497 e-Letters

  • Revisiting the Research on Flavor Bans and Youth Smoking: A Response to Liu et al (2022)

    On March 17th, 2021, Tobacco Control published a paper online revealing that the 2019 wave of the Youth Risk Behavior Surveillance System (YRBSS) in San Francisco was fielded in the fall of 2018, as opposed to spring of 2019 as is typical for that survey. [1] On March 21st 2022, I received confirmation from San Francisco’s YRBSS site coordinator that the 2019 wave was fielded from November 5th, 2018 to December 14th, 2018. I appreciate Liu and colleagues bringing this to light. However, their claim that this information invalidates the findings from my 2021 JAMA Pediatrics paper [2] —linking San Francisco’s ban on sales of flavored tobacco and nicotine products to increases in youth cigarette smoking—is both methodologically and historically inaccurate: it overlooks both the assumptions required for difference-in-differences research designs and the full timeline of San Francisco’s flavor ban implementation.

    In its simplest form, a difference-in-difference (DD) analysis of a particular policy compares outcomes in jurisdictions that did vs. did not adopt the policy, before vs. after that policy officially went into effect (See Figure at https://figshare.com/articles/figure/Figure_1_BasicDDExplanation_pdf/203...). If time-trends in the adopting and non-adopting jurisdictions’ outcomes were parallel in the pre-policy period, the non-adopters’ trends are c...

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  • In reply: Youth tobacco use before and after flavoured tobacco sales restrictions in Oakland, California and San Francisco, California

    These arguments by Pesko and Friedman cannot undo the central flaw in the Friedman paper. We are surprised that Pesko and Friedman continue to argue that Friedman’s analysis of the YRBSS fall data as “after” data is valid despite the Friedman paper defining the exposure variable as follows: “A binary exposure variable captured whether a complete ban on flavoured tobacco product sales was in effect in the respondent’s district on January 1 of the survey year.”[1] If Friedman had intended to treat the period immediately after July 21 2018 as the “after” period, why had she not selected July 21 of each year as the cut-off date for indicating exposure to the policy effects? It seems apparent that Friedman chose the January 1, 2019 as the cut-off for “after” data because she knew this was the enforcement date and she assumed wrongly that the YRBSS data were collected after January 1, 2019. This is evident in her own response[2] to a critique[3] of her paper as we already noted in our previous response.[4]
    Friedman states that “the official/legislated effective date are used to ensure that resulting estimates capture unconfounded responses to the policy change.” Again, if this approach made sense in the specific San Francisco case, why did Friedman use January 1, 2019 in her paper? Perhaps because it simply doesn’t make sense to attribute a policy’s effects before the policy is actually implemented. Similarly, the use of enforcement date rather than...

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  • Friedman's Use of a Pre-Post Study Design was Appropriate

    After seeing the response from the authors of “Youth tobacco use before and after flavored tobacco sales restrictions in Oakland, California and San Francisco, California” to the Rapid Response, “Scientific Concerns,” I was dismayed by the reply of the authors that dismissed the efforts of fellow scientists to rigorously discern the effects of flavored tobacco sales restrictions. The central point of their critique of Friedman’s paper is that it only contains pre-flavored tobacco product sales ban datapoints. Hence, a pre-post difference-in-differences design is inappropriate. Friedman most certainly had post-data in her sample. Despite the criticisms from Liu et al, they have not unseated her primary contribution; after a policy change, youth tobacco use behavior in San Francisco changed. Liu et al. provide no rigorous counter-analysis on this point. The author’s argument that no behavior had changed in San Francisco during YBRSS data collection in late 2018 falls apart at close inspection.
    First, Liu et al. claim the flavored tobacco sales ban was not yet affecting retailer behavior in late 2018. This question is binary; it can either be answered yes or no. As of July 21, 2018, it was not legal to sell flavored tobacco products in San Francisco. No grace period was in place. Sales of all prohibited flavored products plummeted in the months after the policy became effective (Gammon et al., 2021 ; Table S1). However, sales did not reach zero,...

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  • Remaining scientific concerns unaddressed by authors

    In their response to my reply, the authors appear to not address mistakes in their analysis. It's important that any inaccurate statements be corrected for the benefit of other researchers trying to learn from this conversation. 1) The authors say in their response (and the paper) that there is no "after" period in the Friedman study. However, as reported by Gammon et al. (2022), there was an immediate decline in e-cigarette sales in San Francisco at the effective date. The authors need to explain how they can say there is no "post" period if other research clearly shows that e-cigarette sales declined starting July 2018. This is a central part of their argument and the paper unravels if there actually is a reduction in July 2018 as has been documented previously. The authors mention in their reply that they are aware of changes beginning in July 2018 ("merchant education and issuing implementing regulations"). The press may also have widely covered the effective date, which led to changes in youth's demand for e-cigarettes. Many retailers may have wished to become compliant immediately rather than wait until enforcement. All of these are valid potential mechanisms explaining why e-cigarette sales declined starting July 2018. So for the authors to say that Friedman doesn't have a "post" period is ignorant of both the literature and many valid reasons explaining why e-cigarette sales declined at...

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  • In Reply: Youth tobacco use before and after flavoured tobacco sales restrictions in Oakland, California and San Francisco, California

    Pesko’s central argument is that it does not matter that Friedman’s assessment of the effect of San Francisco’s ban on the sale of flavored tobacco products is not based on any data collected after the ban actually went into force. In particular, Friedman’s “after” data were collected in fall 2018, before the ordinance was enforced on January 1, 2019.[1] Pesko incredibly argues that Friedman’s “before-after” difference-in-difference analysis is valid despite the fact that she does not have any “after” data.

    Pesko justifies this position on the grounds that the effective date of the San Francisco ordinance was July, 2018. While this is true, it is a matter of public record that the ordinance was not enforced until January 1, 2019 because of the need for time for merchant education and issuing implementing regulations.[2]

    Friedman is aware of the fact that the enforcement of the ordinance started on January 1, 2019 and used that date in her analysis. In her response[3] to critiques[4] of her paper, she stated “retailer compliance jumped from 17% in December 2018 to 77% in January 2019 when the ban went into effect.” Friedman thought the YRBSS data was collected in Spring 2019; she only learned that the “2019” San Francisco YRBSS data she used were in fact collected in fall 2018 from our paper.[1]

    Rather than simply accepting this as an honest error and suggesting Friedman withdraw her paper, Pesko is offering an after-the-fact justification for the cl...

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  • Methods question / comment on the discussion

    ¶ I enjoyed reading this paper. I appreciate the author's use of difference-in-difference (DD) methodology. There were some things I found unclear that I would like to ask the authors to comment on.

    ¶ First, could the authors provide greater clarity on the model for column 1 of Table 1? Is the dependent variable here a yes/no for current cigarette use? The authors write, "Adolescents reported lifetime and prior month use of cigarettes, which we combined into a count variable of days smoked in the past month (0–30)." How does lifetime cigarette use help the authors to code the current number of cigarette days? The authors later state that they show that "increasing implementation of flavoured tobacco product restrictions was associated not with a reduction in the likelihood of cigarette use, but with a decrease in the level of cigarette use among users." Do the authors mean lifetime cigarette use here, or current cigarette use? The authors estimate this equation with an "inflation model," which I am not aware of. Could the authors provide more information on this modelling technique? This is not discussed in the "Analysis" section.

    ¶ Second, I felt like this statement is too strong. "Our findings suggest that[...] municipalities should enact stricter tobacco-control policies when not pre-empted by state law." Municipalities need to weigh many factors in making these decisions, including the effects of popu...

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  • Scientific concerns

    ¶ The authors make some points in their article that are reasonable: 1) the generalizability of San Francisco's flavor ban compared to other places is an open question, and 2) the original study uses the San Francisco ban effective date rather than enforcement date. The original author (Friedman), who does not accept tobacco industry funding and is a well-respected scientist in the field, had pointed to both facts in her original article. So that information isn’t new.
    ¶ The current authors appear to construct a straw man argument claiming that Friedman argued that she was studying the effect of San Francisco enforcing its flavor ban policy. Friedman specifically wrote in her original article that she was studying, “a binary exposure variable [that] captured whether a complete ban on flavored tobacco product sales was in effect in the respondent’s district on January 1 of the survey year.” She specifically uses effect in the above sentence, so there is no ambiguity that she is studying effective date. San Francisco’s flavor ban effective date was July 2018 (Gammon et al. 2021).
    ¶ The authors found new information that the San Francisco YRBSS survey was collected between November to December of 2018. Gammon et al. 2021 (Appendix Figure 1) shows that flavored e-cigarette sales declined in San Francisco between the effective date and the end of August 2018 (compensating for a 30-day look-back period for the YRBSS question wording), even though the flavor ban...

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  • Response to Wang, 'Some discrepancies and limitations'


    We would like to thank Mr. Wang for his feedback on our paper, Indicators of dependence and efforts to quit vaping and smoking among youth in Canada, England and the USA.

    With regards to the ‘discrepancies’ in vaping and smoking prevalence between those reported in Table 1 and an earlier publication [1], we have previously published these same estimates [2], along with a description of the survey weighting procedures—which were modified since the first estimates were published (as outlined in a published erratum to the cited publication [3]). Briefly, since 2019, we have been able to incorporate the smoking trends from national ‘gold standard’ surveys in Canada and the US into the post-stratification sampling weights. A full description is provided in the study’s Technical Report [4], which is publicly available (see http://davidhammond.ca/projects/e-cigarettes/itc-youth-tobacco-ecig/).

    Mr. Wang has also noted a change in the threshold used for a measure of frequent vaping/smoking: ≥20 days in past 30 days rather than ≥15 days, as previously reported [1]. We have adopted the convention of reporting using ≥20 days in past 30 days to align with the threshold commonly used by the US Centers for Disease Control for reporting data from the National Youth Tobacco Survey (NYTS), as well as the Population Assessment of Tobacco and Health (PATH) Study and the Mo...

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  • Some discrepancies and limitations


    There’s a published paper by Hammond and colleagues in 2019[1] using the same survey results, but there are some discrepancies.

    1. The Table 2 of the 2019 paper, prevalence of vaping in 2018 for ever, past 30 days are 37.0% (1425), 14.6% (562) in Canada, 32.7% (1276), 8.9% (346) in England and 33.6% (1360), 16.2% (655) in the US, respectively. However, in this article’s Table 1, for vaping in the same year 2018 for ever, past 30 days are 33.2% (1275), 12.1% (463) in Canada, 33.1% (1283), 9.0% (351) in England and 33.1%(1336), 15.7% (635) in the US. More discrepancies can be found on cigarette smoking section as well. These numbers warrant further explanation particularly why numbers in Canada and the US decreased while numbers in England increased? Considering previous correction of numbers to the 2019 paper has raised serious concern among some readers[1], such timely clarification in this article will be very necessary.

    2. The 2019 paper use the criteria of ≥15 days in past 30 days but the current paper adopts different criteria of ≥20 days in past 30 days, for both vaping and cigarette smoking. Further explanation is needed for such change.

    Additionally, a few considerations on possible limitations of the paper’s findings:

    1. Since the invitations were sent to nearly twice more parents than youth themselves according to the technical report[2], responds to survey questions might be biased because study has shown many...

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  • Our primary assertion is not impacted by the limitations in our statistical analyses

    We thank Mr. Clive Bates (1) and Dr. Moira Gilchrist (2) for their reconsideration of our work (3) and previous response where we corrected some errors (4). We also reiterate that all data informing our Industry Watch are publicly available at Tobacco Watcher (https://tobaccowatcher.globaltobaccocontrol.org/) for anyone to analyze. As with any analyses of observational data, there are limitations and we do not disagree with some of the limitations that Gilchrist and Bates point out in our analyses (as we addressed nearly all of these in our previous response (4)). However, we remain unchanged in our conclusion that, as the title of our initial article stated, “Philip Morris International used the e-cigarette, or vaping, product use associated lung injury (EVALI) outbreak to market IQOS heated tobacco” (3).

