I am writing in response to the article "Smoke-free law compliance and predictive factors in Ethiopia: observational assessment of public places and workplaces" published in Tobacco Control. As a psychiatrist from Taiwan, I would like to commend the authors for shedding light on the low compliance rates of smoke-free laws in public places and workplaces in Ethiopia.
The study's findings highlight the urgent need to strengthen smoke-free laws and promote compliance to reduce tobacco use and its related health consequences. As a country that has implemented comprehensive smoke-free laws for over a decade, Taiwan has faced similar challenges in enforcing the ban in indoor environments. However, our government has taken various measures to address non-compliance, including increasing penalties and expanding the scope of smoke-free areas.
In addition to government efforts, collaboration between businesses, civil society organizations, and public health advocates is crucial in promoting compliance and a smoke-free culture. The Ethiopian government and civil society can learn from our experiences in Taiwan and other countries that have successfully implemented smoke-free laws.
The study's findings provide a valuable framework for policymakers and public health advocates to address the challenges of enforcement and promote a smoke-free culture. I urge the Ethiopian government and civil society to work together to im...
I am writing in response to the article "Smoke-free law compliance and predictive factors in Ethiopia: observational assessment of public places and workplaces" published in Tobacco Control. As a psychiatrist from Taiwan, I would like to commend the authors for shedding light on the low compliance rates of smoke-free laws in public places and workplaces in Ethiopia.
The study's findings highlight the urgent need to strengthen smoke-free laws and promote compliance to reduce tobacco use and its related health consequences. As a country that has implemented comprehensive smoke-free laws for over a decade, Taiwan has faced similar challenges in enforcing the ban in indoor environments. However, our government has taken various measures to address non-compliance, including increasing penalties and expanding the scope of smoke-free areas.
In addition to government efforts, collaboration between businesses, civil society organizations, and public health advocates is crucial in promoting compliance and a smoke-free culture. The Ethiopian government and civil society can learn from our experiences in Taiwan and other countries that have successfully implemented smoke-free laws.
The study's findings provide a valuable framework for policymakers and public health advocates to address the challenges of enforcement and promote a smoke-free culture. I urge the Ethiopian government and civil society to work together to implement and enforce smoke-free laws to protect the health of their citizens.
In conclusion, the study's findings are crucial in highlighting the need for improved compliance rates of smoke-free laws in Ethiopia and other countries. Strengthening smoke-free laws and promoting compliance is vital in reducing the burden of tobacco use on public health.
Sincerely,
Lien-Chung Wei, M.P.H.
Department of Addiction Psychiatry,
Republic of China Ministry of Health and Welfare,
Taiwan.
NOT PEER REVIEWED
The study by Gallus et al. [1] sought to establish whether electronic cigarettes (ECs) and heated
tobacco products (HTPs) reduce or increase the probability of smoking in a cohort of Italian
participants and concluded that both EC and HTP use predict smoking initiation and relapse
among respondents. We would like to raise some concerns about the interpretation of the study
findings. The study suffers from a potentially crucial bias of the outcome being present at baseline, as
compared non-users with people who were already using products at baseline. Specifically,
smokers who were using ECs or HTPs at baseline may already represent failed attempts to quit at
baseline. Additionally, ex-smokers using these products may have already been in a trajectory to
relapse to smoking at, or even long before, baseline, and may in fact have initiated such product
use in order to avoid relapse. Still, this group may represent ex-smokers who were at higher risk
for relapsing at baseline compared to ex-smokers who did not use these products. Similarly,
never smokers who use novel nicotine products may represent individuals prone to the
engagement of an inhalational habit. Therefore, they would be more likely to initiate smoking.
The situation is very similar to assessing if people who drink beer at baseline are more likely to
drink whiskey at follow up compared to non-drinkers of bee...
NOT PEER REVIEWED
The study by Gallus et al. [1] sought to establish whether electronic cigarettes (ECs) and heated
tobacco products (HTPs) reduce or increase the probability of smoking in a cohort of Italian
participants and concluded that both EC and HTP use predict smoking initiation and relapse
among respondents. We would like to raise some concerns about the interpretation of the study
findings. The study suffers from a potentially crucial bias of the outcome being present at baseline, as
compared non-users with people who were already using products at baseline. Specifically,
smokers who were using ECs or HTPs at baseline may already represent failed attempts to quit at
baseline. Additionally, ex-smokers using these products may have already been in a trajectory to
relapse to smoking at, or even long before, baseline, and may in fact have initiated such product
use in order to avoid relapse. Still, this group may represent ex-smokers who were at higher risk
for relapsing at baseline compared to ex-smokers who did not use these products. Similarly,
never smokers who use novel nicotine products may represent individuals prone to the
engagement of an inhalational habit. Therefore, they would be more likely to initiate smoking.
The situation is very similar to assessing if people who drink beer at baseline are more likely to
drink whiskey at follow up compared to non-drinkers of beer. People who want to use alcohol
and are using alcohol at baseline, would be much more likely to use stronger liquor at follow up
compared to those who do not use alcohol. This represents a typical case of the common liability
model of addressing risk behaviors, which has been frequently misinterpreted as a “gateway”
theory. Moreover, the study design does not allow for any assessment of the motivations to use these
products. It is unclear if and how many participants were using nicotine products in an attempt to
quit (for smokers) or an attempt to prevent relapse (for ex-smokers) instead of simply
experimenting out of curiosity. Notably, while the study examined daily use through the
questionnaire, results were presented only for current users, a classification that includes both
occasional and daily users. Studies have shown that classifying daily and occasional users in the
same group can often be misleading (2-5), since frequency of use is an indirect indicator of
motivation for use (6), but also a determinant of their success as smoking substitutes (7). The study also suffers from the unpredictability of conducting surveys during COVID-19
lockdowns. Of note, there is convincing evidence that the coronavirus outbreak has had a
negative impact, inducing or exacerbating addictive behaviors as coping mechanisms. It is
possible that smokers preferred smoking – rather than alternatives – depending on their level of
distress (8,9).
Last but not least, the latest Cochrane Review finds high certainty evidence that nicotine e-cigarettes
are more effective than traditional nicotine-replacement therapy (NRT) in helping people quit
smoking (10). In conclusion, methodological issues of the study design makes it inappropriate to address the
research question.
1. Gallus S, Stival C, McKee M, Carreras G, Gorini G, Odone A, van den Brandt PA,
Pacifici R, Lugo A. Impact of electronic cigarette and heated tobacco product on
conventional smoking: an Italian prospective cohort study conducted during the COVID19 pandemic. Tob Control. 2022 Oct 7:tobaccocontrol-2022-057368. doi: 10.1136/tc2022-057368.
2. Hitchman SC, Brose LS, Brown J, Robson D, McNeill A. Associations Between ECigarette Type, Frequency of Use, and Quitting Smoking: Findings From a Longitudinal
Online Panel Survey in Great Britain. Nicotine Tob Res 2015;17:1187-94.
3. Farsalinos, K. E.; Poulas, K.; Voudris, V.; & Le Houezec, J. Prevalence and correlates of
current daily use of electronic cigarettes in the European Union: analysis of the 2014
Eurobarometer survey. 2017, Internal and emergency medicine, 12(6), 757–763. https://doi.org/10.1007/s11739-017-1643-7
4. Farsalinos, K. E.; & Barbouni, A. Association between electronic cigarette use and
smoking cessation in the European Union in 2017: analysis of a representative sample of
13 057 Europeans from 28 countries. 2021, Tobacco control, 30(1), 71–76. https://doi.org/10.1136/tobaccocontrol-2019-055190
5. Farsalinos, K. E.; Polosa, R.; Cibella, F.; & Niaura, R. Is e-cigarette use associated with
coronary heart disease and myocardial infarction? Insights from the 2016 and 2017
National Health Interview Surveys. 2019, Therapeutic advances in chronic disease, 10,
2040622319877741. https://doi.org/10.1177/2040622319877741.
6. Amato MS, Boyle RG, Levy D. How to define e-cigarette prevalence? Finding clues in
the use frequency distribution. Tob Control. 2016 Apr;25(e1):e24-9. doi:
10.1136/tobaccocontrol-2015-052236
7. Harlow AF, Stokes AC, Brooks DR, Benjamin EJ, Leventhal AM, McConnell RS,
Barrington-Trimis JL, Ross CS. Prospective association between e-cigarette use
frequency patterns and cigarette smoking abstinence among adult cigarette smokers in the
United States. Addiction. 2022 Dec;117(12):3129-3139. doi: 10.1111/add.16009.
8. Avena NM; Simkus J; Lewandowski A; Gold MS; Potenza MN. Substance Use
Disorders and Behavioral Addictions During the COVID-19 Pandemic and COVID-19-
Related Restrictions. Front Psychiatry. 2021;12:653674.
HTTPS://doi.org/10.3389/fpsyt.2021.653674
9. Caponnetto, P.; Inguscio, L.; Saitta, C.; Maglia, M.; Benfatto, F.; & Polosa, R. Smoking
behavior and psychological dynamics during COVID-19 social distancing and stay-athome policies: A survey. 2020, Health Psychology Research, 8(1). https://doi.org/10.4081/hpr.2020.9124
10. Hartmann-Boyce J; Lindson N; Butler AR; McRobbie H; Bullen C; Begh R; Theodoulou
A; Notley C; Rigotti NA; Turner T; Fanshawe TR; Hajek P. Electronic cigarettes for
smoking cessation. 2022, Cochrane Database of Systematic Reviews 2022, Issue 11. Art.
No.: CD010216. DOI: 10.1002/14651858.CD010216.pub7. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010216.pub7/...
s
NOT PEER REVIEWED
We welcome discussion of our research even when it comes from those whose view on accepting tobacco industry funding is very different from ours. Tomaselli and Caponnetto, from the Center of Excellence for the acceleration of HArm Reduction (CoEHAR),[1] a group funded by the Foundation for a Smoke-Free World (FSFW), an organisation established by Philip Morris International (PMI) with funding of US$1 billion that promotes electronic cigarettes (e-cigarette) and heated tobacco products (HTP),[2] take issue with our finding [3] that these products increase smoking initiation and relapse and reduce quitting. [4]
First, we are puzzled by their main criticism. Of course we agree that smokers who have failed to quit, ex-smokers prone to relapse, and never smokers prone to engage in addictive behaviours could be overrepresented among the baseline e-cigarette or HTP users in our study.[4] But this does not undermine our main conclusions. Even if we were to assume that either none or all novel product users in our cohort were more prone to addiction, our results would still be incompatible with the argument, which underpins the work of FSFW, that these products can reduce smoking conventional cigarettes when used as consumer products.
Second, we hope that they agree with us that we should consider the totality of evidence on a topic as it is rare for a single study to provide a definitive answer, and especially given the record of the tobacco ind...
NOT PEER REVIEWED
We welcome discussion of our research even when it comes from those whose view on accepting tobacco industry funding is very different from ours. Tomaselli and Caponnetto, from the Center of Excellence for the acceleration of HArm Reduction (CoEHAR),[1] a group funded by the Foundation for a Smoke-Free World (FSFW), an organisation established by Philip Morris International (PMI) with funding of US$1 billion that promotes electronic cigarettes (e-cigarette) and heated tobacco products (HTP),[2] take issue with our finding [3] that these products increase smoking initiation and relapse and reduce quitting. [4]
First, we are puzzled by their main criticism. Of course we agree that smokers who have failed to quit, ex-smokers prone to relapse, and never smokers prone to engage in addictive behaviours could be overrepresented among the baseline e-cigarette or HTP users in our study.[4] But this does not undermine our main conclusions. Even if we were to assume that either none or all novel product users in our cohort were more prone to addiction, our results would still be incompatible with the argument, which underpins the work of FSFW, that these products can reduce smoking conventional cigarettes when used as consumer products.
