= offering help to quit tobacco use, W= warning about its hazards, E= enforce to ban its advertisement, R = Raise tobacco taxes [3].
For smoke free Pakistan and all over the world four key factors should be instruments: Education, legislation, quitting support and financial policies.
NOT PEER REVIEWED
This is a well written original research about the burning issue of tobacco manufacturer lobbying. These manufacturing industries have developed strategies to undercut minimum price laws. By increasing tobacco taxes an effective policy has been designed to decrease tobacco use. In Pakistan currently, 209 million people smoke and about 83 billion cigarettes are smoked per year. As Pakistan has not ratified any anti-smoking policies, there should be great effort made to raise excise duties and taxes on tobacco companies to reduce the demand for cigarettes. In 2017 the local price of cigarettes was about 75 rupees of which half was excise duties [1].
With this expansion of taxes, there will be responses of reducing tobacco consumption, but the cigarette manufacturing industries developed specific promotions and lobbies to encourage their consumers to purchase lower taxed or lower priced tobacco products. It is the responsibility of health authorities to regulate the prices and promotion of such hazardous products [2]. According to WHO, “MPOWER” was the slogan in 2015, according to which M= monitor tobacco usage, P= Protect people from tobacco smoke, O= offering help to quit tobacco use, W= warning about its hazards, E= enforce to ban its advertisement, R = Raise tobacco taxes [3].
For smoke free Pakistan and all over the world four key factors should be instruments: Education, legislation, quitting support and financial policies.
1. Bate R. Large cigarette tax hikes, illicit producers, and organized crime: Lessons from Pakistan. AEI Paper & Studies. 2018 Jun 1:1.
2. Apollonio DE, Glantz SA. Tobacco industry promotions and pricing after tax increases: An analysis of internal industry documents.
3. World Health Organization. WHO report on the global tobacco epidemic 2015: raising taxes on tobacco. World Health Organization; 2015 Jul 31.
The atomizer used for testing has a maximum rating of 80 watts.
200 watts was applied. Needless to say, horrible results occurred.
This is not reputable science, it is a failed experiment, it should never have been published.
It should be noted that the Aspire Cleito coils used in this study have a manufacturer stated operating power range of between 55 and 75 watts. This is noted both on the box and laser etched into the side of the coil housing proper. it should be noted that the first data points in the graph ( to demonstrate the presence of CO in both liquid samples are in excess of the stated power range of the element.
"Strawnana" at 80 watts
"Black Ice" at 100 watts
This leads me to question the normalizing curve for the black ice sample as there are no data points in the graph (Figure 2) within the manufacturer noted operating range for that coil.
Furthermore, while this statement " ...though the bulk liquid temperature is controlled by boiling limits of the e-liquid component" would be accurate were the coil to be completely submerged in liquid, the mechanics of coil design will confound that principle. The resistance coils in electronic cigarettes are not, by design, submerged in liquid, they are in contact with a liquid saturated wick. Any heat energy applied to the coil whether in magnitude or duration, that exceeds the supply of liquid saturating the wick will result in a temperature spike which could cause the temperature to spike causing thermal degradation of what liquid does remain, and the singeing of the cotton wick.
It can be expected that where combustion occurs, carbon compounds will...
It should be noted that the Aspire Cleito coils used in this study have a manufacturer stated operating power range of between 55 and 75 watts. This is noted both on the box and laser etched into the side of the coil housing proper. it should be noted that the first data points in the graph ( to demonstrate the presence of CO in both liquid samples are in excess of the stated power range of the element.
"Strawnana" at 80 watts
"Black Ice" at 100 watts
This leads me to question the normalizing curve for the black ice sample as there are no data points in the graph (Figure 2) within the manufacturer noted operating range for that coil.
Furthermore, while this statement " ...though the bulk liquid temperature is controlled by boiling limits of the e-liquid component" would be accurate were the coil to be completely submerged in liquid, the mechanics of coil design will confound that principle. The resistance coils in electronic cigarettes are not, by design, submerged in liquid, they are in contact with a liquid saturated wick. Any heat energy applied to the coil whether in magnitude or duration, that exceeds the supply of liquid saturating the wick will result in a temperature spike which could cause the temperature to spike causing thermal degradation of what liquid does remain, and the singeing of the cotton wick.