    While statistical analysis indicated a correlation between (a) PMI’s public statements regarding EVALI and their IQOS brand of heated tobacco posted to their corporate “media center” (5) and (b) trends in news coverage of EVALI and IQOS, our primary assertion is that PMI used EVALI to market IQOS. The necessary and sufficient analysis to substantiate this assertion is reporting what PMI publicly claimed, which we did by analyzing the statement made by PMI which promoted IQOS through mentioning, contrasting or describing it along with EVALI and/or vaping.

    The full text...

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  • Hagen's response to the authors


    Thank you for the corrections and for acknowledging the omission. The additional analysis performed by ITC is greatly appreciated and provides further insight into the impact of both interventions. Although unstated, Canada’s regional characterizing flavour bans contributed significantly to the development of a national menthol additive ban as chronicled by the U.S. Tobacco Control Legal Consortium[1] . I look forward to reading the full analysis when published.

    1. Kerry Cork, Tobacco Control Legal Consortium, Leading from Up North: How Canada Is Solving the Menthol Tobacco Problem (2017). https://www.publichealthlawcenter.org/sites/default/files/resources/tclc...

  • Increasing quitting in older smokers should be top priority in rich countries

    Reducing smoking rates in older smokers will achieve a far greater reduction in deaths & disease and do this much earlier than reducing already much lower smoking rates in teens & young populations. Tobacco harm reduction (THR) options, such as vaping, Heated Tobacco Products (HTP), snus & nicotine pouches, all avoid inhalation of smoke from tobacco combustion and are less risky than smoking cigarettes which are responsible for the death of more than 50% of long term smokers. Cigarette sales in Japan declined by over 40% in five years after HTPs entered the Japanese market in 2016. There are now many other examples of other THR options substituting for deadly cigarettes in other countries.
    New drug harm reduction interventions usually face fierce opposition for many years after their introduction. Needle syringe programs to reduce HIV spread among and from people who inject drugs were still strongly resisted long after the evidence for their effectiveness, safety and cost effectiveness was incontrovertible. It is not surprising to me therefore, as a veteran of many battles over new drug harm reduction interventions, to observe the acrimonious debate over THR.
    If it is made easy for older smokers to switch to THR options, the benefits will not only be an acceleration in the decline of smoking related deaths and disease, but also a more rapid decline in cigarette sales.

  • Authors’ response to L Hagen

    In his comment, Les Hagen brings up an important distinction between two types of restrictions on menthol: a menthol additive ban, and a menthol characterizing flavour ban. Canada's menthol ban across the provinces did indeed involve both types. Between May 2015 and July 2017, Nova Scotia, Alberta, Quebec, Ontario, Prince Edward Island, and Newfoundland & Labrador implemented characterizing flavour bans, whereas New Brunswick implemented a menthol additive ban [1]. When the Federal Government implemented a menthol additive ban in October 2017 [2] , it applied only to the remaining provinces—British Columbia, Saskatchewan, Manitoba—as well as Nunavut, Yukon, and the Northwest Territories. Thus, the "menthol cigarette ban" in Canada is a mixture of the two types.

    Our article [3] evaluated the impact of menthol bans implemented between the 2016 and 2018 waves of the Canadian arm of the ITC Four Country Smoking and Vaping Surveys. Hagen incorrectly stated that "the analysis was performed exclusively on provincial characterizing flavour bans." In fact, the provinces evaluated in our study included both those that implemented characterizing flavour bans (Quebec, Ontario, Prince Edward Island, Newfoundland & Labrador) and those that implemented the Federal menthol additive ban (British Columbia, Saskatchewan, Manitoba).

    In our original study, we did not test for differences between the two kinds of bans, beca...

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  • In Response to Michael Pesko's Comments "Scientific Concerns"

    We thank Pesko for his comments and the opportunity for us to respond and clarify.

    First, we appreciate Pesko’s clarification that Cotti et al. (2020) clustered standard errors to account for clustering. In the present study, we used multilevel analysis not only to account for clustering of respondents (i.e., design effects) but also to incorporate different error terms for different levels of the data hierarchy which yields more accurate Type I error rates than nonhierarchical methods where all unmodeled contextual information ends up pooled into a single error term of the model.

    Second, we understand that Cotti et al. (2020) evaluated the magnitude of e-cigarette tax values, which does not contradict to our statement because our study focused on the effects of e-cigarette excise tax policies on individual e-cigarette use and prevalence rather than aggregated sales at state or county levels. We also clearly described the reason why we examined the e-cigarette excise tax policy implementation indicator rather than its magnitude in our paper’s discussion section.

    Third, our study used a nationally representative sample of young adults (rather than a nationally representative sample of general adult population). While we understand Pesko’s concern that a sample’s representativeness might be lost when subgroups are explored, we believe our use of sampling weights in analysis has reduced such a concern.

    Fourth, in Table 3,...

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  • In Response to Clive D Bates' Comments "By ignoring the impact of a vaping tax on smoking, the paper misses the most important point"


    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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  • Scientific Concerns

    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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  • Omission of reporting characterizing flavour bans

    This article does not distinguish between characterizing flavour (menthol) bans that were implemented in Canadian provinces between 2015 and 2017 and the implementation of a national ban on menthol additives in Canada in October 2017. Although unreported, the analysis was performed exclusively on provincial characterizing flavour bans. This significant distinction should be reported to ensure that researchers and policy makers are aware of the potential impact of a characterizing flavour ban and to ensure that this policy measure is not dismissed or discounted.

  • By ignoring the impact of a vaping tax on smoking, the paper misses the most important point

    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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  • Authors’ Response Reveals Several New and Serious Issues

    Replication attempts are one of the self-correcting mechanisms of science, and we thank the Authors for their response to our concerns and their attempt to replicate aspects of their study [1]. Regrettably, they have failed to adequately address the central point raised in our letter of 23rd April 2021, namely that the title and conclusions of their original Article are patently invalid and have no basis in fact or evidence [2]. Instead of strengthening their argument in support of the Article’s findings and conclusions, the Authors’ response considerably weakens them. Strikingly, the Authors reveal several new and serious issues and yet maintain that their “principle finding is unchanged”.

    Methodological Problems:

    The Authors acknowledge that they were unable to replicate an important aspect of their original analysis, namely that a Philip Morris International (PMI) News Article [3] published on its website (falsely described as a “press release”) was “republished […] in 14 additional news outlets”. In their response, they note that “Our original assertion that there were 14 duplicate articles is not supported by our replication analysis”. This failure to replicate a key finding—in their own proprietary database, which several of them co-developed—is concerning. The Authors provide no explanation for the irregularity. Notably, on 20th April 2021, we were able to source these 14 articles in Tobacco Watcher since they were clearly mar...

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  • The authors' response to criticisms suggests White Hat Bias

    The authors’ response published on 14 July 2021 is far from satisfactory and implausibly asserts that “Our original findings and conclusions remain plausible” [1]

    The original study [2] uses a media analysis to make a claim that a statement made by the tobacco company Philip Morris International (PMI) about an outbreak of lung disease in the US [3] was a marketing ploy for its heated tobacco product, iQOS. At the time, the lung injury outbreak was falsely attributed by many to nicotine vaping. Heated tobacco products are an alternative to nicotine vaping for smokers looking for a low-risk alternative to smoking.

    I will now list some of the problems with this claim.

    1. The research findings do not support the headline claim

    The study title contains a strong and unqualified assertion of cynical opportunism on the part of the company. The new formulation that findings "remain plausible" does not justify the confidence in the assertion made in the title. "Plausible" is a reasonable basis for choosing a hypothesis to investigate, but a far from sufficient basis for drawing an aggressive conclusion. The authors do not seem to dispute the technical or factual accuracy of the statement about iQOS and EVALI made by PMI. Their allegation is about malign motives and, as such, it should be a cause for caution and a high standard of evidence.

    2. No specific articles were provided to substantiate the...

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  • Our original findings and conclusions remain plausible


    We thank Dr. Moira Gilchrist (1) for her careful attention to our work (2). Gilchrist argues our principal findings were erroneous and any change in news coverage of IQOS and the e-cigarette, or vaping, product use associated lung injury (EVALI) outbreak were confounded by other Philip Morris International (PMI) media materials and not those specifically discussing EVALI and IQOS (3) which we attributed our findings to. However, a deeper inspection of this argument suggests our original findings and conclusions remain plausible.

    Tobacco Watcher is a dynamic resource with continuous data collection and processing. Thus, the results of analyses on the platform can vary over time. On June 10, 2021 we replicated our analysis. After correcting an error that the PMI’s materials on EVALI and IQOS (3) was initially published on 24 September 2021 (not 25 September) the principal finding is unchanged. News coverage mentioning both “IQOS” and EVALI (i.e., including the terms ‘vaping’ and ‘illness’) reached an all-time high immediately after PMI published materials about EVALI and IQOS on their website. Thirty days prior to PMI posting this material (August 25th through September 23rd) 2.0 news stories per day matched our search compared to 12.8 for the 30 days after their publication (September 24th through October 23rd), with 384 news reports matching our keyword search for the latter period. Our original assertion that there were 14 duplicate articl...

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  • Review of this study suggests its findings are based on a major confounding error


    A review of this study has been published by the target of its criticism, the tobacco company Philip Morris International (PMI), via the post-publication review server Qeios [1]

    The main finding of this study, and the allegation raised in its title, is that PMI cynically used an outbreak of lung injuries in the United States (initially but incorrectly attributed to nicotine vaping) to promote its heated tobacco product, iQOS. Heated tobacco products are one alternative to vaping for those looking for a safer alternative to smoking. On 24th September 2019, PMI published an information notice about its products in response to the lung injury outbreak. The authors assert that PMI was trying to gain commercial publicity from a health crisis: a serious allegation. But the allegation appears to be based on a major error by the authors.

    The study used a "fully automated media analysis engine" to count stories that mention iQOS around that time, showing that there were considerably more than usual. On this basis, the authors concluded that PMI's unethical promotional gambit had worked. However, the day after PMI allegedly disreputably sought publicity for iQOS, the company also issued a press release disclosing that merger negotiations with the American tobacco company, Altria, had ceased. PMI and Altria have a joint marketing agreement for iQOS in the United States. The end of merger talks would be big news in the business pre...

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  • Response to “E-cigarette manufacturers’ compliance with clinical trial reporting expectations: a case series of registered trials by Juul Labs.”


    I write on behalf of Juul Labs in response to “E-cigarette manufacturers’ compliance with clinical trial reporting expectations: a case series of registered trials by Juul Labs.” We appreciate the public health community’s interest in understanding the Company’s research. However, we want to clarify the article’s reporting on Juul Labs’ research program and publications to date, as well as our legal obligations to report the results of clinical investigations.

    First, our studies were conducted in anticipation of our submission of a Premarket Tobacco Product Application (PMTA) to the U.S. Food and Drug Administration (FDA). As such, raw data, results, and statistical code underlying our analyses of all ten registered Juul Labs studies referenced in the Tobacco Control paper have been submitted to FDA (1)

    In addition, we have been working on sharing our data in publications and posters. In fact, by the end of this month, we will have published or presented data on nine of the ten studies, in addition to having provided the clinical results to FDA. Of our ten registered studies, we have published the results of four (2, 3, 4, 5) submitted the results of an additional two studies for peer review, presented the results of two as posters (6,7) and have the results of one accepted for presentation this summer. We appreciate that the authors of the Tobacco Control paper may have drafted their article months ago, but note that there...

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  • Trials Transparency in E-cigarette Research


    On behalf of my co-authors, we thank Dr. Mishra for taking the time to comment on our paper examining reporting of trials registered by Juul Labs Inc.

    We do not doubt that Juul has submitted the results from all of these studies to the FDA as part of their Premarket Tobacco Product Application (PMTA). Unfortunately, this step does not ensure the full results of these trials will be made available to the public, clinicians, and other key stakeholders.