Second, we hope that they agree with us that we should consider the totality of evidence on a topic as it is rare for a single study to provide a definitive answer, and especially given the record of the tobacco industry in cherry picking those bits that support their case.[5] Their concern about motivation of users was addressed in the US PATH cohort study. This rejected the hypothesis that e-cigarettes as consumer products are effective quit aids even when being used for this purpose, rather than as a recreational product.[6] It compared recent quitters using e-cigarettes during their last quit attempts with those using any pharmaceutical aid, finding that smokers who reported using e-cigarettes in their most recent quit attempt were less likely to successfully quit, and that subjects who switched to e-cigarettes reported higher relapse rates than attempters who did not use e-cigarettes to quit.[6] Similarly, a meta-analysis of 20 observational studies found that, when restricting the analyses to participants who wanted to quit, the odds ratio (OR) of smoking cessation for users of e-cigarettes as compared to non-users was 0.85 (95% confidence interval: 0.68-1.06).[7] Although we did not report it in our paper,[3] we did collect information on quit attempts over the past month among current smokers in our study: all four e-cigarette users and four HTP users who made any quit attempt continued smoking at follow-up.
Tomaselli and Caponnetto also express concern around the fact that we considered current product user, a classification that includes both occasional and daily users. Although we had collected the information on occasional vs. daily use of these products, several models to estimate relative risk (RR) did not converge when these were analysed separately, while combining them generated more stable and robust RR estimates.[3] Table 1 (available online at: http://www.epideuro.eu/wp-content/uploads/2022/12/Table1.pdf) shows OR estimates also considering occasional and daily users separately. The association between HTP regular use and relapse did not reach statistical significance. This is almost certainly because of the small number, eight, of ex-smokers who were regular HTP users. This does not change the key message of our study: the use (both occasional and regular) of e-cigarettes and HTPs predicts smoking initiation and relapse, and appear to reduce smoking cessation rates.
Tomaselli and Caponnetto point to the last Cochrane Review of randomized controlled trials (RCT) comparing e-cigarettes with nicotine replacement therapy (NRT) for smoking cessation.[8] However, this has almost no relevance to our findings. We do not dispute that any form of nicotine delivery can aid cessation when part of a structured and time-limited therapeutic package supported by behavioural interventions. This is entirely different from their use as a consumer product. However, as they mention this review, we feel obliged to raise our concerns on its findings, including: i) the extremely low success rate (e-cigarettes fail in 90% of cases)[8]: ii) no RCT compares e-cigarettes with standard care in clinical settings (i.e., varenicline or bupropion or cytisine), by far more effective in smoking cessation according to other Cochrane Library reviews;[8, 9] iii) e-cigarettes are heterogeneous products so those used in RCTs cannot be considered representative of all products; and iv) more than 80% of those quitting through e-cigarette continue its use after treatment,[8] increasing the risk of relapse, as outlined in our study.[3] More importantly, our study concurs with the totality of the scientific literature that, when used as a consumer product, e-cigarettes are not effective in increasing smoking cessation.[7]
To study the individual trajectories of conventional cigarette smoking in the general population (including non-smokers) outside the clinical setting, interventional studies are clearly not an option. Hence, we are forced to rely on observational studies, with prospective cohort studies best able to reduce risk of bias and increase reliability and generalizability. To our knowledge, our study is the first cohort designed so far involving the general population, at least in Europe. It supports findings from other Italian cross-sectional studies[10] and analyses of trends of the prevalence of conventional cigarette smoking (for the first time substantially increasing after seven decades of continuous decrease) and sales of conventional cigarettes (for the first time no more decreasing after two decades of substantial fall).[11]
Our assessment of the totality of the evidence, including our findings, persuades us that these products represent a threat to tobacco control and we remain unconvinced by the arguments by those associated with CoEHAR whose commentaries challenge the accumulating evidence opposing novel nicotine-containing products undertaken by researchers without conflicts of interests.[12]
References
1. Tobacco Tactics. Centre of Excellence for the Acceleration of Harm Reduction (CoEHAR) (available online at: https://tobaccotactics.org/wiki/coehar/; last access 13 December 2022). 2022.
2. van der Eijk Y, Bero LA, Malone RE. Philip Morris International-funded 'Foundation for a Smoke-Free World': analysing its claims of independence. Tob Control 2019; 28: 712-718.
3. Gallus S, Stival C, McKee M et al. Impact of electronic cigarette and heated tobacco product on conventional smoking: an Italian prospective cohort study conducted during the COVID-19 pandemic. Tob Control 2022.
4. Tomaselli V, Caponnetto P. Inappropriate study design cannot predict smoking initiation and relapse with e-cigarette and heated tobacco product use. Tob Control 2022.
5. Diethelm P, McKee M. Denialism: what is it and how should scientists respond? Eur J Public Health 2009; 19: 2-4.
6. Chen R, Pierce JP, Leas EC et al. Effectiveness of e-cigarettes as aids for smoking cessation: evidence from the PATH Study cohort, 2017-2019. Tob Control 2022.
7. Wang RJ, Bhadriraju S, Glantz SA. E-Cigarette Use and Adult Cigarette Smoking Cessation: A Meta-Analysis. Am J Public Health 2021; 111: 230-246.
8. Hartmann-Boyce J, Lindson N, Butler AR et al. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev 2022; 11: CD010216.
9. Howes S, Hartmann-Boyce J, Livingstone-Banks J et al. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2020; 4: CD000031.
10. Liu X, Lugo A, Davoli E et al. Electronic cigarettes in Italy: a tool for harm reduction or a gateway to smoking tobacco? Tob Control 2020; 29: 148-152.
11. Gallus S, Borroni E, Odone A et al. The Role of Novel (Tobacco) Products on Tobacco Control in Italy. Int J Environ Res Public Health 2021; 18.
12. Polosa R, Farsalinos K. A tale of flawed e-cigarette research undetected by defective peer review process. Intern Emerg Med 2022.
In his rapid response to our paper, Dr Pesko expresses concern with the paper’s conclusions. Our study, conducted at the US population level, demonstrated that the prolonged decline in cigarette smoking among young adults was largely unaffected by the introduction of e-cigarettes. Dr Pesko reminds us that this conclusion is contrary to findings from several quasi-experimental designs, which he feels should have primacy over our population-level analysis of time trends. We acknowledge that there are potential threats to the validity and generalizability of the findings of our study, and indeed of every study. Hence, a conclusion of causality requires that an association be robust and replicable across settings and methods. Given the significant public policy implications of any finding that e-cigarette vaping has a role in reducing cigarette smoking prevalence, we feel that presentation of transparent and easily understood population trends have an important role to play in policy discussions. In particular, to support the argument that high e-cigarette taxes cause increased smoking among youth, it would be important to have an exemplar of one or more jurisdictions that imposed a high e-cigarette tax and subsequently experienced an increase in cigarette smoking.
A substantial portion of Dr Pesko’s critique of our paper is directed towards our commentary on a paper that he co-authored, Abouk et al. (1). This commentary was incorporated at t...
In his rapid response to our paper, Dr Pesko expresses concern with the paper’s conclusions. Our study, conducted at the US population level, demonstrated that the prolonged decline in cigarette smoking among young adults was largely unaffected by the introduction of e-cigarettes. Dr Pesko reminds us that this conclusion is contrary to findings from several quasi-experimental designs, which he feels should have primacy over our population-level analysis of time trends. We acknowledge that there are potential threats to the validity and generalizability of the findings of our study, and indeed of every study. Hence, a conclusion of causality requires that an association be robust and replicable across settings and methods. Given the significant public policy implications of any finding that e-cigarette vaping has a role in reducing cigarette smoking prevalence, we feel that presentation of transparent and easily understood population trends have an important role to play in policy discussions. In particular, to support the argument that high e-cigarette taxes cause increased smoking among youth, it would be important to have an exemplar of one or more jurisdictions that imposed a high e-cigarette tax and subsequently experienced an increase in cigarette smoking.
A substantial portion of Dr Pesko’s critique of our paper is directed towards our commentary on a paper that he co-authored, Abouk et al. (1). This commentary was incorporated at the request of a reviewer. Abouk et al. studied surveillance data for US adolescents and concluded that “there were sizable positive cigarette cross-tax effects, suggesting economic substitution between cigarettes and ENDS for youth,” or in other words, that raising taxes on e-cigarettes would drive youth tobacco consumption away from e-cigarettes and towards traditional cigarettes. Our study considered the same jurisdictions used in Abouk et al., and looked for potential exemplars with substantial populations and with high e-cigarette taxes. We then reported cigarette and e-cigarette prevalence data for these exemplars for the 18-24-year-old population (i.e. for young adults still within the age window for smoking initiation).
Table 1 of Abouk et al. outlines the 13 jurisdictions that taxed e-cigarettes between 2015 and 2019, providing average tax figures for the first two quarters of the years 2015, 2017 and 2019. Unfortunately, none of the high-quality US tobacco-use surveillance systems (including the two used by Abouk et al.) draws representative samples at the county or city levels. Thus, in three of their jurisdictions, it is not possible to present valid estimates of the change in tobacco use; simply raking the larger sample to the population distribution within the county or city does not make it representative of that jurisdiction. An additional five states did not meet the minimum population criterion of our paper (5 million), needed for reasonably tight confidence limits on the state-level population estimates. Therefore, only the following five states of the original 13 jurisdictions could be considered as possible exemplars in our paper: California, Minnesota, North Carolina, New Jersey, and Pennsylvania.
Dr Pesko’s suggestion in his critique that we should have used 2019 rather than 2017 e-cigarette tax data is problematic, because the most recent population survey with state-level estimates of tobacco use (TUS-CPS) collected two-thirds of its data in 2018. A fundamental principal of causal inference asserts that to test whether an exposure influenced an outcome, the exposure must have been in place before the outcome was assessed. (2) Accordingly, we used the 2017 e-cigarette tax data, so that the taxes were assessed prior to the prevalence estimates of 2018.
From Abouk et al. table 1, during the first two quarters of 2017, e-cigarettes taxes (per milliliter) for the five states under consideration were: Minnesota ($2.50), Pennsylvania ($1.05), California ($0.72), North Carolina ($0.05) New Jersey ($0). Pesko argues that we should have focused on the top three states as possible exemplars. However, California introduced a major increase in all tobacco taxes in the latter half of 2017 and, importantly, the tax rate on non-cigarette tobacco products was required to be equivalent to the tax imposed on cigarettes. (3) Thus, the effect of e-cigarette taxes on cigarette smoking in California is confounded by the concurrent increases in cigarette taxes. Accordingly, we concluded that there were only two possible exemplars from the Abouk et al. paper: Minnesota and Pennsylvania.
In the supplement to our paper (eTable 3) we presented data on exclusive e-cigarette vaping for each of the 24 most populous US states, for both 2014/15 and 2018/19. For Minnesota, exclusive e-cigarette vaping remained constant at 2.8% in both years, in contrast to a 2.7-fold increase in its comparable group of states. For Pennsylvania, exclusive vaping declined from 3.3% to 0.9%, in contrast to an over twofold increase in its comparable group of states. This aligns with economic theory, (4) suggesting that in each of these two states higher taxes are associated with lower demand for e-cigarettes. Thus, both of these states can be used as transparent examples of the Abouk et al. hypothesis. However, in our paper, we noted that smoking prevalence among 18-24-year-olds across all of the 24 most populous US states declined by 43% from 12.9% (95% CI: 12.2%,13.7%) in 2014/15 to 7.4% (95% CI: 6.7% to 8.1%) in 2018/19. Pesko rightly points out the wide confidence limits for individual state smoking prevalence estimates in each of these years. However, there was no discernible evidence, not even suggestive evidence, indicating that, in either of these two exemplar states, the rate of decline in cigarette smoking was slower compared to other US states.
In summary, it is important to have robust and replicable results before making conclusions that associations are causal. Before making an argument that states should refrain from increasing e-cigarette taxes because such taxes will slow down the decline in smoking initiation, it is particularly important to have transparent examples demonstrating such a cause and effect. None of the 13 jurisdictions used in the Abouk et al. study provides such a demonstration.