It can be expected that where combustion occurs, carbon compounds will be present.
I would be interested in seeing the data sets to better understand exactly how far out of operating range CO began to manifest in the study.
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Show MoreRuth Malone's pursuit of common ground in the tobacco control and broader public health communities is most welcome. As I emphasize in a new commentary that has received wide circulation (https://drive.google.com/file/d/1C1nk1XEZ8WhnOXtCGTqHdeqomc9HOuko/view), we must collectively climb out of our bunkers, come to the table and genuinely work together. Everyone, on all sides of the concurrent debates over tobacco harm reduction and protecting youth must stop skirting the truth when it feels inconvenient and open our minds and ears to all of the science that is before us, while discouraging and abandoning studies and pronouncements that are demonstrably biased or inadequate. We must move beyond the adversarial nature of the debate and transparently acknowledge areas of ambiguity or concern.
Combating the smoking epidemic is a social justice issue, as too little attention is now being given in many places, including the U.S., to prioritizing the importance of promoting adult smoking cessation and, for those adults addicted to smoking who cannot or are unwilling to quit nicotine -- many of whom are socially marginalized, poor, less educated, experience serious mental health conditions, or are members of the military or veterans -- helping them switch to less-hazardous, noncombustible forms of nicotine.
Regardless of ideology and policy preferences, we...
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Show MoreI appreciated the editorial by Ruth Malone on finding "common ground" on the topic of product regulation and more broadly the role of tobacco control. I would certainly agree that the current climate in smoking harm reduction has become toxic and emotional, non-scientific, and counterproductive to achieving the public health goal of reducing premature deaths caused by using smoked tobacco (i.e., mainly cigarettes). I also agree that the cigarette companies are likely using this as a wedge to advance their own financial interests - what else would you expect? I don't think anyone interested in public health is suggesting that we dismiss the past bad actions of the cigarette manufacturers, nor accept the claims of manufacturers of alternative nicotine products. Rather, we need to heed the lessons of the past so as not to make the same mistakes going forward. The United States, the Tobacco Control Act created a framework that should incentivize manufacturers to move away from profiting from the sale of cigarettes that causes so much harm to consumers. Promoting dialogue summits would allow for participants to engage in a civil manner, educate one another about challenges and opportunities and agree to specific measurable goals and objectives. Bringing stakeholders together will not resolve all differences but it will allow serious and responsible stakeholders the opportunity to bring ideas forward and find areas of common ground...
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Professor Malone’s call for a better understanding of the context of the tobacco epidemic is timely. For tobacco as for sugar and alcohol, the extent of population harm is linked to the historic growth of an oligopoly which has used economies of scale, aggressive sales tactics and ingredient modification to transform commodities into highly-processed, convenient and affordable artefacts1-3. At a time when the pandemic has brought the role of governments in protecting the public into greater focus, the implementation of market restrictions which we know to be effective in reducing demand (higher tax, minimum price, minimum pack size)4 should receive a new impetus.
Professor Malone’s call to unite opponents and proponents of ‘newer and novel nicotine and tobacco products’ (NNNTPs) around opposition to the tobacco industry should be heeded. Imperial Brands’s recent decision to turn back to ‘neglected’ cigarettes after being ‘overly focused’ on alternative nicotine products shows that profits, not smokers’ lives, will always be the tobacco companies’ priority5. The enormous influence exercised by the tobacco industry over governments worldwide is perhaps the most pressing tobacco control issue today, with countries including the US continuing to score highly on the Global Index of Tobacco Industry Interference6.
As to whether NNNTPs represent a ‘breakthrough’, it is not so much the products themselves that are disruptive, but rather the...
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We thank Tobacco Control for the opportunity to respond to the comment above. Our study was obviously not looking into the harms of secondhand aerosol from e-cigarettes (SHA). Our paper departs from previous compelling research on the harms of SHA and assesses the prevalence and duration of such exposure among e-cigarette non-users, i.e., bystanders who are potentially exposed to the aerosols emitted by e-cigarette users.