    We also acknowledge and appreciate that since conducting our analysis in August 2020, two additional studies, of the five we examined, have appeared in the peer reviewed literature (published in December 2020 and January 2021)[1,2] and additional results may become available through other methods. We understand that these publications may contain additional outcome reporting compared to the posters we assessed. We welcome any and all additional results disclosures from Juul Labs. That said, we believe the risk of outcome reporting bias remains and is, unfortunately, not addressed in Juul’s comment despite being a major facet of our paper. The one publication that was available as of our analysis date excluded 4 of the 19 prespecified secondary outcomes without comment and another 5 outcomes had clear issues in their reporting compared to the registered outcomes. While we have not conducted a detailed assessment of the two new publications, it is apparent that journal publication does no...

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  • Study alleging Philip Morris International used the EVALI outbreak to market IQOS requires substantial methodological revision and further peer review, or retraction


    A brief review of this ‘Industry Watch’ article alleging heated tobacco product advertising through an earned media approach highlights significant methodological errors that are serious enough to invalidate the article’s conclusions, including its title. The authors allege that Philip Morris International (PMI) used the e-cigarette, or vaping, product use associated lung injury (EVALI) outbreak to promote IQOS in September 2019 and the weeks that followed. Using the authors’ own tool (TobaccoWatcher.org), we replicated their search strategy and revealed several fundamental and concerning errors in the authors’ analysis.

    They report a rise in news stories mentioning IQOS on and after 25th September 2019, and falsely attribute this rise to an article published on our website on 24th September 2019, which they also falsely describe as a “press release”, despite it never being published through a press release distribution service. Our analysis shows that the authors failed to consider several confounding and unrelated events that caused the rise in news coverage of both IQOS and EVALI during the time period in question and which can be found by replicating the authors’ search strategy in TobaccoWatcher.org.

    For example, on 25th September 2019, Philip Morris International (PMI) issued a single press release via Business Wire (1) entitled “Philip Morris International Inc. and Altria Group, Inc. End Merger Discussions” (PMI/Altria Annou...

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  • 'Tobacco crisis is industrially made' is a western construct, prevents effective solutions

    The single-minded focus in this article that only multinational tobacco companies are to blame for the tobacco epidemic presents a narrow view of the problem and ultimately prevents formulation of effective interventions. It is also a uniquely western framing which does not apply to large swathes of the developing world where most tobacco users currently live.

    In India for instance, home to the second largest population of tobacco users totaling nearly 270 million, industrially produced cigarettes form a small component of overall use, with hand-rolled bidis being far more widely used, and even more prevalent, comprising twice the number of smokers, is the smokeless form, khaini. Both bidis and khaini are produced by a largely unorganised sector and are not industrially made. This situation is mirrored across many countries in Asia and other parts of the developing world — where over 80% of tobacco users live and where 90% of tobacco cultivation is done.

    Further, about half of the global tobacco trade is run by state-owned tobacco companies (SOTCs), and a majority of these nations are part of the FCTC protocol, yet continue to operate without focus or repercussions. The Indian state owns nearly a third of the cigarette monopoly. Despite this, it currently chairs WHO’s executive board.

    Hence, to cast the tobacco crisis as industrially made and caused by multinational tobacco companies can’t be farther from the truth. While they h...

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  • What did you expect?

    If PMI attempted to profit from the “EVALI” scaremongering they could only do so because of the blatantly dishonest reporting of that issue by federal authorities, activist academics, tobacco control organisations and the media who quote them with question. It was obvious as early as August 2019 that the lung injuries were caused by black market THC cartridges cut with vitamin E acetate and not nicotine containing e-cigarettes and the CDC eventually came to the same conclusion. Yet activists in positions of authority continue to link the injuries with nicotine vaping, thus providing a fertile ground of misinformation in which such marketing campaigns can flourish.

  • We Must Seek Harmony

    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...

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  • Fighting tobacco harm in the new nicotine landscape

    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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  • Support Civil Dialogue on Issues of Smoking Harm Reduction

    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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  • Response to Luke Marshall, owner of a vape shop in Ontario, Canada

    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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  • Lacks Objectivity

    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.

  • Author's Reply

    Thank you for the opportunity to clarify and correct some of the recent statements about our research article, ‘Exploring the Twitter activity around the eighth meeting of the Conference of the Parties to the WHO Framework Convention on Tobacco Control’.

    Mr Sarangapani, Director of the Association of Vapers India (AVI), is incorrect in claiming that our article makes “false allegations” and “unsubstantiated claims”, and that it frames AVI as a tobacco industry (TI) front group. We categorise his organisation as a ‘next generation product (NGP) advocate’ and we state that AVI is a member of the International Network of Nicotine Consumer Organisations (INNCO). We also report that INNCO has received funding from the Foundation for a Smoke-Free World (FSFW),[1] which is an organisation that continues to be funded solely by Philip Morris International.[2] Thus, AVI is a member of an organisation that receives indirect funds from Philip Morris International, via the FSFW. Those statements are factual and substantiated; readers can locate further details and references to the FSFW’s grantees and tax returns via our Tobacco Tactics pages, as referenced in our article. In his letter, Mr Sarangapani points out that the Founder-Director of AVI is the current President of INNCO’s Governing Board; however, our research article makes no mention of that fact. We clearly state that: “We found no evidence that the individuals affiliated with INNCO or its mem...

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  • Non-profit associations of nicotine consumers are not Tobacco Industry fronts.

    I am writing as co-founder of Pro-Vapeo Mexico, a non-profit consumer association affiliated with the International Network of Nicotine Consumer Organisations (INNCO), explicitly mentioned in the article “Exploring the Twitter activity around the eighth meeting of the Conference of the Parties to the WHO Framework Convention on Tobacco Control”. The authors of this article explicitly recognize that “We found no evidence that the individuals affiliated with INNCO or its member organizations were themselves funded by FSFW [Foundation for a Smoke Free World] or by the TI [Tobacco Industry] directly”. While this statement is correct, it still leaves missing information that we believe it is necessary and useful, for the benefit of your readers, to fully clarify: not only has Pro Vapeo Mexico never received any funding (direct or indirect) from any industry sector (tobacco, e-cigarettes or pharmaceutical) or from INNCO or the FSFW, we are a fully independent NGO whose activities are not (and have never been) directed by the TI or the FSFW or INNCO. Our affiliation with INNCO stems from its role as an umbrella organization grouping consumer associations worldwide united in advocating for Tobacco Harm Reduction, a strategy to improve global health by providing adult smokers the option to consume nicotine without having to inhale toxic cigarette smoke.

    Regrettably, the authors of the above-mentioned article claim that our twitter activity in the...

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  • Unsubstantiated Claims


    When doing scientific research, following the scientific method, you have a hypothesis (question) that you are going to investigate - in this case: Does xxx consumer organisation have any direct ties to tobacco companies that influence their advocacy?

    After you have chosen your method, you then gather your evidence, make an objective analysis and state your findings and make a conclusion.

    Your method SHOULD be thorough and your research should be objective in order to maintain the integrity of your research (and yourself). The evidence will either prove/disprove your original hypothesis.

    Instead, the authors have chosen to not only demonise the participation of consumers in the narrative of their own health, one has lobbied false claims about tobacco industry connections that do not exist.

    It is very concerning that the authors find it necessary to disenfranchise the very people who are fighting for their right to make informed choices about their health. It defies logic, and the principles of fairness and decency.

    It perhaps would have been more helpful to all concerned if the authors had done due diligence beyond looking at a website that does not have verified information, to cast aspersions on consumer advocacy organisations.

    It definitely would be more productive to welcome the voices of the people for whom felt impassioned enough to get involved in consumer advocacy to help smokers not only hav...

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  • It should be welcomed that consumers are engaging with decisions which affect them

    It is disappointing to see the BMJ publishing a research paper which smears consumer advocates for tobacco harm reduction by attempting to link consumer activity on social media with the tobacco industry. One can only conclude that the goal was to devalue the opinions of former smokers who have found safer nicotine products to have been beneficial to their lives.
    I write as chair of the UK New Nicotine Alliance and as it is highly likely that tweets from our supporters have been included in this research, so we welcome the right to reply to the article.
    The attempt to paint consumers as part of some mythical tobacco industry plot is offensive to individuals and organisations promoting tobacco harm reduction. We and our supporters, along with many other vapers, are systematically excluded from the FCTC conferences and yet have a strong stake in the outcomes of the meeting. Social media is one of the few opportunities we have to get our views across. Consumers of safer nicotine products have been acutely aware of an increasing warfare against the products which have helped them to stop smoking.
    In 2018, there were clear threats being expressed by the WHO FCTC in advance of COP8 towards products that vaping consumers value highly for helping them to quit smoking. Many vapers travelled to Geneva in 2018 at their own expense, but as ‘members of the public’ were excluded from the meeting.
    The article by Robertson et al was funded b...

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  • The Scientific Case for Civility

    Freedom of speech is a fundamental right in a free society. There is no justification to either interfere with the right of stakeholders to participate in the public debate regarding tobacco harm reduction policy, or to malign those that exercise that right. Given that the outcome of these policy discussions will affect the lives of more than one billion people on the planet who smoke, everyone must be free to advance arguments for and against any policy, and each argument must be scrutinized and evaluated on its evidence base and merits. Unfortunately, the recent paper in Tobacco Control—Exploring the Twitter activity around the eighth meeting of the Conference of the Parties to the WHO Framework Convention on Tobacco Control—missed the opportunity to do this.
    Instead of engaging in a discussion on the key issues and arguments put forth in the public discussion around the eighth meeting of the Conference of the Parties (COP8), the authors employ diversionary ad hominem tactics. They mischaracterize Philip Morris International’s (PMI’s) legitimate participation in the public debate on the role that products with the potential to reduce the risk of harm compared to smoking can play in global public health policy. Using phrases like ‘tobacco industry actors’ and ‘front groups’ the authors falsely imply that any person or organization who publicly supports tobacco harm reduction are paid to do so by the tobacco industry, and specifically PMI....

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  • Flawed understanding of nicotine consumer advocacy

    It’s surprising finding oneself involuntarily part of a research study. Given no chance to contribute, perhaps I can offer privileged insight into the processes the authors seek to describe.

    Analysis of tweets around the COP8 meeting show that nicotine consumer advocates were the most active, followed by public health advocates and the tobacco industry. My company – Knowledge Action Change – also tweeted, at the Geneva launch of our tobacco harm reduction report. [1] Tweeting by tobacco harm reduction advocates out-shadowed “official” FCTC messaging (and if the authors had searched #FCTCCOP8 and #COP8 as well as #COP8FCTC, they would have uncovered more).

    The article asserts that tobacco industry money is behind this activity. But it is beyond this study’s narrow methodological reach to illuminate why nicotine consumer advocates tweet. My discussions with nicotine consumer advocates – the majority of whom are volunteers - demonstrate passionate interest in the policymaking that influences their lives. Having found safer alternatives to smoking, they fear that inappropriate regulation including bans will see their options disappear. They are frustrated that they are ignored by tobacco control policymakers, regulators and researchers. Barred from COP8 along with the public and press, consumer organisations are also barred from the NGO coalition Framework Convention Alliance. No other field of health policy excludes the affected. Consu...

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  • INNCO rebuts allegations of industry influence

    We appreciate the authors’ concern about industry “astroturfing.” We believe astroturf activities undermine the genuine consumer movement that INNCO and its members represent. But the conclusions that the authors draw from their research are attenuated and inaccurate. In particular, we object strenuously to the authors’ conclusion that because INNCO has received funding from the Foundation for a Smoke-Free World (the Foundation), we are a tobacco front group.

    INNCO was formed in 2016, a year before the Foundation was established. All of INNCO’s members are autonomous, independent consumer organisations, and with rare exception are run by volunteers on a shoe-string budget. These organisations joined forces to create INNCO, and they nominate and elect INNCO’s Governing Board members, who serve without compensation.