References
1. Abouk R, Courtemanche C, Dave D, Feng B, Friedman AS, Maclean JC, et al. Intended and unintended effects of e-cigarette taxes on youth tobacco use. J Health Econ. 2023 Jan 1;87:102720
2. Bradford Hill A. (1965). The Environment and Disease: Association or Causation?. Proceedings of the Royal Society of Medicine. 58 (5): 295–300. doi:10.1177/003591576505800503.
3. California State Board of Equalization New Tax Rate on Other Tobacco Products Effective July 1 2017 through June 30, 2018. Available at: https://www.cdtfa.ca.gov/formspubs/l502.pdf
4. International Agency for Research on Cancer (IARC). Handbooks of Cancer Prevention, Tobacco Control, Vol. 14. Effectiveness of Tax and Price Policies for Tobacco Control. Lyon, France., 2011
The current article has a number of problems, including factual errors, unsupported statements, failure to conduct relevant statistical testing, and failure to include relevant studies.
The authors state: “Abouk et al studied 14 jurisdictions with at least some tax on e-cigarettes,43 but only two of these were large states with taxes large enough to possibly influence behaviour.44 They concluded that taxing e-cigarettes would push young people to cigarettes; however, in the two states with sizeable e-cigarette taxes, we did not find this to be the case.”
First, the referenced study uses data through mid-2019, at which different jurisdictions have the following standardized tax rates (according to Abouk et al.’s Table 1): District of Columbia ($2.52), Minnesota ($2.49), California ($1.65), Cook County, IL ($1.50), and Pennsylvania ($1.05). The current study treats only Minnesota and Pennsylvania as being large states with large taxes, but the authors’ failure to include these other states that are used in Abouk et al. (2023) makes their comparison incomplete.
Second, the authors state: “During this period, the prevalence of cigarette smoking in Pennsylvania declined by 6.3% pp and, in Minnesota, it declined by 8.6% pp (online supplemental eTable 4). Thus, the cigarette smoking prevalence decline in both states with meaningful e-cigarette taxes was greater than the 5.6% decline for the USA as a whole (2014–15=13.0%, 95% CI 12...
The current article has a number of problems, including factual errors, unsupported statements, failure to conduct relevant statistical testing, and failure to include relevant studies.
The authors state: “Abouk et al studied 14 jurisdictions with at least some tax on e-cigarettes,43 but only two of these were large states with taxes large enough to possibly influence behaviour.44 They concluded that taxing e-cigarettes would push young people to cigarettes; however, in the two states with sizeable e-cigarette taxes, we did not find this to be the case.”
First, the referenced study uses data through mid-2019, at which different jurisdictions have the following standardized tax rates (according to Abouk et al.’s Table 1): District of Columbia ($2.52), Minnesota ($2.49), California ($1.65), Cook County, IL ($1.50), and Pennsylvania ($1.05). The current study treats only Minnesota and Pennsylvania as being large states with large taxes, but the authors’ failure to include these other states that are used in Abouk et al. (2023) makes their comparison incomplete.
Second, the authors state: “During this period, the prevalence of cigarette smoking in Pennsylvania declined by 6.3% pp and, in Minnesota, it declined by 8.6% pp (online supplemental eTable 4). Thus, the cigarette smoking prevalence decline in both states with meaningful e-cigarette taxes was greater than the 5.6% decline for the USA as a whole (2014–15=13.0%, 95% CI 12.2% to 13.7%; 2018–19=7.4%, 95% CI 6.7% to 8.1%).” Examination of the last column of supplemental eTable 4 shows that both Minnesota and Pennsylvania’s smoking rates could have not only decreased less than the national rate, but actually even increased given the confidence intervals. Given these wide confidence intervals for state-specific estimates, the authors cannot argue that, “cigarette smoking prevalence decline in both states with meaningful e-cigarette taxes was greater than the 5.6% decline for the USA as a whole” as this is not supported by statistical testing. In fact, these wide confidence intervals point to the futility of trying to do a state-specific exercise like the authors do, and point to the need to consider all e-cigarette tax states like Abouk at al. (2023) does in order to be powered to say anything meaningful.
Curiously, eTable 4 also shows California’s smoking decline was -1.2 pp over this time period, which by the authors’ own faulty method would provide evidence opposite of their claim that higher e-cigarette taxes are associated with larger-than-average declines in cigarette smoking prevalence. The omission of California as a large state with a large tax is quite suspicious. California’s e-cigarette tax began 2Q 2017, well before the last period in 2019. There is no justification for Pennsylvania being included but not California is not, since California had higher taxes and a larger population.
Third, the authors conjecture that there are taxes of a certain threshold that are “large enough to possibly influence behavior.” As far as I can tell, they believe that a $1 per fluid ml e-cigarette tax is the threshold at which behavior is influenced, though they obviously missed California, District of Columbia, and Cook County, IL. The author’s reference (43) was published in 2011 before e-cigarettes were even widely on the marketplace, and as such this doesn’t seem to offer e-cigarette-specific evidence to support their argument. The idea that there is a threshold at all seems arbitrary and poorly supported by decades of research. The literature is full of examples of small cigarette taxes having impacts; for example, one study found a $0.55 per pack cigarette tax increase would reduce maternal smoking by about 22% (2). It’s reasonable to say that taxes of certain sizes may be needed to be powered to detect effects, but the current statement as written suggests small taxes do not influence behavior (in even small ways), which is incorrect.
Fourth, the current study fails to control for other tobacco policies like cigarette taxes that reduce smoking. For example, Pennsylvania had a sizable cigarette tax in 2016, Minnesota had multiple tax increases since 2013, California had a sizable tax increase in 2017, etc. Of course, other policies are changing as well like indoor air laws. The authors of the current paper essentially compare descriptive evidence of changes in smoking at two points in time, not accounting for cigarette policies that may also be reducing smoking rates. This does nothing to weaken arguments made in Abouk et al. (2023) that conditional on controls, e-cigarette taxes both reduce youth e-cigarette use and raise youth cigarette use. Further, Abouk et al. (2023) use all e-cigarette tax variation and not variation from specific states.
Fifth, the paper does not include several relevant citations. There are many other quasi-experimental studies that reach a similar conclusion to Abouk et al. (2023) that are not referenced. Other e-cigarette tax studies of youth (4) and young adults (5) find supporting evidence to Abouk et al. (2013). A recent editorial summarized the quasi-experimental literature on youth use as follows: “There are seven natural experiment difference-in-difference-style studies of e-cigarette minimum legal purchase age laws and e-cigarette tax rates on youth, six of which find that these policies increase cigarette use.” (6). The literature further crystallizes when we add older populations and sales data to the mix, with another review finding that 14 of 16 quasi-experimental studies of e-cigarette policies find that e-cigarette availability displaces cigarette use (7). Finally, reference 40 might have been an error, as I don’t see that paper discussing e-cigarette taxes at all, despite the paper claiming it does.
The preponderance of evidence from quasi-experimental studies supports e-cigarette availability reducing youth cigarette use. The quasi-experimental studies attempt to solve concerns about common liabilities impacting both e-cigarette use and cigarette use by using policy variation to mimic the randomization of a RCT, which allows causal interpretation from observational data (if we’re willing to believe recent Noble Prize award committee statements; and a recent Tobacco Online Policy Seminar panel of world-renowned methodological experts) (8). The current study does not seem to mimic randomization in any way since e-cigarette use is self-selected and influenced by the same factors as cigarette use, and as such the current study suffers from common liability concerns that the quasi-experimental studies have attempted to address.
It is therefore very difficult for me to understand what the contribution of this paper is, and I recommend against future research using these methods to explore this question when stronger methods are available.
1. Abouk R, Courtemanche C, Dave D, Feng B, Friedman AS, Maclean JC, et al. Intended and unintended effects of e-cigarette taxes on youth tobacco use. J Health Econ. 2023 Jan 1;87:102720. <p>
2. Ringel JS, Evans WN. Cigarette taxes and smoking during pregnancy. Am J Public Health. 2001;91(11):1851–6. <p>
3. Cotti C, Nesson E, Pesko MF, Phillips S, Tefft N. Standardising the measurement of e-cigarette taxes in the USA, 2010–2020. Tob Control. 2021 Dec 15;tobaccocontrol-2021-056865. <p>
4. Pesko, Warman. Re-exploring the early relationship between teenage cigarette and e-cigarette use using price and tax changes. Health Econ. 2021;
5. Friedman AS, Pesko MF. Young adult responses to taxes on cigarettes and electronic nicotine delivery systems. Addiction. 2022 Jul 29;add.16002. <p>
6. Pesko MF, Cummings KM, Douglas C, Foulds J, Miller T, Rigotti NA, et al. United States Public Health Officials Need to Correct E-cigarette Health Misinformation. Addiction. 2022; <p>
7. Pesko MF. Effects of E-Cigarette Minimum Legal Sales Ages on Youth Tobacco Use in the United States. J Risk Uncertain. 2022; <p>
8. Pesko MF. How Data Security Concerns Can Hinder Natural Experiment Research: Background and Potential Solutions. JNCI Monogr. 2022 Jul 5;2022(59):89–94. <p>
Despite 20 years of sustained engagement and reductions in smoking prevalence rates globally, smoke free policy implementation remains inconsistently applied in low- and middle-income countries where there are high smoking prevalence rates and where >80% of the 1.3 billion smokers reside.1-2 Merrit’s study3 is a stark reminder that despite the forward steps of the Framework Convention on Tobacco Control,2,4-5 variations in achieving smoke free policies in specialist settings persist. Acknowledged challenges in implementing smoke free hospital policies include a lack of data, inadequate reporting, and reduced prioritisation of tobacco control at governmental level.1,3 The lack of an intersectional lens and co development with communities continues with policy development. 6
Inconsistencies in application of smoke free policies are balanced by reporting of positive implementations demonstrating improvements in some hospital systems evidenced by reductions in smoking rates and improved access to smoking cessation services underpinned by longitudinal data. 7-9
Previously, Chan 10 indicated that ‘tobacco use … threatens development in every country on every level and across many sectors — economic growth, health, education, poverty and the environment — with women and children bearing the brunt of the consequences’, - this continues today intensifying the impact of the social, structural and commercial determinants of health and n...
Despite 20 years of sustained engagement and reductions in smoking prevalence rates globally, smoke free policy implementation remains inconsistently applied in low- and middle-income countries where there are high smoking prevalence rates and where >80% of the 1.3 billion smokers reside.1-2 Merrit’s study3 is a stark reminder that despite the forward steps of the Framework Convention on Tobacco Control,2,4-5 variations in achieving smoke free policies in specialist settings persist. Acknowledged challenges in implementing smoke free hospital policies include a lack of data, inadequate reporting, and reduced prioritisation of tobacco control at governmental level.1,3 The lack of an intersectional lens and co development with communities continues with policy development. 6
Inconsistencies in application of smoke free policies are balanced by reporting of positive implementations demonstrating improvements in some hospital systems evidenced by reductions in smoking rates and improved access to smoking cessation services underpinned by longitudinal data. 7-9
Previously, Chan 10 indicated that ‘tobacco use … threatens development in every country on every level and across many sectors — economic growth, health, education, poverty and the environment — with women and children bearing the brunt of the consequences’, - this continues today intensifying the impact of the social, structural and commercial determinants of health and need for increased pricing, incentivizing quitting and raising taxes. 11,12 The inequalities in the wider health systems will undoubtedly compound the ability of Vietnam to meet the global sustainable development goals target. 3,13
The new evidence base supports the evidence from a Cochrane system review examining the impact of no-smoking policies at the meso level in three specialist settings - hospitals, prisons and universities/ colleges. 14 An inconsistent evidence base from observational studies, with no validated biochemical measure of cotinine reported reductions in staff smoking rates in prisons and university settings post introducing smoking policies.14 However pooled data (12,485 participants) indicated a 29% reduction in active smoking rates in staff in hospitals only (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.64 to 0.78) and a 14% reduction for patients (RR 0.86, 95% CI 0.76 to 0.98)- extreme heterogeneity in pooled 11 studies. Reduced mortality rates associated with smoking-related illnesses after the introduction of a smoking ban were noted in prison settings, but inconsistent evidence exists supports an effect on reducing smoking rates (1 study, RR 0.99, 95% CI 0.84 to 1.16).