Firstly, it is clear that we conducted the study on the basis of knowledge that bystanders were involuntarily exposed to potentially hazardous SHA in many places. We have clearly mentioned the growing evidence that supports our assertion about the potential harms of SHA in the Introduction and Discussion sections of the paper. SHA contains many toxicants, including nicotine, particulate matter and carcinogens (e.g., volatile organic compounds, polycyclic aromatic hydrocarbons, formaldehyde, acetaldehyde and tobacco specific nitrosamines-TSNAs). As mentioned, this evidence comes from previous scientific research (please, foresee the references 11 to 14 of our paper). Of special interest, fine particulate matter (PM2.5) concentration increased during e-cigarette use sessions with human volunteers in settings such as a room[1–3], during vapers’ conventions[4,5], and in vape shops and their neighbouring businesses[6]. Some TSNAs, such as N-nitrosonornicotine and nicotine-derived nitrosamine ketone, which are carcinogenic[7], hav...
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I wish to express my dismay with the clear and obvious intention to promote an agenda of fear. One might ask why you are not looking to see whether there actually are any harms from second hand aerosol as the study clearly acts upon a preface that this is the case. I would point you to the CDC's own testing of the air quality found here. Something smells a lot less like science and a lot more like virtue signalling funded by an agenda eager to skip the important part of knowing what you're dealing with before searching for potential victims.
https://tobaccoanalysis.blogspot.com/2017/05/vape-shop-air-sampling-by-c...
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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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This is a well written original research about the burning issue of tobacco manufacturer lobbying. These manufacturing industries have developed strategies to undercut minimum price laws. By increasing tobacco taxes an effective policy has been designed to decrease tobacco use. In Pakistan currently, 209 million people smoke and about 83 billion cigarettes are smoked per year. As Pakistan has not ratified any anti-smoking policies, there should be great effort made to raise excise duties and taxes on tobacco companies to reduce the demand for cigarettes. In 2017 the local price of cigarettes was about 75 rupees of which half was excise duties [1].
With this expansion of taxes, there will be responses of reducing tobacco consumption, but the cigarette manufacturing industries developed specific promotions and lobbies to encourage their consumers to purchase lower taxed or lower priced tobacco products. It is the responsibility of health authorities to regulate the prices and promotion of such hazardous products [2]. According to WHO, “MPOWER” was the slogan in 2015, according to which M= monitor tobacco usage, P= Protect people from tobacco smoke, O= offering help to quit tobacco use, W= warning about its hazards, E= enforce to ban its advertisement, R = Raise tobacco taxes [3].
For smoke free Pakistan and all over the world four key factors should be instruments: Education, legislation, quitting support and financial policies.
1....
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The atomizer used for testing has a maximum rating of 80 watts.
200 watts was applied. Needless to say, horrible results occurred.
This is not reputable science, it is a failed experiment, it should never have been published.
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It should be noted that the Aspire Cleito coils used in this study have a manufacturer stated operating power range of between 55 and 75 watts. This is noted both on the box and laser etched into the side of the coil housing proper. it should be noted that the first data points in the graph ( to demonstrate the presence of CO in both liquid samples are in excess of the stated power range of the element.
"Strawnana" at 80 watts
"Black Ice" at 100 watts
This leads me to question the normalizing curve for the black ice sample as there are no data points in the graph (Figure 2) within the manufacturer noted operating range for that coil.
Furthermore, while this statement " ...though the bulk liquid temperature is controlled by boiling limits of the e-liquid component" would be accurate were the coil to be completely submerged in liquid, the mechanics of coil design will confound that principle. The resistance coils in electronic cigarettes are not, by design, submerged in liquid, they are in contact with a liquid saturated wick. Any heat energy applied to the coil whether in magnitude or duration, that exceeds the supply of liquid saturating the wick will result in a temperature spike which could cause the temperature to spike causing thermal degradation of what liquid does remain, and the singeing of the cotton wick.
It can be expected that where combustion occurs, carbon compounds will...
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