    INNCO only accepts funding from sources where our independence as an organisation run by and for consumers is assured. INNCO operated for more than two years with only volunteer efforts and no funding. (Funding from the Foundation was received in December of 2018, which is after the period this paper covers.)

    As the authors note, INNCO was formed in large part to ensure the consumer voice is heard on international platforms. However, we question the authors’ intent in casting our desire to engage as legitimate stakeholders as nefarious.

    While the authors have cited numerous references on the motivations of t...

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  • False allegations, unsubstantiated claims

    We object to the framing of Association of Vapers India (AVI), erroneously referred to as ‘Vape India’ in the paper, as a tobacco industry front group, without providing any basis for the claim except our membership of International Network of Nicotine Consumer Organisations (INNCO).

    AVI was organised in August 2016, when consumers of low-risk alternatives came together to arrest the tide of state bans in India, which were being lobbied for by the Bloomberg Philanthropies network the authors belong to.[1] Though one of our directors is the current president of INNCO’s governing board, elected through a member vote in the 2020 General Assembly, he is serving in unpaid, honorary capacity.

    AVI has not received funding from INNCO, nor from the Foundation for Smoke-free World (FSFW), and neither from the tobacco industry. Our work is financed through voluntary contributions, and like INNCO, the affairs are conducted by a governing board comprising unpaid consumer volunteers.

    It is scurrilous to cast AVI as a tobacco industry group or anything other than a consumer-led movement that is seeking access to harm reduction avenues for India’s nearly 270 million tobacco users, among whom cancers are rising[2] even as most have meagre means to deal with the health consequences, which makes harm prevention a vital mitigation strategy. We are product agnostic and advocate access to lower-risk alternatives for both smokers and smokeless tobacco...

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  • Clarification of claims made about e-cigarettes

    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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  • Gateway effect from vaping to smoking likely to be small

    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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  • Declines in Adolescent Use of Cigarettes and Other Substances Consistent With Common Liability Model

    Miech and colleagues demonstrate declines in prevalence of non-medical use of prescription drugs among US high school students and show that these declines can be explained by trends in cigarette smoking.1 These observations are taken as support of the gateway hypothesis in which cigarette smoking increases the likelihood of subsequent other drug use. The authors further argue that these results are inconsistent with a ‘common liability’ model, and that the common liability model predicts that adolescent drug use would have “stayed steady or even increased as adolescents continued to use these drugs regardless of whether they smoked.” In this scenario, adolescents with a predilection toward substance might substitute cigarettes with other drugs as smoking rates decline.

    However, this conceptualization of the common liability model is inconsistent with how such models are typically understood. Models that posit a common liability do not assert that the degree of liability is fixed in the population, such that changes in risk for use of one drug increases risk for other drug use. Instead, common liability can be influenced by environmental factors and environmental changes can coherently impact multiple outcomes, resulting in trends similar to those observed by Miech and colleagues.

    For over 40 years, Problem Behavior Theory has provided a comprehensive theory and empirical approach to common liability. “Problem behaviors” (later termed...

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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.


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  • Carbon Monoxide to be expected with combustion


    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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  • Irresponsible methodology


    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.

  • Response to Jane Native


    Greetings –
    We thank you for your response to our paper. We honor and acknowledge that there are more than 564 Tribal Nations and that each has their own name and language. In this article, we used the term “American Indian,” which was a decision guided by our long-standing work with cultural advisors in Minnesota. While we chose to use the term “American Indian,” we recognize that each Tribe and individual may prefer to use a different term. For additional context, please see another article titled “Why the World Will Never Be Tobacco-Free: Reframing “Tobacco Control” Into a Traditional Tobacco Movement,” available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4984762/

  • Third option - cleverer than Tobacco Control


    Whilst it is true that Juul is not exactly popular with those on either side of the fence this article fails to address the major issue.

    The impending regulation which Juul is said to have brought down on the vapor industry helps Juul by eliminating the competition. Only they, and other brands owned by tobacco companies have any hope of being able to afford the process to keep their products on the market. Independent manufacturers and the retailers who sell their products will simply be obliterated.

    Considering that these are people who who have dedicated their lives and often their life savings to helping people switch to safer alternatives, and who are by far and away the most efficient at enforcing strict age verification for purchases, this is a tragedy, not something to be celebrated.

    Lastly, as if it still needs to be said, the outbreak of acute lung injury in the US has not been linked with Juul, or any other commercially available nicotine vaping product.

  • Columbus Was Stupid; Native Americans Not Indians

    I 100% understand the general good intent of this paper. I also must say that I am Cherokee but not "fullblooded" Cherokee. I did grow up in the heart of the Nation, though. However, could people please stop using the term "American Indian"? Indians are from India. Columbus got lost (even though he was a navigator), ran the one ship he captained aground where he was found by the Native population of the island he smashed into (which for the record was not anywhere near North America). He looked around and thought, "I'm on a beach, I was trying to find India, India has a beach. These people are not white, they are tan, Indians are tan! I'm in India!" He then spread his stupid to the world. Now every tan person originating from any American continent (which are when put together the same land mass as the entire "known" world at that time) are all Indians... Please stop. It's just offensive.

  • Foundation for a Smoke-Free World and healthy Indigenous futures: an oxymoron? An Evidence-Based Response

    Mr. Clive Bates’ response to our article, the Foundation for a Smoke-Free World and healthy Indigenous futures: an oxymoron?, indicates the need to clarify several issues. In this response, we emphasise two key issues:
    1. Organisations claiming to serve the good of the public, but who receive direct or third-party funding from the tobacco industry, are faced with serious conflicts of interest (COI); and
    2. harm reduction is only part of a comprehensive approach to reducing commercial tobacco use.

    As Indigenous peoples, we have an inherent responsibility to protect the health and wellbeing of Indigenous peoples now and for our future generations. The tobacco industry poses, and has posed in the past, a significant threat to our health and wellbeing. Therefore, we are deeply concerned about the Philip Morris-funded Foundation focusing on Indigenous peoples.

    Philip Morris International, the Philip Morris Funded-Foundation and the Centre for Research Excellence: Indigenous Sovereignty and Smoking
    Mr. Bates states that “There is no credible analysis (anywhere) of the actual, rather than the imagined, relationship between PMI and the Foundation for a Smokefree World”. This is incorrect 1-5. Researchers in journals such as The Lancet and Tobacco Control have analyzed key documents from the Foundation, including tax returns and bylaws that highlighted numerous relationship issues and conflicts of interest 1-5.


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  • A disappointing and baseless attack on a valuable initiative

    I hope that Tobacco Control will offer a right of reply to the target of this one-sided criticism. In the meantime, let me put a few points to the authors:

    1. There is no credible analysis (anywhere) of the actual, rather than the imagined, relationship between PMI and the Foundation for a Smokefree World (FSFW - ‘the Foundation’) that suggests PMI exerts material control over the Foundation. Its basic legal documents suggest otherwise. Nor have the authors explained why the Foundation's goal of ending smoking within a generation is somehow a bad thing or insincere.

    2. Nor is there a credible assessment of the relationship between the Foundation and the new Centre for Research Excellence: Indigenous Sovereignty and Smoking (the Centre) that is the subject of criticism in this paper. There are two degrees of separation between the Centre and PMI, and the philosophy of the Foundation is to support centres of excellence and to leave them to get on with their work. The Centre has an excellent (Māori) leader and is quite capable of asserting its independence. How it would somehow do the bidding of PMI is not explained by the authors.

    3. The authors dismiss the Centre’s focus on ‘harm reduction’ and instead emphasise: “the need to shift attention away from individuals to the true source of the problem: commercial tobacco and the companies that sell and promote it.”. While I share the sentiment about individual smoking cessat...

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  • Up in smoke: The reported association between e-cigarette use and wheezing in this study is probably spurious


    We read with interest a recent publication by Li, et. al, entitled Association of smoking and electronic cigarette use with wheezing and related respiratory problems in adults: cross-sectional results from the Population Assessment of Tobacco and Health (PATH) study, wave 2. The primary finding, reported in the abstract, was that risk of wheezing and related respiratory symptoms was significantly increased in current exclusive e-cigarette users compared to never users, with an adjusted odds ratio of 1.67 (1.23, 2.15). We think the report is misleading for several reasons.

    First, the main multivariable analysis (Table 2) did not adequately adjust for important confounders that impact wheeze, most importantly, cigarette smoking history. In most analyses of medical outcomes in adults, pack-years of smoking has a strong relation to smoking-related diseases, over-and-above current smoking status. Since three quarters of vapers in the main model were ex-smokers, cigarette smoking history is almost certainly contributing to the size and significance of the main reported finding. Other combustible tobacco use and current marijuana smoking would also be expected to exacerbate cough and wheeze. Our bet is that large numbers of e-cigarette users also use marijuana.

    The authors partially addressed smoking history with a secondary analysis (Table 3), in which they stratified by former smoking status. In that analysis, vaping was not significantl...

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  • A different interpretation

    A key finding of this paper does not find its way into the abstract namely, "no significant differences in wheezing and related respiratory symptoms was found when comparing current vapers who never smoked with never smokers. " This tends to suggest, unsurprisingly, that it is the prior smoking history that is the critical factor in current wheeze. The paper supports the harm reduction hypothesis for switching to vaping completely from smoking as per the conclusion. But the conclusion also states in the first line, "Vaping was associated with increased risk of wheezing and related respiratory symptoms, " which is incorrect without adding "in current smokers." Vapers who previously smoked have lower risk than those who continue to smoke, including dual users, and those who never smoked have no increased risk.

  • Response to Dr. Glantz

    We would like to clear up some misconceptions in Dr. Glantz’s reply to our recent article (1). First, our analytic approach did not assume linearity as the title of Dr. Glantz’s response implies. On the contrary, we applied a log linear form, which not only better fit the data, but also incorporates non-linearities. Additionally, we also conducted and provided results using a linear form in the supplementary material, which yielded similar results.

    In his reply to our paper, Dr. Glantz claims that we should have started the vaping period in 2009 rather than in 2014 or 2013. However, we feel this criticism is wrong since we provided extensive data in the paper showing that vaping among youth was minimal until at least 2013.
    Consequently, we focused on when vaping became more widespread and, by most accounts, became a concern. Further, we conducted analyses that considered changes in trend for other years and obtained qualitatively similar results when the transition was specified as dating back to 2013 or 2012. We also conducted analyses which allowed for changes in trend in both 2009 and 2014 and found no change in trend from 2009 onward, whereas the change in trend from 2014 onward continued to hold. We understand that Dr. Glantz and colleagues in another paper (2) used 2009 as a base year for vaping. However, we feel this choice was a poor one since virtually no students were using e-cigarettes in 2009, and hence vaping would not be...

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  • PMI's response to this paper comes up short

    PMI finally responded to my paper in Tobacco Control1 showing that the data submitted in their MRTP application to the FDA to market IQOS with reduced risk claims did not actually support claims of reduced risks.

    Specifically, PMI’s MRTP application included their 3-month study of 24 non-cancer biomarkers of potential harm (which PMI calls “clinical risk endpoints,” CRE) in humans using IQOS compared to conventional cigarettes. These biomarkers include measures of inflammation, oxidative stress, lipids, blood pressure, and lung function. (PMI did separate studies of biomarkers of exposure, several of which are carcinogens.) While PMI’s application emphasizes that these biomarkers generally changed in positive directions, my examination of the data revealed no statistically detectable difference between IQOS and conventional cigarettes for 23 of the 24 BOPH in Americans and 10 of 13 in Japanese. Moreover, it is likely that the few significant differences were false positives. Thus, despite delivering lower levels of some toxicants, PMI’s own data failed to show consistently lower risks of harm in humans using IQOS compared to conventional cigarettes.

    Their undated response, “The Difference between IQOS and Continued Smoking,”2 presents two arguments:

    • The original study submitted to FDA was “NOT DESIGNED to serve as the sole pivotal evidence with regards to CRE’s and to show statistically significant changes in the CREs.”...