Smoking rates in prisons are 63 times higher than the general population 15 and despite successful policy implementation in some jurisdictions, smoking rates in prisons remain high, especially reported in low and middle-income countries. 16-18 Slow policy development in this specialist setting continues.
Despite the increasing number of countries with enacted legislation banning smoking in fulfilment of Article 8 of FCTC development remains unpredictable. 4,5,19 The difficulties in implementing smoke free policies in hospital settings continue to inform policy makers and practitioners. 3,20 Enforcing smoke free policies in hospital settings are critical to reducing the gap in the nexus of policy and practice to counter systemic inequity. We know that gender and ethnicity are associated with at least twice the all-cause mortality rate of never smoking; 21 therefore, the development of smoke free policies and systems-wide responses in specialist settings remain evermore critical.
References
1. Frazer K. Commentary on Wu et al.: Sustaining and advancing the global war on tobacco. Addiction. 2021 Aug;116(8):2185-6.
2. World Health Organization. The WHO framework convention on tobacco control: 10 years of implementation in the African region. World Health Organization; 2015. https://fctc.who.int/publications/m/item/the-who-framework-convention-on... [Accessed 8th October 2023]
3. Merritt JD, Yen PN, Thu-Anh N, Ngo CQ, Van Giap V, Nhung NV, Ha BT, Thuy MT, Anh NT, An NT, Marks GB. Smoking behaviour, tobacco sales and tobacco advertising at 40 ‘Smoke Free Hospitals’ in Vietnam. Tobacco Control. 2023 Sep 5.
4. World Health Organization (WHO). Factsheet. Tobacco. May 2020. Available at: https://www.who.int/news-room/fact-sheets/detail/tobacco (accessed October 2023).
5. Shibuya K, Ciecierski C, Guindon E, Bettcher DW, Evans DB, Murray CJ. WHO Framework Convention on Tobacco Control: development of an evidence based global public health treaty. Bmj. 2003 Jul 17;327(7407):154-7.Available from: http://www.ncbi.nlm.nih.gov/pubmed/12869461.
6. Marteau T. M., Rutter H., Marmot M. Changing behaviour: an essential component of tackling health inequalities. BMJ 2021; 372: n332. https://doi.org/10.1136/bmj.n332
7. Mattson A, Doherty K, Lyons A, Douglass A, Kerley M, Stynes S, Fitzpatrick P, Kelleher C. Evidence from a Smoking Management Service in a University Teaching Hospital in Dublin, Ireland monitored by repeat surveys, 1997-2022. Preventive Medicine Reports. 2023 Sep 13:102415. https://doi.org/10.1016/j.pmedr.2023.102415
8. Malone V, McLennan J, Hedger D. Smoke-free hospital grounds. Australian Health Review. 2020 Jan 20;44(3):405-9.
9. Fu M, Castellano Y, Feliu A, Saura J, Estrada J, Galimany-Masclans J, Moreno C, Fernández E, Martínez C. Compliance with the smoke-free policy in hospitals in Spain: the patients’ perspective. European Journal of Cancer Prevention. 2023 Jan 1;32(1):81-8.https://doi.org/10.1097/CEJ.0000000000000757
11. Hoffman SJ, Tan C. Overview of systematic reviews on the health-related effects of government tobacco control policies. BMC public health. 2015 Dec;15(1):1-1 https://doi.org/10.1186/s12889-015-2041-6
13. United Nations. The Sustainable Development Goals 2016. eSocialSciences; 2016 Nov.
14. Frazer K, McHugh J, Callinan JE, Kelleher C. Impact of institutional smoking bans on reducing harms and secondhand smoke exposure. Cochrane Database of Systematic Reviews. 2016(5).https://doi.org/10.1002/14651858.CD011856.pub2
15. Plugge E, Leclerc E. Smoking bans in prisons. The Lancet Public Health. 2021 Nov 1;6(11):e781-2.
16. Semple S, Dobson R, Sweeting H, Brown A, Hunt K. The impact of implementation of a national smoke-free prisons policy on indoor air quality: results from the Tobacco in Prisons study. Tobacco control. 2020 Mar 1;29(2):234-6.
17. Tweed EJ, Mackay DF, Boyd KA, Brown A, Byrne T, Conaglen P, Craig P, Demou E, Graham L, Leyland AH, McMeekin N. Evaluation of a national smoke-free prisons policy using medication dispensing: an interrupted time-series analysis. The Lancet Public Health. 2021 Nov 1;6(11):e795-804.
20. Lyons A, Bhardwaj N, Masalkhi M, Fox P, Frazer K, McCann A, Syed S, Niranjan V, Kelleher CC, Kavanagh P, Fitzpatrick P. Specialist cancer hospital-based smoking cessation service provision in Ireland. Irish Journal of Medical Science (1971-). 2023 Sep 23:1-0.
21. Thomson B, Emberson J, Lacey B, Lewington S, Peto R, Jemal A, Islami F. Association between smoking, smoking cessation, and mortality by race, ethnicity, and sex among US adults. JAMA Network Open. 2022 Oct 3;5(10):e2231480- doi: 10.1001/jamanetworkopen.2022.31480. PMID: 36279139; PMCID: PMC9593233.
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He et al cite (ref 43 in their paper) our meta-analysis of the association between e-cigarette use and smoking cessation [1} to support the statement, "[e-cigarettes] have demonstrated potential in recent years in helping smoking cessation." Quite the contrary, the abstract of this paper concludes, "As consumer products, in observational studies, e-cigarettes were not associated with increased smoking cessation in the adult population."
A subsequent meta-analysis [2] concluded the same thing.
Both these meta-analyses include the other paper (ref 44 in their paper) He et al cite to support their statement that e-cigarettes assist smoking cessation [3].
The authors need to accurately represent the literature and stop promoting the myth that e-cigarettes as consumer products increase cigarette smoking cessation. They also need to correct their paper to avoid perpetuating the literature.
REFERENCES
1. Wang RJ, Bhadriraju S, Glantz SA. E-cigarette use and adult cigarette smoking cessation: a meta-analysis. Am J Public Health 2021;111:230–46. doi:10.2105/AJPH.2020.305999
2. Hedman L, Galanti MR, Ryk L, et al. Electronic cigarette use and smoking cessation in cohort studies and randomized trials: a systematic review and meta-analysis.
Tob Prev Cessat 2021;7:62.
3. Zhuang Y-L, Cummins SE, Sun JY, et al . Long-term E-cigarette use and smoking cessation: a longitudinal study w...
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He et al cite (ref 43 in their paper) our meta-analysis of the association between e-cigarette use and smoking cessation [1} to support the statement, "[e-cigarettes] have demonstrated potential in recent years in helping smoking cessation." Quite the contrary, the abstract of this paper concludes, "As consumer products, in observational studies, e-cigarettes were not associated with increased smoking cessation in the adult population."
A subsequent meta-analysis [2] concluded the same thing.
Both these meta-analyses include the other paper (ref 44 in their paper) He et al cite to support their statement that e-cigarettes assist smoking cessation [3].
The authors need to accurately represent the literature and stop promoting the myth that e-cigarettes as consumer products increase cigarette smoking cessation. They also need to correct their paper to avoid perpetuating the literature.
REFERENCES
1. Wang RJ, Bhadriraju S, Glantz SA. E-cigarette use and adult cigarette smoking cessation: a meta-analysis. Am J Public Health 2021;111:230–46. doi:10.2105/AJPH.2020.305999
2. Hedman L, Galanti MR, Ryk L, et al. Electronic cigarette use and smoking cessation in cohort studies and randomized trials: a systematic review and meta-analysis.
Tob Prev Cessat 2021;7:62.
3. Zhuang Y-L, Cummins SE, Sun JY, et al . Long-term E-cigarette use and smoking cessation: a longitudinal study with US population. Tob Control 2016;25:i90–5. doi:10.1136/tobaccocontrol-2016-053096
Regarding the first two questions, the analyses were based on the public use data from both the PATH Study and the MCS, with links to their archives, and the PATH study sample was drawn from the original cohort, the replenishment cohort, and the shadow cohorts (see 1st and 2nd paragraphs of Methods Section). Regarding the remaining questions, please note that our stated goal was to make the MCS and PATH analytical samples as comparable as possible when testing our hypotheses using both cohorts (3rd paragraph of Methods section). As we note in the limitations section (5th paragraph of Discussion section), the MCS had relatively limited items on e-cigarette use and tobacco smoking compared to PATH. The MCS did not assess other combustible tobacco product consumption in early adolescence, nor did MCS measure the sequencing of early adolescent tobacco and e-cigarette use (noted in the limitation section). Also, MCS youth answered survey questions about ever using e-cigarettes from 2015 to 2016 (3rd paragraph of Methods section), which gave us limited variability to test for a wave x e-cigarette interaction in both datasets.
I respectfully request answers to the following questions:
1. Was public use or restricted PATH data used. This is important, since Table 2 contains a cell, n=7, that is not generally approved by NAHDAP.
2. Was the PATH cohort drawn from Waves 1 and 4, with follow-ups to age 17 years as needed from the other waves?
3. There were significant differences in youth smoking-vaping between Wave 1 (2013-14) and Wave 4 (2016-18) that might have affected the results. Was each wave analyzed separately as well as together?
4. The analysis included a variable relating to “parent(s) smoking of cigarettes, cigars, or pipes.” Did the analysis include other combustible tobacco product consumption by the subjects themselves?
5. Did the authors account for age at first smoking or vaping (public use, < 12 years and 12-14 years) or which product(s) had been used first?
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Pichon-Riviere et al concluded that the four tobacco control interventions analyzed could successfully avert deaths and disability and significantly ease the tobacco-attributable economic burden, but are not enough, as smoking remains a leading cause of health and economic burden in Latin America (1). According to the Global Burden of Disease Project (2), regardless of the relative decrease in tobacco prevalence in the last decades, age-standardized rates of deaths and DALYs for smoking-attributable diseases remain high in Latin America, a region hard hit by the epidemic (3). Unfortunately, in most of the countries in Latin America, there are other problems related to the main strategy to reduce tobacco consumption (i.e., taxation falls short of WHO recommendations) for example cigarettes remain affordable mainly due to the commercialization of illegal tobacco products and smuggled cigarettes, an important distractor for public health authorities, as the real number of users is hidden, access for younger people is easier and health risks are surely higher (4).
In addition, as in not all countries among our region there are available pharmacological alternatives to help current smokers, cessation strategies may be adapted for novel products, and treatment recommendations for tobacco use disorder should be made within the context of a harm reduction framework wherein alternative product use may be the desired outcome (5). Also, nicotine e‐cigare...
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Pichon-Riviere et al concluded that the four tobacco control interventions analyzed could successfully avert deaths and disability and significantly ease the tobacco-attributable economic burden, but are not enough, as smoking remains a leading cause of health and economic burden in Latin America (1). According to the Global Burden of Disease Project (2), regardless of the relative decrease in tobacco prevalence in the last decades, age-standardized rates of deaths and DALYs for smoking-attributable diseases remain high in Latin America, a region hard hit by the epidemic (3). Unfortunately, in most of the countries in Latin America, there are other problems related to the main strategy to reduce tobacco consumption (i.e., taxation falls short of WHO recommendations) for example cigarettes remain affordable mainly due to the commercialization of illegal tobacco products and smuggled cigarettes, an important distractor for public health authorities, as the real number of users is hidden, access for younger people is easier and health risks are surely higher (4).
In addition, as in not all countries among our region there are available pharmacological alternatives to help current smokers, cessation strategies may be adapted for novel products, and treatment recommendations for tobacco use disorder should be made within the context of a harm reduction framework wherein alternative product use may be the desired outcome (5). Also, nicotine e‐cigarettes probably do help people to stop smoking for at least six months. They probably work better than nicotine replacement therapy and nicotine‐free e‐cigarettes. They may work better than no support, or behavioral support alone, and they may not be associated with serious unwanted effects (6).
As member of the Latin-American Network for Tobacco Harm Reduction (www.reldat.org) we are actively working on reach the decision-makers to let them better understand the “harm reduction” concept for tobacco consumption, as it applies for other medical conditions.
1. Pichon-Riviere A, Bardach A, Rodríguez Cairoli F, et al. Tob Control Epub ahead of print: Health, economic and social burden of tobacco in Latin America and the expected gains of fully implementing taxes, plain packaging, advertising bans and smoke-free environments control measures: a modelling study. doi:10.1136/tc-2022-057618
2. He H, Pan Z, Wu J, et al. Health effects of tobacco at the global, regional, and national levels: results from the 2019 global burden of disease study. Nicotine & Tobacco Research 2022;24:864–70.
3. GBD. Tobacco collaborators. spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990-2019: a systematic analysis from the global burden of disease study 2019. Lancet 2021;397:2337–60.
4. Ortiz-Prado E, Teran E, Cevallos-Sierra G, Villacres T, Alcivar C, Vasconez E. Anti-tobacco policy and the smuggled cigarettes, a hidden problem in Ecuador. J Public Health Emerg 2022;6:10.
5. Palmer AM, Toll BA, Carpenter MJ, et al. Reappraising Choice in Addiction: Novel Conceptualizations and Treatments for Tobacco Use Disorder. Nicotine Tob Res 2022;24(1):3-9
6. Hartmann-Boyce J, McRobbie H, Butler AR, Lindson N, Bullen C, Begh R, Theodoulou A, Notley C, Rigotti NA, Turner T, Fanshawe TR, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews 2021, Issue 9. Art. No.: CD010216. DOI: 10.1002/14651858.CD010216.pub6. Accessed 10 May 2022.
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I read with interest the article "Global tobacco advertising, promotion, and sponsorship regulation: what’s old, what’s new, and where to next?[1]" published in Tobacco Control. As a psychiatrist specializing in addiction treatment at Taoyuan Psychiatric Center in Taiwan, I wish to share our institution's experience in implementing a successful smoke-free hospital program, which may serve as a model for other psychiatric centers.
Since 2014, Taoyuan Psychiatric Center has made significant progress in promoting a smoke-free environment through a comprehensive tobacco control program. Our program's objectives include creating a smoke-free hospital, increasing smoking cessation services for outpatients and inpatients, and improving patient smoking status documentation. Furthermore, we prioritize smoking cessation counseling for adolescents, pregnant women, and their families.
In psychiatric settings, smoking cessation is crucial as tobacco use can influence the blood concentration of psychotropic medications, potentially destabilizing psychiatric symptoms. Assisting patients in quitting smoking not only lowers the risk of tobacco-related diseases but also contributes to stabilizing their psychiatric conditions.
Our program encompasses various initiatives, including staff training, community tobacco harm prevention promotion, provision of second-generation smoking cessation treatments for outpatients and inpatien...
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I read with interest the article "Global tobacco advertising, promotion, and sponsorship regulation: what’s old, what’s new, and where to next?[1]" published in Tobacco Control. As a psychiatrist specializing in addiction treatment at Taoyuan Psychiatric Center in Taiwan, I wish to share our institution's experience in implementing a successful smoke-free hospital program, which may serve as a model for other psychiatric centers.
Since 2014, Taoyuan Psychiatric Center has made significant progress in promoting a smoke-free environment through a comprehensive tobacco control program. Our program's objectives include creating a smoke-free hospital, increasing smoking cessation services for outpatients and inpatients, and improving patient smoking status documentation. Furthermore, we prioritize smoking cessation counseling for adolescents, pregnant women, and their families.
In psychiatric settings, smoking cessation is crucial as tobacco use can influence the blood concentration of psychotropic medications, potentially destabilizing psychiatric symptoms. Assisting patients in quitting smoking not only lowers the risk of tobacco-related diseases but also contributes to stabilizing their psychiatric conditions.
Our program encompasses various initiatives, including staff training, community tobacco harm prevention promotion, provision of second-generation smoking cessation treatments for outpatients and inpatients with mental disorders, and organizing smoking cessation support groups and counseling. These efforts have led to a substantial increase in patients receiving smoking cessation services and a considerable decline in smoking rates among staff and patients.
In conclusion, Taoyuan Psychiatric Center's experience can serve as a valuable example for psychiatric institutions aiming to implement successful tobacco control programs. By addressing psychiatric patients' unique challenges, we can significantly impact their physical and mental well-being while contributing to global tobacco control efforts.
Sincerely,
Dr. LienChung Wei
Psychiatrist specializing in Addiction Treatment
Taoyuan Psychiatric Center, Taiwan
Reference:
[1] Freeman B, Watts C, Astuti PAS. Global tobacco advertising, promotion and sponsorship regulation: what’s old, what’s new and where to next? 2022;31(2):216-221.
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We acknowledge receipt of a private e-mail message from JLI regarding our paper (Yassine et al., 2022). Given the industry‘s long history of industry obfuscation, interference, and deception regarding research on tobacco products, we decided that the most transparent approach to the private e-mail that we received from an employee of a tobacco product manufacturer would be for us to report our results independently and respond to any public discussion of our work if and when it arose. Now that public discussion has arisen, we are pleased to respond to it.
We very recently analyzed the menthol and nicotine content of samples of liquid from six menthol flavor pods purchased in 2020. Three of these were liquids extracted from the pods in June 2021 for our paper and had been stored since in sealed amber glass containers at 5°C in the dark. The other three pods had been stored in their original sealed packages and were taken from the same batches as the pods analyzed in June 2021. These unopened packages were stored in the dark at room temperature over the intervening 18 months. The data from this small sample demonstrate a 24% reduction in menthol content over that period (12.01±0.46 vs 9.15±0.22 mg/ml), which helps to explain the results we reported (Yassine et al., 2022). We also found a 5% reduction in nicotine content (62.47±0.63 vs 59.52±0.49 mg/ml), as well as discoloration of the liquid in the pods that were stored at room temperatur...
NOT PEER REVIEWED
We acknowledge receipt of a private e-mail message from JLI regarding our paper (Yassine et al., 2022). Given the industry‘s long history of industry obfuscation, interference, and deception regarding research on tobacco products, we decided that the most transparent approach to the private e-mail that we received from an employee of a tobacco product manufacturer would be for us to report our results independently and respond to any public discussion of our work if and when it arose. Now that public discussion has arisen, we are pleased to respond to it.
We very recently analyzed the menthol and nicotine content of samples of liquid from six menthol flavor pods purchased in 2020. Three of these were liquids extracted from the pods in June 2021 for our paper and had been stored since in sealed amber glass containers at 5°C in the dark. The other three pods had been stored in their original sealed packages and were taken from the same batches as the pods analyzed in June 2021. These unopened packages were stored in the dark at room temperature over the intervening 18 months. The data from this small sample demonstrate a 24% reduction in menthol content over that period (12.01±0.46 vs 9.15±0.22 mg/ml), which helps to explain the results we reported (Yassine et al., 2022). We also found a 5% reduction in nicotine content (62.47±0.63 vs 59.52±0.49 mg/ml), as well as discoloration of the liquid in the pods that were stored at room temperature that suggests the possibility of other time-dependent changes in liquid constituents that we have not had an opportunity to evaluate comprehensively.
We acknowledge that the differences in menthol concentrations in JUUL products that were purchased across a three-year period, reported in Yassine et al., 2022, are consistent with changes in product composition that can occur during storage. A correction to the manuscript is now being published.
Our findings highlight that tobacco product manufacturers should be required to release to the public and the scientific community everything they know about their products, including product ingredients, abuse liability, potential adverse health consequences, and time- and temperature-dependent degradation of quality. For example, much of this information may be available in Premarket Tobacco Product Applications submitted to the Food and Drug Administration’s Center for Tobacco Products, and thus could be shared easily on each company’s website. This vital information should be available to all. In the meantime, our original article (Yassine et al., 2022), the industry response (Gillman, 2022), and this reply provide needed archival documentation for the scientific record.
References
Yassine A, El Hage R, El-Hellani A, Salman R, Talih S, Eissenberg T, Shihadeh A, Saliba N. Did JUUL alter the content of menthol pods in response to US FDA flavour enforcement policy? Tob Control. 2022 Nov;31(Suppl 3):s234-s237. doi: 10.1136/tc-2022-057506. PMID: 36328458; PMCID: PMC9641543.
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Authors previewed this study on March 16, 2022, at the Annual Meeting of the Society for Research on Nicotine and Tobacco[1]. Prompted by this presentation, on April 5, 2022, I emailed Drs. Talih, Eissenberg, and Shihadeh with product-specific information and questions that raised substantial doubt in the authors’ claims about JUUL products, specifically the purported modification of Menthol JUULpods.
Due to word limits here, we have posted a full copy of my email to the authors on PubPeer[2]. This email predated by almost a month the authors’ submission to the journal. Below please find an excerpt from this correspondence:
“In your presentation, you conclude that Juul Labs has in some way altered or otherwise modified its e-liquid formulations, but these claims are incorrect. Juul Labs has not altered or modified these e-liquid formulations since they were introduced into the market before August 2016 (i.e., FDA’s deeming date). We have supporting documentation, including batch records and certificates of analysis to confirm this.
“Setting aside any issues with methodologies or environmental conditions in the study, there are a number of possible explanations for the variations you found. For example, one potential explanation for the differences in tested products is the loss of menthol over time. It is well-documented in scientific literature[3] that menthol may migrate from areas of high concentration to low concentration,...
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Authors previewed this study on March 16, 2022, at the Annual Meeting of the Society for Research on Nicotine and Tobacco[1]. Prompted by this presentation, on April 5, 2022, I emailed Drs. Talih, Eissenberg, and Shihadeh with product-specific information and questions that raised substantial doubt in the authors’ claims about JUUL products, specifically the purported modification of Menthol JUULpods.
Due to word limits here, we have posted a full copy of my email to the authors on PubPeer[2]. This email predated by almost a month the authors’ submission to the journal. Below please find an excerpt from this correspondence:
“In your presentation, you conclude that Juul Labs has in some way altered or otherwise modified its e-liquid formulations, but these claims are incorrect. Juul Labs has not altered or modified these e-liquid formulations since they were introduced into the market before August 2016 (i.e., FDA’s deeming date). We have supporting documentation, including batch records and certificates of analysis to confirm this.
“Setting aside any issues with methodologies or environmental conditions in the study, there are a number of possible explanations for the variations you found. For example, one potential explanation for the differences in tested products is the loss of menthol over time. It is well-documented in scientific literature[3] that menthol may migrate from areas of high concentration to low concentration, and therefore flavor levels may decrease over time.” [4][5][6][7]
I never received a reply to this email from the publication’s authors and the manuscript does not recognize the issues that were raised, nor does it provide sufficient information to address the most likely flaw in the authors’ interpretation: that likely the loss of menthol during product storage played a vital and determinative role in the lower menthol amount observed in the aged JUULpods purchased in 2017 and 2018.
We request that Tobacco Control require the authors to provide detailed information regarding the timing of their analyses and ideally responses to all of the issues raised in our email to them. We would furthermore appreciate the opportunity to share with Tobacco Control the documentation I referenced in my initial email to study authors - including batch records and certificates of analysis - that demonstrate that we made no changes to our products’ formulations.
Assuming this further engagement demonstrates to the editors that the authors’ assertions that Juul Labs altered its products are unfounded, we ask that this article be retracted.
Dr. Gene Gillman
Vice President, Regulatory Chemistry
Juul Labs
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I would like to make three comments by way of a brief post-publication review.