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  • The reality may not be linear

    David Levy and colleagues’ paper “Examining the relationship of vaping to smoking initiation among US youth and young adults: a reality check” used data from all the surveys over time that measured youth and young adult e-cigarette use and smoking and concluded there was a substantial increase in youth vaping prevalence beginning in about 2014. Time trend analyses showed that the decline in past 30-day smoking prevalence accelerated by two to four times after 2014. Indicators of more established smoking rates, including the proportion of daily smokers among past 30-day smokers, also decreased more rapidly as vaping became more prevalent.

    The inverse relationship between vaping and smoking was robust across different data sets for both youth and young adults and for current and more established smoking. While trying electronic cigarettes may causally increase smoking among some youth, the aggregate effect at the population level appears to be negligible given the reduction in smoking initiation during the period of vaping's ascendance.

    The good news is that Levy and colleagues are finally accepting the overwhelming evidence that kids who start with e-cigarettes are more likely to end up smoking cigarettes, the so-called “gateway effect.”

    Now they have fallen back to arguing that the gateway effect is not big enough to overcome the benefits of e-cigs as substitutes for cigarettes.

    The approach they used, interrupted ti...

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  • Sell cigarettes only in alcohol-licensed premises

    In view of the rising prevalence of adolescent smoking worldwide, it makes a lot of sense to strictly limit cigarette sales only to alcohol licensed premises, particularly, in countries where there are minimum age requirements for buying alcohol. In a previous letter (1) to Lancet Global Health we had argued in favor of the same as we believe that restricting sale of cigarettes or other tobacco products will bring about a decrease in consumption by adolescents.

    Smoking addictions are usually acquired during adolescence and this usually happens due to an apparently unregulated sale of tobacco products. Regulation is difficult when the number of tobacco selling establishments far exceeds the managing capacity of local administration. In India, adolescents have unrestricted access to tobacco products as small vendors, whose only source of income is by selling tobacco products, tend not to compromise on any business opportunity.

    Although there is a positive association between alcohol and smoking, as the authors have pointed out “tobacco sales are not financially important for the majority of alcohol-licensed tobacco retailers”, so it is a win-win situation for preventing initiation of cigarette smoking by adolescents as alcohol vendors will have no incentive to bypass regulations by selling tobacco products to those who do not qualify as per legal age restrictions. In India, smoking and consumption of alcohol are also social taboos and th...

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  • Evidence of the absence of hepatotoxicity of IQOS

    More than 1,000 participants were exposed to IQOS in our clinical studies. The authors of the letter “Possible hepatotoxicity of IQOS" based their analysis on approximatively 10% of the data instead of examining the data as a whole. For example, for the five-day exposure studies in confinement, they stated that the percentage of participants with elevated bilirubin in IQOS arm was more than three times higher than that observed in the smoking abstinence (SA) arm in the European study (8.8% [7 participants] in IQOS arm, 2.6% [1 participant] in SA arm). However, they missed reporting that this percentage was lower in the IQOS arm than in the cigarette smoking (CC) arm in the Japanese study (10% [8 participants] in IQOS arm, 15% [6 participants] in CC arm). They also stated that the mean increase in alanine aminotransferase (ALT) was higher with IQOS than with CC or SA in the Japanese study but did not report that in the European study, the mean increase in ALT was lower in the IQOS arm than in the CC or SA arm.
    Similarly, for the 90-day exposure studies in an ambulatory setting, they mentioned that the percentage of participants with increased ALT levels after 60 days of exposure was higher within the IQOS arm (6.3% [5 participants] in IQOS arm, 0% in CC arm, 2.6% [1 participant] in SA arm) in the U.S. study. However they omitted to mention that in the Japanese study, this percentage was lower in IQOS arm compared with CC or SA arms after 3...

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  • Clarification regarding FDA authorities relating to modified risk claims

    This study has some important findings that could, if replicated, guide FDA decision making on applications from manufacturers to make modified risk tobacco product claims. However, while it does not detract from the study’s findings, the article does not accurately describe the standards FDA must apply when evaluating those applications. The abstract inaccurately suggests that tobacco products in the U.S. may make reduced-risk or reduced-exposure claims so long as they are not misleading, and does not mention that any explicit or implicit reduced-exposure or reduced-risk claims may not be legally made without first submitting an application to FDA and receiving a permissive order, which considers various other factors, as well.

    The introduction of the paper does a bit better, accurately stating that the Tobacco Control Act requires prior review by FDA before making lower-exposure or lower-risk claims. But it then suggests that manufacturers can receive that permission if they either demonstrate that the product lowers harm or risk compared with other tobacco products or if they demonstrate that the product is free of or contains reduced levels of harmful chemicals and the related claims don’t mislead consumers to believe that the reduced-exposure means lower risk. While that description is accurate as far as it goes, it leaves off the enormously important requirement, in both cases, that a manufacturer’s application for permission to...

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  • Biomarkers of harm -- not exposure -- are key to reduced risk claims


    The "serious criticism" that Mr. Bates refers to is from him (on another website).

    In order for the FDA to issue an order allowing Philip Morris International to market IQOS in the United States as a reduced risk tobacco product, the law required that, among other things, FDA "determines that the applicant [PMI] has demonstrated that such product [IQOS], as it is actually used by consumers will significantly reduce harm and the risk of tobacco- related disease to individual tobacco users."

    That is why PMI provided the information of biomarkers of potential harm to the FDA. and how they compare to values observed in smokers. My paper shows that, using PMI's own data, IQOS will not significantly reduce risk to consumers compared with cigarettes.

    Bates ignores this reality and instead talks about biomarkers of exposure, which is a different question.

  • This study has already been severely criticised

    NOT PEER REVIEWED The main problem with the claim of equivalence between smoking and switching to iQOS is that some biomarkers of potential harm change over a much longer timeframe than the 90-day duration of the trials. Biomarkers of potential harm can reflect years of accumulated physical changes arising from smoking and only improve slowly after smoking cessation. The trial did, of course, pick up very substantial reductions in biomarkers of exposure, which would, over time, emerge as reductions in biomarkers of potential harm.
    This would have been apparent and obvious to readers if the paper had also shown the results for the third arm of the trial, smoking abstinence. The biomarkers of potential harm for smoking abstinence and for switching to iQOS are quite similar in this trial. This is a curious omission. Furthermore, biomarkers of exposure turned quite similar for both switching to iQOS and smoking abstinence - both are greatly reduced, which is an encouraging finding about the iQOS product.
    It is unlikely that anyone would argue against smoking abstinence on the basis of the biomarkers of potential harm in the original PMI study. However, the author has selectively used the iQOS data from these trials without the context of the smoking abstinence data to oppose the Modified Tobacco Product Application that PMI made to the U.S. FDA - the author's attempt to block this reduced-risk product from entering the US market.

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  • Experimental demonstration of the absence of formaldehyde cyanohydrin emission from PLA using a reference standard

    The potential presence of formaldehyde cyanohydrin in the polylactic acid (PLA) filter of Marlboro Heatstick when heated was reported by Davis and al. PLA is a biodegradable thermoplastic derived from renewable resources such as corn starch. This tentative identification is based on the GC-MS analysis of the headspace of a heated piece of PLA, and the subsequent compound identification by mass spectra matching (acceptance criteria >85%) with the spectra library of the National Institute of Standard and Technology (NIST). However, this was not confirmed by injecting a purchased analytical grade reference standard, in order to unambiguously prove the presence of formaldehyde cyanohydrin. Therefore, we decided to repeat the experiment using headspace injection gas chromatography coupled to high resolution mass spectrometry under similar conditions as described in the publication. Our headspace GC-HR-MS analyses showed four peaks, at retention times of 16.38, 16.47, 17.14, and 18.58 min, in good agreement with the reported data reported (figure 4).

    From the analysis of reference standards, we have confirmed the presence of both e-caprolactone (CAS# 502-44-3) and (S,S)-lactide (CAS# 4511-42-6) eluting at 16.47 and 17.14 min, respectively. We identified triacetin (CAS# 102-76-1) at 18.58 min, based on the reference standard, instead of 1,2-diacetin (their EI mass spectra are very similar).
    However, we have demonstrated unambiguously the a...

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  • Transparent and open approach

    Euromonitor International is a privately held, independent provider of strategic market research with no agenda other than to present the most realistic illicit trade data impartially and within its wider industry context. Subscribers to Euromonitor’s Passport Tobacco database are varied and include tobacco control/ public health groups, academia, retailers, manufacturers of raw materials as well as tobacco brand owners and banks/ consultancies, amongst others.

    These same stakeholders are approached by Euromonitor for comment on industry trends, including those of illicit sales. Euromonitor’s stated sources for illicit cigarettes sales thus include trade press, customs offices, interviews with manufacturers and retailers, government and academic organisations. This is reconciled against local knowledge of the market and illicit trade’s wider context – eg national economic performance, trends in taxation, unit prices and duty paid sales, porosity of borders, law enforcement efforts, and so on. There is no reliance on any one source.

    By its very nature, illicit trade in tobacco products is a contentious area and one that is difficult to quantify – there are often wide discrepancies between various sources on illicit trade, reflecting vested interests in either deflating or inflating figures. In these circumstances, Euromonitor strives to present the most widely accepted and realistic estimate of the illicit market, based on a holistic...

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  • The missing elephant in the room of vaping transition

    Coleman et al’s important report [1] on transitions in the vaping and smoking status of a nationally representative cohort of American 18+ adults who use electronic cigarettes (EC) from the PATH study provides rich data that can greatly advance our understanding of the natural history of EC use and their potential in harm reduction.

    However, we were struck by the absence of emphasis in the report of what is perhaps its most important finding. If we examine the report’s data and consider the net impact of vaping on the critical goals of having vapers stopping smoking and vaping non-smokers not starting to smoke, the findings are very disturbing and should strong reason for pause among those advocating e-cigarettes as a game-changing way of stopping smoking.

    At Wave 2, 12 months on from Wave 1, of the cohort of 2036 dual users (EC + smoking) only 104 (5.1%) had transitioned to using only EC and another 143 (7%) had quit both EC and smoking for a combined total of 247 or 12.1%. Of the 896 exclusive EC users at Wave 1, 277 (30.9%) had stopped vaping at Wave 2. Together, 524 out of the 2932 EC users (17.9%) followed from Wave 1 might be considered to have had positive outcomes at Wave 2.

    The other side of the coin however, shows that of the 2036 dual users at Wave 1, 886 (43.5%) relapsed to using cigarettes exclusively. In addition, among the 896 exclusive EC users from Wave 1, 109 (12.2%) had stopped vaping and were now smoking, wit...

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  • Experimental demonstration of the absence of formaldehyde cyanohydrin emission from PLA using a reference standard

    The potential presence of formaldehyde cyanohydrin in the polylactic acid (PLA) filter of Marlboro Heatstick when heated was reported by Davis and al. PLA is a biodegradable thermoplastic derived from renewable resources such as corn starch. This tentative identification is based on the GC-MS analysis of the headspace of a heated piece of PLA, and the subsequent compound identification by mass spectra matching (acceptance criteria >85%) with the spectra library of the National Institute of Standard and Technology (NIST). However, this was not confirmed by injecting a purchased analytical grade reference standard, in order to unambiguously prove the presence of formaldehyde cyanohydrin. Therefore, we decided to repeat the experiment using headspace injection gas chromatography coupled to high resolution mass spectrometry under similar conditions as described in the publication. Our headspace GC-HR-MS analyses showed four peaks, at retention times of 16.38, 16.47, 17.14, and 18.58 min, in good agreement with the reported data reported (figure 4).

    From the analysis of reference standards, we have confirmed the presence of both e-caprolactone (CAS# 502-44-3) and (S,S)-lactide (CAS# 4511-42-6) eluting at 16.47 and 17.14 min, respectively. We identified triacetin (CAS# 102-76-1) at 18.58 min, based on the reference standard, instead of 1,2-diacetin (their EI mass spectra are very similar).
    However, we have demonstrated unambiguously the a...