1. The impacts of vaping tax on smoking have been completely overlooked
For a study of e-cigarette taxation to have any public health relevance, it must consider the impact of e-cigarette prices on *cigarette* demand. Cigarettes and e-cigarettes are economic substitutes. The demand for one responds to changes in the price of the other, an idea well understood in economics and quantified through the concept of cross-elasticity. The paper appears to pay no regard to the impact of vaping taxes on cigarette demand, Yet such effects might easily overwhelm any benefits from reduced e-cigarette use - in fact, impact on demand for other tobacco products and the development of informal markets are by far the most important impacts of a vaping tax. By way of example, a 2020 paper by Pesko et al. [1] concluded:
"Our results suggest that a proposed national e-cigarette tax of $1.65 per milliliter of vaping liquid would raise the proportion of adults who smoke cigarettes daily by approximately 1 percentage point, translating to 2.5 million extra adult daily smokers compared to the counterfactual of not having the tax."
2. The case for reducing adult vaping by taxation has not been made
The authors have based their paper on an unexamined assumption that it is a justifiable goal of policy to lower rates of adult e-cigarette use. Why should...
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I would like to make three comments by way of a brief post-publication review.
1. The impacts of vaping tax on smoking have been completely overlooked
For a study of e-cigarette taxation to have any public health relevance, it must consider the impact of e-cigarette prices on *cigarette* demand. Cigarettes and e-cigarettes are economic substitutes. The demand for one responds to changes in the price of the other, an idea well understood in economics and quantified through the concept of cross-elasticity. The paper appears to pay no regard to the impact of vaping taxes on cigarette demand, Yet such effects might easily overwhelm any benefits from reduced e-cigarette use - in fact, impact on demand for other tobacco products and the development of informal markets are by far the most important impacts of a vaping tax. By way of example, a 2020 paper by Pesko et al. [1] concluded:
"Our results suggest that a proposed national e-cigarette tax of $1.65 per milliliter of vaping liquid would raise the proportion of adults who smoke cigarettes daily by approximately 1 percentage point, translating to 2.5 million extra adult daily smokers compared to the counterfactual of not having the tax."
2. The case for reducing adult vaping by taxation has not been made
The authors have based their paper on an unexamined assumption that it is a justifiable goal of policy to lower rates of adult e-cigarette use. Why should this be a policy goal any more than reducing caffeine use or moderate alcohol use? The goal of public health policy is to address significant harms or self-destructive patterns of use, not to modify behaviours that the authors find distasteful. What are the harms that justify state intervention to reduce adult vaping with a tax? Further, they appear indifferent to welfare costs and the distributional impact of imposing a regressive tax burden on people who use vaping products. Tobacco control advocates should become more familiar with the idea that punitive policies impose harm on users, even though these users are supposed to be the intended beneficiaries. For example, a vaping tax harms families by drawing on the household budget of those who continue to vape.
3. The analysis to support the policy recommendations is wholly inadequate
The authors make over-confident policy recommendations without considering the full range of impacts of the measures they are proposing.
"Our findings suggest that adopting a vaping product excise tax policy may help reduce ENDS use and suppress the increase of ENDS use prevalence among young adults. Considering that there are still a number of US states that have not implemented vaping product excise tax policy, wider adoption of such policy across the nation would likely help mitigate ENDS use prevalence."
Without considering all the possible responses to the tax they support, they may easily be proposing tobacco control policies that do more harm than good. In fact, the most important public health impact of this policy is entirely excluded from the analysis. That is the effect of a vaping tax on smoking or other tobacco use. Given the two orders of magnitude difference in risk between smoking and vaping, only a tiny uptick in smoking would be needed to completely offset the benefits, if any, arising from reduced vaping
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I have a number of concerns with the paper as currently written.
1) The authors write: “Besides, none of the previous studies except Pesko et al (15) that examined the associations between vaping product excise tax adoption and ENDS use has accounted for the clustering of respondents within the same localities…” This is not accurate, as citation 19 also clusters standard errors at the locality level in all specifications.
2) The authors write: "A working paper reported reduced ENDS sales, but not ENDS use prevalence or behaviours, after implementation of a vaping product excise tax policy. (19)” This is not accurate, as the cited study uses the magnitude of e-cigarette tax values, rather than an indicator variable for tax implementation. States have adopted e-cigarette taxes of different magnitudes and a number of them (such as California) have changed the magnitudes of these taxes after adoption. All of this variation is used in citation 19, contrary to the current study’s description. It's also unclear from the sentence whether citation 19 studied use and found imprecise estimates, or did not study use. It's the latter and this should be clarified. It's also unclear why the authors did not use magnitude of e-cigarette taxes themselves in the current paper, as has been commonly done in the referenced literature.
3) Authors write they use a “nationally representative sample of US young adults.” I do not beli...
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I have a number of concerns with the paper as currently written.
1) The authors write: “Besides, none of the previous studies except Pesko et al (15) that examined the associations between vaping product excise tax adoption and ENDS use has accounted for the clustering of respondents within the same localities…” This is not accurate, as citation 19 also clusters standard errors at the locality level in all specifications.
2) The authors write: "A working paper reported reduced ENDS sales, but not ENDS use prevalence or behaviours, after implementation of a vaping product excise tax policy. (19)” This is not accurate, as the cited study uses the magnitude of e-cigarette tax values, rather than an indicator variable for tax implementation. States have adopted e-cigarette taxes of different magnitudes and a number of them (such as California) have changed the magnitudes of these taxes after adoption. All of this variation is used in citation 19, contrary to the current study’s description. It's also unclear from the sentence whether citation 19 studied use and found imprecise estimates, or did not study use. It's the latter and this should be clarified. It's also unclear why the authors did not use magnitude of e-cigarette taxes themselves in the current paper, as has been commonly done in the referenced literature.
3) Authors write they use a “nationally representative sample of US young adults.” I do not believe this is not accurate. The TUS-CPS sample itself may be nationally representative, but this representativeness may be lost when subgroups are explored.
4) The “vaping product excise tax policy” variable in Table 3 appears to be re-defined mid-table. Based on the discussion of the results, in column 1 it appears that this variable is an indicator equal to 1 only at the time when a state has an e-cigarette tax in place. In column 2 though, this indicator equals 1 when a state ever has an e-cigarette tax in place (even prior to it being in place). The use of the same row for a variable that changes across columns is unusual and can easily lead to the wrong interpretation.
We appreciate the comments from Bates and the opportunity for us to respond and clarify.
First, Bates' argument heavily relies on the assumption that e-cigarettes and combustible cigarettes are substitutes, which is theoretically possible as some consider vaping as a harm reduction alternative to combustible cigarettes. Empirically, however, there have been mixed findings about whether e-cigarettes and combustible cigarettes are substitutes (or complements). Bates cited Pesko et al. (2020) that concludes e-cigarettes and combustible cigarettes are substitutes, whereas other studies have shown that they are complements. For example, Cotti et al. (2018) found that higher cigarette excise taxes, in fact, decrease sales of both e-cigarettes and combustible cigarettes, suggesting that they are complements. Such mixed results abate Bates' argument that taxing ENDS could lead to more use of combustible cigarettes.
Second, Bates might have ignored that our study focused on young adults aged 18-24 years rather than general adults when examining the effect of vaping product tax on e-cigarette use. Although Pesko et al. (2020) suggests that e-cigarettes and combustible cigarettes are substitutes, the findings are based on the general adult population (average age: 55 years) which may not be generalizable to the young adult population. In fact, one study conducted by Abouk and Adams (2017) indicates that e-cigarettes and combustible ci...
We appreciate the comments from Bates and the opportunity for us to respond and clarify.
First, Bates' argument heavily relies on the assumption that e-cigarettes and combustible cigarettes are substitutes, which is theoretically possible as some consider vaping as a harm reduction alternative to combustible cigarettes. Empirically, however, there have been mixed findings about whether e-cigarettes and combustible cigarettes are substitutes (or complements). Bates cited Pesko et al. (2020) that concludes e-cigarettes and combustible cigarettes are substitutes, whereas other studies have shown that they are complements. For example, Cotti et al. (2018) found that higher cigarette excise taxes, in fact, decrease sales of both e-cigarettes and combustible cigarettes, suggesting that they are complements. Such mixed results abate Bates' argument that taxing ENDS could lead to more use of combustible cigarettes.
Second, Bates might have ignored that our study focused on young adults aged 18-24 years rather than general adults when examining the effect of vaping product tax on e-cigarette use. Although Pesko et al. (2020) suggests that e-cigarettes and combustible cigarettes are substitutes, the findings are based on the general adult population (average age: 55 years) which may not be generalizable to the young adult population. In fact, one study conducted by Abouk and Adams (2017) indicates that e-cigarettes and combustible cigarettes are not substitutes for young people. Established cigarette smokers may use e-cigarettes as a cessation tool but it is less common in young adults. In addition, even if e-cigarettes and combustible cigarettes are substitutes to some degree, the direction of substitution as well as co-use versus subsequent use should not be overlooked. Studies have shown that e-cigarettes may serve as a gateway to future combustible cigarette smoking among young people. For example, a study conducted by Hair et al. (2021) shows that youth and young adults who reported ever e-cigarette use had significantly higher odds of ever cigarette use one year later. Therefore, e-cigarette use versus combustible cigarette smoking is not simply an issue of substitution in particular among young people.
Disclosure: We did not receive any funding from the tobacco industry.
References:
1. Abouk, R., & Adams, S. (2017). Bans on electronic cigarette sales to minors and smoking among high school students. Journal of Health Economics, 54, 17-24.
2. Cotti, C., Nesson, E., & Tefft, N. (2018). The relationship between cigarettes and electronic cigarettes: Evidence from household panel data. Journal of Health Economics, 61, 205-219.
3. Hair, E. C., Barton, A. A., Perks, S. N., Kreslake, J., Xiao, H., Pitzer, L., ... & Vallone, D. M. (2021). Association between e-cigarette use and future combustible cigarette use: Evidence from a prospective cohort of youth and young adults, 2017–2019. Addictive Behaviors, 112, 106593.
4. Pesko, M. F., Courtemanche, C. J., & Maclean, J. C. (2020). The effects of traditional cigarette and e-cigarette tax rates on adult tobacco product use. Journal of Risk and Uncertainty, 60(3), 229-258.
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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.
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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, please note that vaping product excise tax policy indicator is a time-variant variable in Model 1. However, to present results of a standard difference-in-differences model with a binary indicator, the policy implementation status was operationalized as a time-invariant variable in Model 2, which is not unusual.
Disclosure: We did not receive any funding from the tobacco industry.
References
1. Cotti, C. D., Courtemanche, C. J., Maclean, J. C., Nesson, E. T., Pesko, M. F., & Tefft, N. (2020). The effects of e-cigarette taxes on e-cigarette prices and tobacco product sales: evidence from retail panel data. National Bureau of Economic Research. NBER Working Paper No. w26724.
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We appreciate the interest of the world’s largest transnational tobacco company, PMI,1 in our recent systematic review and would like to follow up on the points raised in Dr Baker’s rapid response.
Our review did not seek to assess the harms or benefits of HTPs. As public health researchers we are most interested in the quality of studies according to whether they give reliable evidence of the health outcomes and public health impact of HTPs. We sought to critically appraise the quality of clinical trials on HTPs and lay out for Tobacco Control readers all aspects of their design which may have implications for interpretation, especially in regard to the potential impacts of HTPs.
We decided to explore overall risk of bias when excluding the blinding of participants and personnel domain because we wanted to differentiate between studies. This is a really important domain. We excluded it because so few studies were judged to be at low risk of bias in this domain. Performance bias (which blinding if done well can guard against) remains an important source of bias that can influence study results, and one which was present in all of PMI's studies submitted to the U.S. Food and Drug Administration (FDA).1 As we explain in our risk of bias assessments, the consequences of this bias could have been minimised had the control intervention been active. Likewise, PMI’s withdrawal of its carbon-heated tobacco product from the market, which o...
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We appreciate the interest of the world’s largest transnational tobacco company, PMI,1 in our recent systematic review and would like to follow up on the points raised in Dr Baker’s rapid response.