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  • Please publish full data and provide key specific facts

    The reporting of the results of this study is far from complete, which is concerning given the highly politicised controversy that surrounds this product. I hope the authors should respond to this comment by publishing supplementary material with all the data they collected in a an accessible form such a CSV file and summarised in tables in a supplementary memo.

    In particular, the authors should provide all data on the following:
    + Vaping and JUUL current use (used in past 30-days) prevalence stratified by age, clearly differentiating between 18 and over and under-18s
    + Frequency of use of vaping products and JUUL within the 30 days among current (past-30 days) users, ideally using the same frequency breakdown used in the National Youth Tobacco Survey
    + Breakdown of vaping status by smoking status and frequency of vaping and JUUL use - to help determine the extent to which regular JUUL use is concentrated among smokers
    + Smoking prevalence and frequency

    There is a rare opportunity to gain insights into a live controversy, yet the reporting of the survey is so incomplete it is difficult to draw any serious conclusions from it about the overall effect. For example, JUUL maybe displacing other vaping products used by youth as it is in the market overall. JUUL may be functioning as an alternative to smoking in both adolescents and adults and contributing to achieving smoke-free public health objectives.


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  • The unanswered question....

    The authors state "These stores have largely stopped carrying e-cigarettes at the same time as starting to stock IQOS HEETS (HEATSTICKS), the cigarette-like component that is smoked in the IQOS device,..." but provide no insight into why that is. Are these retailers being incentivised to stop selling e-cigs by PMI?

    While the risk profile of IQOS is uncertain, the product is highly likely to be much more harmful than vaping e-cigs. Commercial tactics that promote IQOS over vaping devices, excluding the latter from retail chains, would be of major concern for tobacco control.

    Can the authors enlighten us?

  • In response to a recommendation

    In the article Potential deaths averted in USA by replacing cigarettes with e-cigarettes (1), a Status Quo model is performed, which suggests that this change will avoid premature deaths of millions. Although the statement is interesting, it´s necessary to mention that, the quantity of cigarettes consumed wasn´t considered. In addition, it´s important to recognize that a controversy still exists about the use of these devices and their toxicity.

    Believing that e-cigarettes are an alternative against the use of cigarettes is tempting, but we have to be cautious. One of the major risk factors for cancer is an excessive consumption of cigarettes. In Müezzinler A et al (2), a dose response between the number of cigarettes consumed and mortality of any cause was seen. Therefore, it is not only if you smoke, it is also important how much you smoke. Nevertheless, since this outcome was not assessed, we assume that risk was uniform. In addition, they classify as “never smokers” any persons with less of forty years that smoke cigarettes. Is possible that a person of thirty-eight years who smoke twenty cigarettes per day for twenty years could be classified like a “never smoker”? We doubt it.

    Currently, the use of e-cigarettes is controversial. As Chen J et al states in their study (3), we should carefully interpret this idea of a substitution. There is a great quantity of information about the risks of conventional cigarettes in estimation mo...

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  • On the importance of using quit-attempters and focusing on why e-cigarettes were used to assessing e-cigarettes role in smoking cessation


    Berry et al (1) report an analysis of two waves of the Population Assessment of Tobacco and Health (PATH) study focused on the association between the initiation of e-cigarette use by Wave 2 and cigarette abstinence/reduction assessed at Wave 2. They conclude that daily e-cigarette use is associated with both cigarette abstinence and reduced consumption among continuing smokers. While this addresses an important question, we argue that such analyses should be adjusted for the reason e-cigarettes are being used.

    From Wave 1 of PATH (2), we know that ~75% of smokers agreed that e-cigarettes were useful to help people quit. However, ~80% agreed that e-cigarettes allowed someone to replace a cigarette where smoking was prohibited. From the first reason, we can hypothesize that e-cigarette use might be associated with cigarette abstinence/reduction. However, from the second reason, we can also hypothesize that e-cigarettes would be associated with neither cigarette abstinence nor reduction. The recent National Academies report (3) recommended that any assessment of the role of e-cigarettes in cigarette cessation/reduction should focus on smokers who used e-cigarettes to help them quit.
    PATH Wave 2 data does include information on whether smokers tried to quit in the previous year, as well as whether they used e-cigarettes to aid the last quit attempt. Previous research (4) has shown that over half of the smoking population will not ha...

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  • The Tobacco Control Scale: The Emperor’s new clothes?


    Feliu et al’s conclusion “in the European Union countries with the higher scores in the Tobacco Control Scale, which indicates higher tobacco control efforts, have lower prevalence of smokers, higher quit ratios and higher relative decreases in their prevalence rates of smokers.” deserved comment.

    First, it seems a tautology. Tobacco control policies are robustly evidence based. Accordingly, more efforts, less smokers.

    Second, a PubMed search with “"tobacco control scale" only retrieved 27 articles since 2006 and no validation published yet. Obviously, the Scale poorly correlated with smoking rate: r2 being .58 in 2002/3, .15 in 2006/7 and .06 in 2010/11.(From table 3 in 2; n= 11 European countries).

    Third, why make simple stuff complex? This surrogate is complex to calculate and its items are subjective because issuing a decree is useless if no implementation were enforced. In contrast, the smoking rate and its evolution are simple and reliable! How France can be ranked 4th among 28 countries with a 57/100 score (1) while smoking prevalence has been plateauing for so long at more than 30%? In France, from 2004 to 2017 no relevant increase in tobacco taxes, no implementation of the legal smoking ban in cafés or of the ban of sale to minors despite sting operations by NGO showing evidence of serious breaches.(3)

    Fourth, claiming “the European Union should continue implementing comprehensive tobacco control pol...

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  • Jawad et al.'s Policy Recommendations Need Refinement

    This paper’s core findings are quite helpful: (1) Tax/price increases for non-cigarette tobacco products can effectively reduce their use; and (2) Tax/price increases for non-cigarette tobacco products could prompt some users to increase their cigarette smoking if comparable tax/price increases for cigarettes are not done at the same time. But the paper’s related analysis is incomplete, producing misleading conclusions, largely because the paper focuses on cigarettes versus non-cigarette tobacco products without also considering the more important distinction for health-directed tobacco tax strategies between smoked tobacco products and non-combustible tobacco products.

    In its abstract, the paper concludes that the “positive substitutability between cigarettes and non-cigarette tobacco products suggest that tax and price increases need to be simultaneous and comparable across all tobacco products.” But the paper does not appear to consider that the only substitutions that could significantly increase public health harms would be if the tax increases prompted some non-combusted tobacco product users to move to more-harmful smoking or prompted some smokers who would otherwise do so not to move to less-harmful non-combusted tobacco products. As a result, the paper fails to acknowledge that significant tax/price increases for only combusted tobacco products would not prompt any harm-increasing substitution and would directly secure desirable...

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  • Unassisted smoking cessation should be studied, not denigrated

    The paper by Filippidis et al [1] provides data re-confirming the well-known fact that most ex-smokers attempt to quit without using any form of assistance, whether pharmaceutical, professional or via e-cigarettes. Moreover, the proportion of ex-smokers trying to quit unaided increased substantially in Europe between 2012-17 (ex-smokers using no assistance increased from 73.9% to 80.7%), a period where e-cigarette use accelerated in some nations.

    Regrettably however, this study does not permit any comparison of success rates by method, as no data are reported on which method of cessation (assisted v unassisted) was used by ex-smokers on their last, final (and so successful) quit attempt.

    The authors report that those “who successfully quit reported much lower use of cessation assistance compared with smokers who had tried to quit without success” and suggest that this might reflect indication bias, whereby those who find it harder to quit self-select to use assistance, leaving the low hanging fruit of non- or less addicted smokers to fall off the smoking tree using their own determination.

    While this will be true for some, there are many former heavy smokers who quit without assistance. This argument also borrows assumptions from the discredited hardening hypothesis [2], which holds, in the face of evidence to the contrary, that as smoking prevalence falls the concentration of hardened, more deeply addicted smokers increase...

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  • Preventing tobacco Industry interference needs to be included in vaccine

    There is also very clear evidence that tobacco industry interference is either delaying or dumbing down implementation of each of the MPOWER policies particularly in LMICs. The TC vaccine is a good concept but the framework needs to include monitoring, exposing and countering industry tactics.

  • Response to Bashash et al.

    I am grateful to Bashash et al. for raising some important methodological and policy-related issues. Responding to their specific points:

    (1) Very high formaldehyde concentrations may arise in aerosols when atomisers generate excessive heat[1]. Under these circumstances recommended safety limits for formaldehyde may indeed be exceeded and this compound contributes most to the cancer potency summation.

    (2) Goodson et al. [2] provide a framework for assessing whether low dose compounds that are not necessarily individual carcinogens may become involved in carcinogenesis when acting in concert. Although discussed under "Strengths and limitations" synergystic phenomena were not accommodated in the cancer potency model as it is not yet possible to predict the mechanism and magnitude of such interactions in tobacco or e-cigarette aerosols. Under the Goodson et al. model adverse effects reflect adventitious synergystic combinations. These may be statistically more likely in tobacco smoke where the number of different compounds greatly exceeds those of simpler aerosols, however this effect is expected to be minor compared with the exceptionally high carcinogenic potencies of some well-established carcinogens in tobacco smoke.

    (3) Lifetime cancer risk is linearly dependent on the daily volume of vapour inhaled (equation 7) and the effect on risk of increased consumption after switching to heat not burn (HnB) products is directly related to the chang...

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  • A critique of Jawad et al, Price elasticity of demand of non-cigarette tobacco products: a systematic review and meta-analysis

    NOT PEER REVIEWED The Jawad et al systematic review and meta-analysis examining price effects for non-cigarette tobacco and nicotine products appears methodologically sound and was a registered analysis. It provides information that could be used productively by advocates and policymakers seeking to reduce harm. The cross-elasticities reported in this paper can be used to the advantage of public health by increasing the impact of policies that seek to drive down smoking.

    However, this work does not take into account the fact that not all tobacco and nicotine products cause the same level of health harms as combustible cigarettes. The paper examines own- and cross-price elasticity across a wide array of products – from combustible tobacco products such as kreteks and little cigars to nicotine-only products such as e-cigarettes and nicotine patches – and then discusses consumption patterns in terms of an undifferentiated aggregate of nicotine use. Jawad and colleagues do not consider the health implications of policies to move nicotine users from more-harmful to less-harmful means of administration (see, for example, Chaloupka, Warner and Sweanor, 2015, recommending differential taxation according to differential risk).

    From a public health perspective, any analysis of nicotine-use patterns should consider differential harm levels. A focus on nicotine use as the sole outcome variable can be seriously misleading and detrimental to the goal of reducing smoking....

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  • Evolution, Resurrection, or Zombie Apocalypse?

    We thank Dr. Jarvis for his appreciation of our historical scholarship but disagree that our conclusion, “the promotion of tobacco harm reduction may serve the interests of tobacco companies more effectively than the public,” is an attack.

    Our paper is about how policy affects ideas and vice versa. The ideas guiding the product modification program led to bad outcomes. That these ideas have been reanimated merits critical assessment. Voluntary agreements led to industry influence over the ISCSH’s recommendations, which in turn undermined public health. We point out that some of the same premises that led the ISCSH astray are popular again. Jarvis claims that current UK harm reduction policy has nothing to do with the product modification program, and everything to do with the influence of the late Michael Russell. Russell’s impressive scholarship – and oft-quoted statement, “people smoke for the nicotine, but die from the tar” – is indeed hugely influential among proponents of tobacco harm reduction. Jarvis posits that Russell’s work serves as a “paradigm shift” on which the UK’s current embrace of long-term nicotine maintenance and tobacco harm reduction actually rests, and which severs any link between the failures of product modification and widespread fears of a redux today.

    Yet Russell’s work represents more a variation in theme than it does revolution in content. Russell’s policy recommendations operate from the same premises a...