Our review did not seek to assess the harms or benefits of HTPs. As public health researchers we are most interested in the quality of studies according to whether they give reliable evidence of the health outcomes and public health impact of HTPs. We sought to critically appraise the quality of clinical trials on HTPs and lay out for Tobacco Control readers all aspects of their design which may have implications for interpretation, especially in regard to the potential impacts of HTPs.
We decided to explore overall risk of bias when excluding the blinding of participants and personnel domain because we wanted to differentiate between studies. This is a really important domain. We excluded it because so few studies were judged to be at low risk of bias in this domain. Performance bias (which blinding if done well can guard against) remains an important source of bias that can influence study results, and one which was present in all of PMI's studies submitted to the U.S. Food and Drug Administration (FDA).1 As we explain in our risk of bias assessments, the consequences of this bias could have been minimised had the control intervention been active. Likewise, PMI’s withdrawal of its carbon-heated tobacco product from the market, which occurred after our first literature searches, does not excuse the substandard aspects of these trials, including selective reporting of study results.
We are perplexed by Dr Baker's argument that PMI’s clinical studies were designed to meet specific FDA requirements and “are not designed to assess the overall impact of HTPs on public health”. In its assessment the FDA aims to "evaluat[e] the benefit to health of individuals and of the population as a whole" (pg 8)2. As Dr Baker explains, PMI included its clinical studies as evidence on the relative risks of IQOS in its application to the FDA. While we concur no one study could wholly assess the impact of HTPs on public health, each clinical study indirectly or directly assesses this to some extent, whether it be assessing the impact of HTPs on exposure to harmful chemicals or on health outcomes. In the words of PMI's Chief Life Sciences Officer, PMI conducts "biomarker, clinical outcome and real-world evidence studies to demonstrate individual clinical and public health benefit of our smoke-free products."3
On the one hand, PMI suggests its clinical studies are appropriate evidence in establishing whether HTPs are beneficial to public health. Yet, Dr Baker's response contradictorily indicates PMI's studies were never designed to address this question and, in fact, agrees with our conclusion that they are therefore inadequate in assessing whether HTPs are beneficial to public health.
Our review found the existing HTP clinical trials provide evidence on exposure to toxicants compared to cigarettes, but fall short of what is needed to determine whether HTPs reduce the risks of tobacco-related diseases and whether they are beneficial to public health in real-world settings. This is in line with the FDA’s conclusions that PMI "has not demonstrated that, as actually used by consumers, the products sold or distributed with the proposed modified risk information will significantly reduce harm and the risk of tobacco‐related disease to individual tobacco users and benefit the health of the population as a whole, taking into account both users of tobacco products and persons who do not currently use tobacco products" (pg8, emphasis in original)1. We agree with the FDA, as quoted by Dr Baker, that subsequent studies are needed to establish the public health impact of HTPs.
Our review focused on clinical trials as giving the best evidence of a causal effect, but we read the two longer term observational studies Dr Baker points us to with interest. We do note that neither study is able to separate the population health effects of different cigarette alternatives or cessation interventions. We agree longer clinical and epidemiological studies are required to determine the harms or benefits of HTPs. We are pleased such studies are emerging in the literature and we look forward to reading the results of PMI's ongoing studies referenced by Dr Baker. We hope that despite the FDA’s MRTP authorisation for IQOS, PMI will remain incentivised to publish these new longer-term studies with clinical outcomes, as well as the observational study it has already completed.4
We are glad our review provided useful insight to PMI for areas of improvement. Improving future clinical research was fundamental in our desire to conduct this review. PMI's application to the FDA was a valuable source of data which have not been published in traditional academic literature. For future reviewers, the full-length reports provide a greater depth and breadth of clinical data, including data on outcomes yet to be reported in journal articles. The full reports included in the FDA application have been uploaded to PMI's data sharing website, INTERVALS.5 Unfortunately, PMI has not yet made full reports available for all its clinical studies. We encourage PMI to not only publish its study results in a timelier manner, but also to publish the full clinical study reports, which provide far greater detail and results than its journal publications.
With regards to our own funding and conflicts of interest, we accurately declared these as per Tobacco Control's policies. We note, once again, that no funders had any role or input in the design, conduct or reporting of our study.
References
1. Tobacco Tactics. Philip Morris International. 2022. Available: https://tobaccotactics.org/wiki/philip-morris-international/ [accessed 9th December 2022].
2. US Food & Drug Administration. Scientific Review of Modified Risk Tobacco Product Application (MRTPA) Under Section 911(d) of the FD&C Act -Technical Project Lead 2020. Available: https://www.fda.gov/media/139796/download [accessed 9th December 2022].
3. Insuasty, J. A letter from our Chief Life Sciences Officer. PMI Science. Available: https://www.pmiscience.com/en/about/welcome-to-pmi-science/ [accessed 9th December 2022].
4. Sponsiello-Wang Z, Langer P, Prieto L, et al. Household Surveys in the General Population and Web-Based Surveys in IQOS Users Registered at the Philip Morris International IQOS User Database: Protocols on the Use of Tobacco- and Nicotine-Containing Products in Germany, Italy, and the United Kingdom (Greater London), 2018-2020. JMIR Res Protoc. 2019; 8(5):e12061. doi: 10.2196/12061. PMID: 31094340; PMCID: PMC6532333.
5. INTERVALS. 2022. Available: https://intervals.science/homepage [accessed 9th December 2022].
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The objective of the systematic review by Braznell et al. was “𝘵𝘰 𝘤𝘳𝘪𝘵𝘪𝘤𝘢𝘭𝘭𝘺 𝘢𝘴𝘴𝘦𝘴𝘴 𝘵𝘩𝘦 𝘮𝘦𝘵𝘩𝘰𝘥𝘰𝘭𝘰𝘨𝘪𝘤𝘢𝘭 𝘤𝘩𝘢𝘳𝘢𝘤𝘵𝘦𝘳𝘪𝘴𝘵𝘪𝘤𝘴 𝘢𝘯𝘥 𝘲𝘶𝘢𝘭𝘪𝘵𝘺 𝘰𝘧 𝘪𝘯𝘵𝘦𝘳𝘷𝘦𝘯𝘵𝘪𝘰𝘯𝘢𝘭 𝘤𝘭𝘪𝘯𝘪𝘤𝘢𝘭 𝘵𝘳𝘪𝘢𝘭𝘴 𝘪𝘯𝘷𝘦𝘴𝘵𝘪𝘨𝘢𝘵𝘪𝘯𝘨 𝘵𝘩𝘦 𝘦𝘧𝘧𝘦𝘤𝘵𝘴 𝘰𝘧 𝘩𝘦𝘢𝘵𝘦𝘥 𝘵𝘰𝘣𝘢𝘤𝘤𝘰 𝘱𝘳𝘰𝘥𝘶𝘤𝘵𝘴 (𝘏𝘛𝘗𝘴).” ¹ The review was intended to examine the quality of HTP clinical trials “𝘣𝘦𝘧𝘰𝘳𝘦 𝘤𝘰𝘯𝘴𝘶𝘮𝘦𝘳𝘴 𝘢𝘯𝘥 𝘳𝘦𝘨𝘶𝘭𝘢𝘵𝘰𝘳𝘴 𝘮𝘢𝘬𝘦 𝘪𝘮𝘱𝘰𝘳𝘵𝘢𝘯𝘵 𝘥𝘦𝘤𝘪𝘴𝘪𝘰𝘯𝘴 𝘣𝘢𝘴𝘦𝘥 𝘰𝘯 𝘵𝘩𝘦 𝘳𝘦𝘴𝘶𝘭𝘵𝘴 𝘰𝘧 𝘵𝘩𝘦𝘴𝘦 𝘴𝘵𝘶𝘥𝘪𝘦𝘴.” We have three important observations in relation to Philip Morris International’s (PMI) clinical program, which impact the interpretation of the authors’ broad-reaching conclusions.
(𝟭) 𝗥𝗲𝗴𝘂𝗹𝗮𝘁𝗼𝗿𝘆 𝗱𝗲𝗰𝗶𝘀𝗶𝗼𝗻𝘀 𝗵𝗮𝘃𝗲 𝗯𝗲𝗲𝗻 𝗺𝗮𝗱𝗲 𝗯𝗮𝘀𝗲𝗱 𝗼𝗻 𝗣𝗠𝗜’𝘀 𝗰𝗹𝗶𝗻𝗶𝗰𝗮𝗹 𝘀𝘁𝘂𝗱𝗶𝗲𝘀, 𝘄𝗵𝗶𝗰𝗵 𝘄𝗲𝗿𝗲 𝗷𝘂𝗱𝗴𝗲𝗱 𝘁𝗼 𝗯𝗲 𝗮𝘁 𝗹𝗼𝘄 𝗿𝗶𝘀𝗸 𝗼𝗳 𝗯𝗶𝗮𝘀
Whilst we will only comment on the clinical studies performed by PMI, we were pleased to see the confirmation that the study designs in our clinical assessment program were not significantly associated with a risk of bias. The authors judged that all Tobacco Heating System (marketed as IQOS) clinical studies submitted to the United States Food and Drug Administration (FDA) and other regulators were at low risk of bias when the authors excluded “blinding of participants and personnel” to the product, due to the impracticality of concealing visually distinctive products. The authors also noted that the scoring was slightly improved when compared to a similar exercise performed as part of the recent Cochrane review. ²
NOT PEER REVIEWED
The objective of the systematic review by Braznell et al. was “𝘵𝘰 𝘤𝘳𝘪𝘵𝘪𝘤𝘢𝘭𝘭𝘺 𝘢𝘴𝘴𝘦𝘴𝘴 𝘵𝘩𝘦 𝘮𝘦𝘵𝘩𝘰𝘥𝘰𝘭𝘰𝘨𝘪𝘤𝘢𝘭 𝘤𝘩𝘢𝘳𝘢𝘤𝘵𝘦𝘳𝘪𝘴𝘵𝘪𝘤𝘴 𝘢𝘯𝘥 𝘲𝘶𝘢𝘭𝘪𝘵𝘺 𝘰𝘧 𝘪𝘯𝘵𝘦𝘳𝘷𝘦𝘯𝘵𝘪𝘰𝘯𝘢𝘭 𝘤𝘭𝘪𝘯𝘪𝘤𝘢𝘭 𝘵𝘳𝘪𝘢𝘭𝘴 𝘪𝘯𝘷𝘦𝘴𝘵𝘪𝘨𝘢𝘵𝘪𝘯𝘨 𝘵𝘩𝘦 𝘦𝘧𝘧𝘦𝘤𝘵𝘴 𝘰𝘧 𝘩𝘦𝘢𝘵𝘦𝘥 𝘵𝘰𝘣𝘢𝘤𝘤𝘰 𝘱𝘳𝘰𝘥𝘶𝘤𝘵𝘴 (𝘏𝘛𝘗𝘴).” ¹ The review was intended to examine the quality of HTP clinical trials “𝘣𝘦𝘧𝘰𝘳𝘦 𝘤𝘰𝘯𝘴𝘶𝘮𝘦𝘳𝘴 𝘢𝘯𝘥 𝘳𝘦𝘨𝘶𝘭𝘢𝘵𝘰𝘳𝘴 𝘮𝘢𝘬𝘦 𝘪𝘮𝘱𝘰𝘳𝘵𝘢𝘯𝘵 𝘥𝘦𝘤𝘪𝘴𝘪𝘰𝘯𝘴 𝘣𝘢𝘴𝘦𝘥 𝘰𝘯 𝘵𝘩𝘦 𝘳𝘦𝘴𝘶𝘭𝘵𝘴 𝘰𝘧 𝘵𝘩𝘦𝘴𝘦 𝘴𝘵𝘶𝘥𝘪𝘦𝘴.” We have three important observations in relation to Philip Morris International’s (PMI) clinical program, which impact the interpretation of the authors’ broad-reaching conclusions.