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  • There are still lessons to be learned

    NOT PEER REVIEWED Martin Jarvis is right to describe the Hunter Committee era as “a sorry tale” that by and large is well told by Elias and Ling, but his assertion that “taken as a whole their paper reads more as an attack on current UK policy than as a scholarly contribution to the history of tobacco control” is way over the top, as is his criticism of “the editorial processes and decision-making of Tobacco Control”.

    In a paper that runs to a little over five pages of text, there are very brief references to current policies on the first page, then further brief references towards the end, suggesting that there are lessons to be drawn from the earlier episodes.

    The paper might indeed have expanded further on the industry-friendly record of the Hunter Committee, noting that after his term as Chairman of the Committee ended, Lord Hunter became a consultant for Imperial Tobacco, while a civil servant who worked on smoking and serviced the Hunter Committee went on to work for Gallahers. It might also have included more emphasis on the way tobacco substitutes dominated public discourse on tobacco policy issues during the 1970s (1), although in fairness to the authors they appear to have been misled by the re-writing of history evident in some of the material they cite, particularly from industry actors.

    But this would simply have added more weight to the conclusion that during the 1970s discussion, debate and massive promotion of tobacco substitutes by t...

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  • Did mammals evolve from dinosaurs? Current UK harm reduction policy did not come from the product modification fiasco of the 1970s

    Elias & Ling throw useful light on the slow-motion disaster that was the series of voluntary agreements begun in the 1970s between government and the tobacco industry in the UK, overseen by the Independent Scientific Committee on Smoking and Health (ISCSH). These had as their aim to address the issue of tobacco product modification to reduce the health risks of smoking. Industry produced new smoking materials with the aim of reducing the biological activity of the tar fraction of smoke from cigarettes, and agreed to a programme of gradual tar yield reduction across the years. The novel products failed because consumers rejected them (there were too few users even to recruit for trials to examine their potential benefits), and the reductions in machine-smoked tar yields were achieved largely through increasing filter ventilation. The material cited shows that the low tar programme fiasco was characterized by undue influence from tobacco industry and a complete lack of understanding of the dynamics of smoking behaviour on the part of the scientific experts charged by government with supervision of the programme.
    This is a sorry tale from the early days of tobacco control, and Elias & Ling tell it well. So far so good. But in framing and interpreting their material they go well beyond the data they cite, and draw quite unwarranted conclusions about what they see as the deficiencies of the current UK harm reduction policy. Indeed, tak...

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  • Evidence-based tobacco harm reduction

    NOT PEER REVIEWED Elias and Ling conclude that ‘Regulatory bodies should consider toxin exposure, and new products’ actual use, abuse potential and population health effects before endorsing them as safer’. We agree, and that is exactly what Public Health England and the Royal College of Physicians have done [1-4].

    1. Britton, J. and Bogdanovica, I. Electronic cigarettes. A report commissioned by Public Health England. Public Health England, 2014. https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...
    2. Bauld, L., Angus, K., and de Andrade, M. E-cigarette uptake and marketing. A report commissioned by Public Health England. Public Health England, 2014. https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...
    3. McNeill, A., Brose, L., Calder, R., Hitchman, S.C., McRobbie, H., and Hajek, P. E-cigarettes: an evidence update. A report commissioned by Public Health England. Public Health England, 2015. https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...
    4. Tobacco Adviso...

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  • Vapourised nicotine products: Lower concentration does not mean safe

    NOT PEER REVIEWED The results provided by Stephens [1] may suggest to readers that since the concentrations of carcinogens are lower in vapourised nicotine products (VNPs), the risks of cancer are smaller compared to conventional cigarettes. The article uses the linear non-threshold model for risk assessment (a uniform cancer risk per unit dose from higher to lower doses), which is also used by most regulatory agencies. This model is considered to have a high degree of uncertainty; nevertheless, it implies that any dose of carcinogens increases the risk of cancer. Accordingly, the primary conclusion of Stephens and other’s[2] findings of the presence of carcinogens, particularly in heat-not-burn cigarettes (HNB) is that HNB poses a significant risk of cancer. In addition:
    1) The article highlights a summation approach of overall cancer risk for each product, yet the individual concentrations of human carcinogens (for example, formaldehyde [3]) are still at risk level.
    2) The assessment of carcinogenesis of low-level exposure to a mixture of chemicals is challenging [4]. Stephens’s summation model assumes that the effect of chemicals is independent. Even if we assume that for an individual chemical a lower concentration lowers carcinogenicity, we cannot rule out the potential effects of interactions among chemicals.
    3) The analysis relies on holding consumption constant. However, manufacturer studies have suggested that consumption increases after a swi...

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  • Founder

    NOT PEER REVIEWED An often overlooked limitation in smoking-related studies based on surveys conducted by health institutions is the pressure on respondents to provide "the right answer." Especially in this area, where this population has been subjected to high intensity tobacco control policies and messages, sample representativeness cannot be established with certainty when those asking the questions are the originators and/or pursuers of these policies and messages and, undeniably, describing the effort as "denormalization" and seeking to form a stigma around smoking and smokers.

    Furthering this theory is the strongly implied factor contained in this study's "Limitations" section that the respondents have been plucked from prior tobacco research, thereby affording them even more knowledge about the opinions of the researchers. Those who volunteer for smoking-related studies -- perhaps even receiving incentive payments? -- cannot be dismissed as the type who will lean toward providing expected answers in order to please, are indicative of the type who already agree with the perceived direction of the study, or, as already stated, fear telling the truth to those they know hold a general disapproving attitude toward the subject at hand.

    Right now the sample representativeness is skewed because of this. By how much remains the question. But one should not discount wondering what the responses would be and how different...

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    NOT PEER REVIEWED This paper is part of the ongoing discussion about saving lives from tobacco use. As a practicing oncologist and part-time Hospice physician, I have seen real benefit from "vaping". First, many Hospice patients, who have smoked for decades and are actively dying put themselves at real risk if they smoke real cigarettes while dying. Taking away cigarettes during the terminal illness just causes antagonism and much distress for the patient, their family, and the Hospice staff. Vaping at the end of life does prevent burns, suffering, and psychological distress.
    For my oncology patients, I recommend vaping as an alternative to cigarettes for the many cigarette smokers who cannot "quit", despite real effort attempts with nicotine patches, gum, Wellbutrin, or Chantix. I do see lives improving, pulmonary function improving, and less stress in the exam setting, trying to convince the patient to quit yet another time.
    We do need more research about cigarette alternatives for the existing nicotine addicts. There is, most definitely a role for these products, but also a need for researching the safety, efficacy, and best application of these products as an alternative for active adult smokers with health issues.

  • Response to Peters

    NOT PEER REVIEWED The 2014 Surgeon Generals Report (p. 875) stated ““The burden of death and disease from tobacco use in the U.S. is overwhelmingly caused by cigarettes and more must be done to end the deaths from combustible tobacco.” The aim of our study was to show the potential of policies to encourage cigarette smokers to switch to e-cigarettes as a way to reach or at least get closer to that goal. Indeed, FDA Commissioner Gottlieb and Director, Center for Tobacco Products Zeller in a July commentary in NEJM set out a two-pronged approach to the endgame of 1) policies making cigarettes less desirable and 2) policies making e-cigarettes a better substitute for cigarettes. We feel that Dr. Peters misses the point of the article, that the article is an exploratory exercise, and compounds his misunderstanding with unsubstantiated claims.
    First, while Dr. Peters criticizes the 5% excess total mortality risk estimate for e-cigarettes relative to cigarettes and the pessimistic estimate, he does not make a coherent argument as to why we might expect worse outcomes, even though he is a respiratory physician and might be expected to point out specific scientific evidence vaping might approach smoking in harmfulness for respiratory illness at least. Indeed, we have seen no coherent argument for an alternative to the 5% estimate. We note that the UK Royal College of Physicians argued that it was likely to be less, while accepting the 5% as a likely upper bound (not the mos...

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  • Keeping Your Eye on the Ball

    NOT PEER REVIEWED In his critique, Stan Glantz, PhD interprets and presents our study as doing something we explicitly warned readers it was not intended to do. He argues that “the model is based on a series of assumptions that are inconsistent with empirical evidence.” However, we explicitly state and he reiterates, that the model is not meant to be predictive. In our previous work (Addiction 2017: NTR 2017), we presented a framework to help better understand the effects of e-cigarettes and argued that we need better information before we rush to judgement about the actual impact of e-cigarette use.

    Our goal in writing this paper was simply to show that e-cigarettes could help us reach a real smoking and tobacco control endgame. In the US, we have made great progress applying traditional policies, such as tax increases, smoke-free air laws and media campaigns. However, SimSmoke models for the US and other countries indicate that traditional tobacco control policies can only get us partially to the endgame. We think that we can achieve more. Many countries have complied fully or near fully with the FCTC and still have unacceptably high rates of smoking prevalence. The point of our paper is to show that strategies shifting smokers to e-cigarettes can play a role in achieving the endgame.

    While Glantz recognizes that we provide a “pessimistic” as well as an “optimistic” scenario, he dwells on the optimistic scenario. Many in the public health community see...

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  • This model has major flaws

    NOT PEER REVIEWED The data, interpretations and implications of the data modelling exercise conducted by Levy et al(1) should not go unchallenged. Regardless of the number and confidence of the opinions voiced, and the observation of lower levels of selected toxicants in e-cigarette users that are alluded to, there is great uncertainty about the extent to which harm might be reduced by the exclusive use of electronic cigarette rather than combustible tobacco. On this background, to describe one of two models, a 95% harm reduction as optimistic and the second, still a substantial, hopeful estimate of 60% reduction as pessimistic betrays a bias at the outset. The use of this “pessimistic” descriptor would to a casual reader imply that the truth lay, inevitably, somewhere between the two estimates.

    Then there is the detail of the model. Firstly, the use of Holford projections(2) overestimated 2015 smoking rates in the US by at least 10% compared to CDC data(3) - underestimating the recent rate of decline in smoking prevalence in men and women between 2005 and 2015 by one-third. A higher base rate and slower rate of decline exaggerate tobacco-related harms in the status quo – naturally favouring each of the modelled scenarios. Starting with lower, more accurate estimates of current smoking and rates of decline would also increase the counterbalancing harms from initiation in non-smokers.

    There are other obvious problems. In the status quo, 20% of boys and 14...

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  • Assuming ecigs will cut smoking does not prove that ecigs will save lives; new paper an exercise in tautology

    The paper, “Potential deaths averted in USA by replacing cigarettes with e-cigarettes” by David Levy et al. published in Tobacco Control on October 2, 2017, attracted a moderate amount of attention with its conclusion that “Compared with the Status Quo, replacement of cigarette by e-cigarette use over a 10-year period yields 6.6 million fewer premature deaths with 86.7 million fewer life years lost in the Optimistic Scenario. … Our projections show that a strategy of replacing cigarette smoking with vaping would yield substantial life year gains, …”

    This is a pretty impressive result until you consider that the Optimistic Scenario is based on a series of assumptions that are of which are inconsistent with empirical evidence to date:

    Cigarette smoking prevalence drops from 17% to 5% in 10 years (from 19.3% to 4.6% in men and from $14.1% to 4.6% in women between 2016 and 2026).
    The existence of e-cigarettes does not, on average, depress quitting cigarettes.
    There is no relapse from e-cigarette use to cigarette smoking.
    No youth who initiate with e-cigarettes progress to cigarette use.
    No dual use of cigarettes and e-cigarettes.
    The evidence free claim that e-cigarettes are 5% as dangerous as cigarettes.

    (These assumptions were not clearly stated in the main paper; we figured them out based on the appendix and by examining the Excel spreadsheet of the model that the authors s...

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  • Smoking is not a game; it needs to be abolished

    NOT PEER REVIEWED It is disappointing that Robert Proctor’s advocacy for tobacco abolition, so clearly expressed in his magisterial ‘Golden Holocaust’ (2011) and, indeed, in Tobacco Control (1), appears to have been diluted to the same degree that he now seems in favour of diluting the concentration of nicotine in cigarettes. And this in spite of the various potential difficulties he points out in implementing the proposal to reduce nicotine in cigarettes to sub-addictive levels, not least that it could well result in decades-long delays before such cigarettes might eventually replace conventional ones.

    I also have argued that the only realistic way to deal with the tobacco problem is through abolition (2). This is easier than it might seem, because, as Robert Proctor himself has said (1):

    ‘[S]moking is not a recreational drug; most smokers do not like the fact they smoke and wish they could quit.’

    Is it not time for tobacco abolition, rather than ‘control’, to become part of the debate?


    1. Proctor RN. Why ban the sale of cigarettes? The case for abolition. Tobacco Control 2013;22:i27-i30.

    2. http://nicotinemonkey.com/?p=1702

  • More to e-cigarettes than meets the eye?

    NOT PEER REVIEWED The United Kingdom government is now recommending e-cigarettes as important tools in helping individuals to quit smoking (http://www.bbc.co.uk/news/health-41339790). It is widely acknowledged that, for many, smoking tobacco is detrimental to health. However, it is perhaps less widely appreciated that we have only a limited understanding of why smoking tobacco is bad for our health. Why, for example, might you be 40 times more likely of succumbing to lung cancer if you are a persistent heavy smoker? What is it in tobacco or in the act of smoking which is damaging to health? These are the enigmas of smoking tobacco which have remained largely unanswered. We are interested in the myriad ways that humans are exposed to aluminium in everyday life (http://pubs.rsc.org/en/content/articlepdf/2013/em/c3em00374d). Intriguingly one such way is smoking tobacco and the main reason for this is the presence of significant amounts of aluminium in tobacco (http://www.amjmed.com/article/S0002-9343(05)00710-2/pdf).When tobacco is smoked its components form an aerosol which is taken down into the lung before it is eventually expired. Anyone who has set up a ‘smoking machine’ to investigate this will no doubt have been impressed by the efficiency with which a surrogate lung fluid transforms th...

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  • E-cigarettes & sociodemographic considerations

    NOT PEER REVIEWED The authors point out that rates of adolescent ever use of e-cigarettes are substantial and increasing, but rates of regular use remain low. Yet it is also worth placing these rates of adolescent use in the context of other groups of e-cigarette users. In particular, a recent systematic review colleagues and I published into sociodemographic differences in e-cigarette use gives further salience to Conner et al’s findings. Although the availability of UK evidence for our review was limited, some very clear patterns emerged internationally. For instance, within the 38 studies reporting ever use and the 22 reporting current use, these outcomes were particularly prevalent in older adolescents and younger adults (versus younger children and older adults respectively). This therefore lends further weight to Conner et al’s recommendations around regulating the marketing and sale of e-cigarettes to minors in countries which lack sufficient legislation in this area. Both papers also show the importance of future studies stratifying findings by sociodemographic variables such as age to ensure more subgroup analyses are possible.

    1) Hartwell G, Thomas S, Egan M, et al E-cigarettes and equity: a systematic review of differences in awareness and use between sociodemographic groups Tobacco Control Published Online First: 21 December 2016. doi: 10.1136/tobaccocontrol-2016-053222

  • Misinterpretation of prevalence estimates from Japan

    NOT PEER REVIEWED In the second column of this article, the author describes findings from a survey in Japan (Tabuchi et al, 2016, reference 15). However, there is a misinterpretation of Tabuchi et al’s table 2 which leads to wrong percentages for having tried heat not burn products in Caputi’s article. The figures 8.4% and 7.8% are not the percentages who had ever tried these products in the population but instead percentages out of those respondents who had ever tried an e-cigarette or a heat not burn product.

    The actual figures for the population are therefore about 0.6% for iQOS (8.4% of 6.6%) and 0.5% for Ploom (7.8% of 6.6%).

    Further information on the ever use of different products by age, gender and smoking status (about 1% of 15-19 year olds had tried each of the two heat not burn products), is found in supplementary table 3 of Tabuchi et al.

  • Study on flavours in NYC tobacco products is misleading on preemption

    Without citing any sources or providing any related analysis or explanation, this paper makes several sloppy and misleading statements about the scope and impact of federal preemption relating to state and local restrictions of flavored tobacco products.

    We know from the preemption provisions in the federal Tobacco Control Act that state and local governments may not regulate the ingredients or characteristics of a tobacco product if the state or local regulation is “different from, or in addition to” an FDA tobacco product standard. [Sec. 916(a)(2)] But we do not yet know how FDA or the courts will interpret or apply that “different from, or in addition to” phrase. For example, it could mean that state and local governments are free to prohibit or limit the use of certain flavorings in certain types of tobacco products unless or until FDA prohibits or limits flavorings for those same types of tobacco products. To assert and publish a more restrictive interpretation of federal preemption with no qualification or clarification is not only misleading but promotes a more restrictive interpretation than necessary or desirable.

    The paper also fails to note that the courts have ruled that the Tobacco Control Act’s preemption provisions leave state and local governments free to restrict the sale of flavored tobacco products within their boundaries. [See, e.g., U.S. Smokeless Tobacco v. City of New York, 708 F.3d 428 (2nd Cir., 2013).] The...

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  • E-cigarettes: The Indian Perspective

    E-cigarette is a delusive name for what the product actually is; an electronic vaporization device. Basic parts of an e-cigarette include: a tank containing the liquid to be vaporized, some sort of heating element, a battery to power the device, and a mouth piece. The liquid, often referred to as e-liquid, usually contains a base (for production of thick vapor) and flavor. E-liquid may or may not contain nicotine. The heating element converts the e-liquid into aerosol, which is then inhaled by the user. While many models resemble a conventional cigarette, others look nothing alike. Colloquially referred to vaporizers, such models have become more common in the recent years.
    In the western world e cigarettes proposed as a tobacco control strategy for possible nicotine reduction and stressed on policy appraisals of harm and safety on regulation of other ingredients of the products. The related conflicts and controversies of e cigarettes as a contemporary tobacco control are discussed (1).
    E-cigarettes began to appear in the Indian market around 2010. Today, E-cigarettes pose a complex challenge for the tobacco stricken country. According to Global Adult Tobacco Survey (GATS) 2010, 34.6% of the Indian adults were current tobacco users with 14% of adults indulging in current tobacco smoking (5.7% current cigarette smokers, 9.2% current bidi smokers) (2). Global Youth Tobacco Survey (GYTS) 2009 estimated current toba...

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  • Blogging is a good practice for accessibility

    The editors of this journal, Tobacco Control, and specifically the authors of the editorial “Blog fog? Using rapid response to advance science and promote debate” [1] highlight the need - or requirement, depending on the viewpoint - of utilising a specified platform to debate the finer points of an article.

    From an academic standpoint, individuals that have an interest in a specific field of study - such as Tobacco Control - will see, and respond to, such articles in the appropriate manner. However, one of the pitfalls prevalent in any rapid response platform, and this isn’t limited to the journal Tobacco Control, is the necessity of the journal’s guidelines to adhere to a specific writing format. This does have some advantages in keeping the debate over an article related exclusively to the article. However, there are some respondents that prefer to write an unabridged version of a critique lest the comment not pass the rapid response system for publication.

    There are several advantages to publishing a critique of an article outside the rapid response system [2] that allows for a broader audience to read and respond to both the article content and the critique.

    Personal blogs often reflect the style of the author, and also allow for greater freedom of expression including the use of imagery to illustrate vital points that many readers find both enjoyable and informative.

    Providing a platform within the journal must allo...

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  • Good case for subsidies

    NOT PEER REVIEWED This seems a good case for encouraging rechargeable cigalikes and 3rd generation refillable systems in the locations that charge a low cigarette tax.

    Time for subsidies?

  • Chairperson New Nicotine Alliance Sweden/Press Officer INNCO.org

    This is a test message to ascertain if BMJ and Tobacco Control have gotten the rapid response feature up and running. If so this message should appear and those scientists globally wanting to file responses will be immediately alerted that this is now possible. The essence of any critique I personally may have with the BlogFog article is summarized in my declarations of intellectual COI. Submitted March 2nd, 2017.

  • Disappointing retreat from the public square

    The editors of this journal, Tobacco Control, argue in their blog that debate about published articles should be concentrated on their rapid reaction facility. It is possible that they are making a constructive invitation to their critics to join a debating platform they might otherwise be wary of. However, the blog has been widely read as disparagement of other forms of engagement, notably social media and blogs. It is possible that the editors do not fully appreciate why people use blogs and social media to respond to papers they find problematic, and not Tobacco Control's rapid response feature. Here are several reasons:

    1. Trust

    Critics may consider, rightly or wrongly, that Tobacco Control has a track record of publishing papers that have dubious scientific merit, overconfident conclusions and policy recommendations that cannot be supported by the paper - almost always reinforcing a particular (abstinence-only) perspective. Critics may be concerned that their work will be treated unfairly or sidelined, or that they will be judged or ridiculed. They may distrust the editors, believe the journal is not impartial, or hold it in low esteem.

    2. Conflict of interest and incentives

    Not everyone is content to have their reactions edited or approved by the same people whose work they are criticising. Once a journal has published an article that is open to criticism, it develops a conflict of interest between its own r...

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  • Request for a few important clarifications

    NOT PEER REVIEWED The authors of this editorial assert that a journal article’s authors are “entitled to be aware of and respond to critiques”, and imply that this is only possible if critiques appear in a forum attached to the journal. Setting aside the fact that authors can easily become aware of and respond to critiques on other forums, I am curious if the authors could offer some basis for claiming such an entitlement? It seems quite contrary to all existing laws, principles of ethics, cultural norms, and standard practices that relate to commentary about published work. Moreover the behavior of many of these very authors suggests they are willing to go to great lengths to avoid being made aware of critiques.

    It seems safe interpret the statement as saying that at least these particular authors would like responses to their work to appear on this page. And so, I am fulfilling their request. (Assuming this is allowed to appear, that is. I say that not because I believe there is anything in this comment that would warrant censorship, but to emphasize the blindness of this process. That is, the commentator really has no idea what will be allowed to appear.) I call the authors’ attention to two blog posts I have written critiquing this editorial to ensure they have the requested opportunity to be aware: https://antithrlies.com/2017/02/20/editors-of-t...

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  • The value of this largly depends on the willingness to publish comments

    While I would agree that comments that are directly applied to the article in question are better than blogs scattered across the internet, this policy is entirely dependent on the willingness of editors to publish critical comments that may not be formatted or composed in a style that they are entirely comfortable with. Will editors provide feedback to, for example, citizen activists on why their comments were not published, and how they could change them to make them more acceptable? This seems unlikely, and will only reinforce the perceived inequality of position.

    I would also be moved to wonder how editors will deal with rapid responses that link to lengthier works elsewhere? For example, the format of the rapid response does not lend itself well to appending images, which can often be useful to highlight problems.much more effectively than text.

    A more likely outcome of this policy is, I fear, an increasing separation into two echo chambers with no overlap, and with far too little exchange of thoughts between the proponents and opponents of vaping, to the detriment of the vast majority who are neither,

  • Prevalence of e-cigarette prevalence among Korean adolescent is decreasing
    Hong-Jun Cho

    NOT PEER REVIEWED This ad watch shows an interesting example of illegal marketing activity of an e-cigarette company in Korea. However, the description of the trend of e-cigarette prevalence among Korean adolescents is not correct. According to the national annual surveys that the author quoted (reference 4), prevalence of current (30-day) e-cigarette use among Korean adolescents was 4.7% in 2011 and 5.0% in 2014. It decre...

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  • Cigarette Butt Waste and Resolution
    Dave Conlin

    NOT PEER REVIEWED Back when I used to own property with several hundred feet highway frontage, I was distressed to find and pick up an average of 50 or more butts along my property every time I walked the perimeter.

    I thought about the bottle deposit idea as a solution, but many simply won't care and the unrefunded deposits end up as an added profit for the manufacturer.

    Why not mandate a special plas...

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