(𝟭) 𝗥𝗲𝗴𝘂𝗹𝗮𝘁𝗼𝗿𝘆 𝗱𝗲𝗰𝗶𝘀𝗶𝗼𝗻𝘀 𝗵𝗮𝘃𝗲 𝗯𝗲𝗲𝗻 𝗺𝗮𝗱𝗲 𝗯𝗮𝘀𝗲𝗱 𝗼𝗻 𝗣𝗠𝗜’𝘀 𝗰𝗹𝗶𝗻𝗶𝗰𝗮𝗹 𝘀𝘁𝘂𝗱𝗶𝗲𝘀, 𝘄𝗵𝗶𝗰𝗵 𝘄𝗲𝗿𝗲 𝗷𝘂𝗱𝗴𝗲𝗱 𝘁𝗼 𝗯𝗲 𝗮𝘁 𝗹𝗼𝘄 𝗿𝗶𝘀𝗸 𝗼𝗳 𝗯𝗶𝗮𝘀
Whilst we will only comment on the clinical studies performed by PMI, we were pleased to see the confirmation that the study designs in our clinical assessment program were not significantly associated with a risk of bias. The authors judged that all Tobacco Heating System (marketed as IQOS) clinical studies submitted to the United States Food and Drug Administration (FDA) and other regulators were at low risk of bias when the authors excluded “blinding of participants and personnel” to the product, due to the impracticality of concealing visually distinctive products. The authors also noted that the scoring was slightly improved when compared to a similar exercise performed as part of the recent Cochrane review. ²
We agree that regulatory decisions should be based on a critical scientific review of the evidence available, taking into consideration the quality and source of the data. The U.S. FDA performed a rigorous multi-year review of the totality of evidence for IQOS which resulted in the granting of Modified Risk Tobacco Product orders with exposure modification claims for the product. They concluded “𝘵𝘩𝘢𝘵 𝘢 𝘮𝘦𝘢𝘴𝘶𝘳𝘢𝘣𝘭𝘦 𝘢𝘯𝘥 𝘴𝘶𝘣𝘴𝘵𝘢𝘯𝘵𝘪𝘢𝘭 𝘳𝘦𝘥𝘶𝘤𝘵𝘪𝘰𝘯 𝘪𝘯 𝘮𝘰𝘳𝘣𝘪𝘥𝘪𝘵𝘺 𝘰𝘳 𝘮𝘰𝘳𝘵𝘢𝘭𝘪𝘵𝘺 𝘢𝘮𝘰𝘯𝘨 𝘪𝘯𝘥𝘪𝘷𝘪𝘥𝘶𝘢𝘭 𝘵𝘰𝘣𝘢𝘤𝘤𝘰 𝘶𝘴𝘦𝘳𝘴 𝘪𝘴 𝘳𝘦𝘢𝘴𝘰𝘯𝘢𝘣𝘭𝘺 𝘭𝘪𝘬𝘦𝘭𝘺 𝘪𝘯 𝘴𝘶𝘣𝘴𝘦𝘲𝘶𝘦𝘯𝘵 𝘴𝘵𝘶𝘥𝘪𝘦𝘴, 𝘢𝘯𝘥 𝘪𝘴𝘴𝘶𝘢𝘯𝘤𝘦 𝘰𝘧 𝘢𝘯 𝘰𝘳𝘥𝘦𝘳 𝘪𝘴 𝘦𝘹𝘱𝘦𝘤𝘵𝘦𝘥 𝘵𝘰 𝘣𝘦𝘯𝘦𝘧𝘪𝘵 𝘵𝘩𝘦 𝘩𝘦𝘢𝘭𝘵𝘩 𝘰𝘧 𝘵𝘩𝘦 𝘱𝘰𝘱𝘶𝘭𝘢𝘵𝘪𝘰𝘯 𝘢𝘴 𝘢 𝘸𝘩𝘰𝘭𝘦, 𝘵𝘢𝘬𝘪𝘯𝘨 𝘪𝘯𝘵𝘰 𝘢𝘤𝘤𝘰𝘶𝘯𝘵 𝘣𝘰𝘵𝘩 𝘶𝘴𝘦𝘳𝘴 𝘰𝘧 𝘵𝘰𝘣𝘢𝘤𝘤𝘰 𝘱𝘳𝘰𝘥𝘶𝘤𝘵𝘴 𝘢𝘯𝘥 𝘱𝘦𝘳𝘴𝘰𝘯𝘴 𝘸𝘩𝘰 𝘥𝘰 𝘯𝘰𝘵 𝘤𝘶𝘳𝘳𝘦𝘯𝘵𝘭𝘺 𝘶𝘴𝘦 𝘵𝘰𝘣𝘢𝘤𝘤𝘰 𝘱𝘳𝘰𝘥𝘶𝘤𝘵𝘴.” ³
(𝟮) 𝗖𝗹𝗶𝗻𝗶𝗰𝗮𝗹 𝘀𝘁𝘂𝗱𝗶𝗲𝘀 𝗶𝗻 𝗴𝗲𝗻𝗲𝗿𝗮𝗹, 𝗯𝘂𝘁 𝘀𝗽𝗲𝗰𝗶𝗳𝗶𝗰𝗮𝗹𝗹𝘆 𝗣𝗠𝗜’𝘀 𝗰𝗹𝗶𝗻𝗶𝗰𝗮𝗹 𝘀𝘁𝘂𝗱𝗶𝗲𝘀, 𝘀𝗵𝗼𝘂𝗹𝗱 𝗻𝗼𝘁 𝗯𝗲 𝗲𝘃𝗮𝗹𝘂𝗮𝘁𝗲𝗱 𝗮𝗴𝗮𝗶𝗻𝘀𝘁 𝗽𝗼𝘀𝘁 𝗵𝗼𝗰 𝗼𝗯𝗷𝗲𝗰𝘁𝗶𝘃𝗲𝘀
Braznell et al. fail to acknowledge that almost all of PMI’s clinical studies were specifically designed to deliver the pre-market scientific evidence that regulatory agencies need to authorize modified risk tobacco products (see FDA’s “Modified Risk Tobacco Product Applications. Guidance for Industry” ). ⁴
This means that the study duration, study populations, study endpoints, and analyses are selected to answer very specific research questions and are not designed to assess the overall impact of HTPs on public health by themselves. Some studies were of short duration (e.g., pharmacokinetic/ pharmacodynamic studies); some were performed in confinement because they were designed to provide evidence on the impacts of confirmed complete switching, and some with ambulatory study phases to better evaluate the impacts with a closer representation of real-world use. The ultimate real-world use studies are being conducted in the post-market setting.
It is inappropriate to assess the quality of a diverse set of studies—studies that were specifically designed to answer a range of different scientific questions—against a broad post hoc scientific objective that none of the studies were intended or designed to address by themselves. It is, therefore, misguided for Braznell et al. to conclude that “many characteristics of the reported clinical trials, such as short duration, confined settings, and choice of comparator and participants, are not representative of real-world use and fail to adequately investigate whether HTPs reduce harm and are beneficial to public health.” What the authors describe as “inadequacies” are, in fact, crucial elements of the individual study design.
As a follow-up to these pre-market studies, in 2022, PMI initiated three new clinical studies on IQOS—a 3-year chronic obstructive pulmonary disease (COPD) study (NCT05569005) ⁵, a 1-year cardiovascular disease study (NCT05566678) ⁶, and a cross-sectional study to assess reduced exposure, inflammation, and oxidative stress two years after switching compared to continued smoking (NCT05385055) ⁷—which will examine longer-term switching and clinically relevant health changes in adult smokers who have switched to IQOS. These studies should be reassuring for those who have expressed concern that the assessment of HTPs relies on short-term studies in the absence of long-term epidemiological studies. The authors may perhaps be unaware of more recent epidemiological studies in the published literature (by both PMI and independent researchers), which have assessed the potential impact of HTPs and other smoke-free alternatives in the real world. Choi et al., 2021 ⁸ looked 5.16 million South Korean adult men and concluded that smokers switching to smoke-free products were associated with a lower cardiovascular disease risk than those continuing to smoke cigarettes, although higher than cessation (no smoke-free product use). Van der Plas et al., 2022 ⁹ observed a significant reduction in the number of hospitalizations for COPD and a non-significant reduction in hospitalizations for COPD plus lower respiratory tract infections as well as ischemic heart disease following the introduction of HTPs in a time-trend analysis of the Japanese Medical Data Center (JMDC) database.
(𝟯) 𝗔𝗿𝗲𝗮𝘀 𝗳𝗼𝗿 𝗶𝗺𝗽𝗿𝗼𝘃𝗲𝗺𝗲𝗻𝘁 𝗲𝘅𝗶𝘀𝘁 𝗳𝗼𝗿 𝗮𝗹𝗹 𝗽𝗮𝗿𝘁𝗶𝗲𝘀
We recognize that our reporting on clinicaltrials.gov may not meet the expectations of today; however, at the time the clinical program was initiated, publishing smoking cessation studies was common; however, publishing tobacco and tobacco harm reduction studies in this database was not common; in fact, we were among the first to report these types of studies there and did so to increase our scientific transparency. The authors accurately reflect incomplete reporting on a small number of our clinical studies, including studies on a carbon-heated tobacco product. However, in 2021, we took a decision not to proceed with commercialization ¹⁰, meaning that, according to the authors’ exclusion criteria, this study should not have been part of their analysis. Additionally, we have two studies that have been completed. Although the data for the endpoints have been posted on clinicaltrials.gov and therefore are in the public domain, the study publications with additional secondary and exploratory endpoints have just been or are in the process of being published. Whilst we are actively working on publishing these studies, we acknowledge that this delay in publication is not ideal and must be improved in the future. We recognize the importance of publishing the results of our studies in peer-reviewed journals but also note that we often face significant challenges in achieving timely publication because a number of journals (including Tobacco Control) refuse to accept or even review such publications based purely on affiliation and not the quality of the research.
Constructive criticism of our research is always welcome, but we reject the suggestion that PMI’s clinical studies “ 𝘸𝘦𝘳𝘦 𝘴𝘶𝘣𝘴𝘵𝘢𝘯𝘥𝘢𝘳𝘥 𝘪𝘯 𝘮𝘢𝘯𝘺 𝘳𝘦𝘴𝘱𝘦𝘤𝘵𝘴.” As mentioned above, the FDA conducted a substantive review of our studies, including inspection visits at our facilities and at some of our clinical research partners. FDA noted that their inspections of two U.S. clinical sites “𝘳𝘦𝘷𝘦𝘢𝘭𝘦𝘥 𝘯𝘰 𝘮𝘢𝘫𝘰𝘳 𝘉𝘐𝘔𝘖 [𝘉𝘪𝘰𝘳𝘦𝘴𝘦𝘢𝘳𝘤𝘩 𝘔𝘰𝘯𝘪𝘵𝘰𝘳𝘪𝘯𝘨] 𝘪𝘴𝘴𝘶𝘦𝘴 𝘰𝘳 𝘤𝘭𝘪𝘯𝘪𝘤𝘢𝘭𝘭𝘺-𝘴𝘪𝘨𝘯𝘪𝘧𝘪𝘤𝘢𝘯𝘵 𝘱𝘳𝘰𝘵𝘰𝘤𝘰𝘭 𝘥𝘦𝘷𝘪𝘢𝘵𝘪𝘰𝘯𝘴 𝘵𝘩𝘢𝘵 𝘸𝘰𝘶𝘭𝘥 𝘤𝘰𝘮𝘱𝘳𝘰𝘮𝘪𝘴𝘦 𝘥𝘢𝘵𝘢 𝘷𝘢𝘭𝘪𝘥𝘪𝘵𝘺 𝘢𝘯𝘥 𝘪𝘯𝘵𝘦𝘨𝘳𝘪𝘵𝘺.” In addition, the results of the authors’ own review confirm the appropriate design and conduct of our studies (i.e., low risk of bias). Therefore, the authors’ non-scientific statement that their failure to find significant differences in the risks of bias between the trials from different affiliations should only be interpreted as “𝘢𝘣𝘴𝘦𝘯𝘤𝘦 𝘰𝘧 𝘦𝘷𝘪𝘥𝘦𝘯𝘤𝘦, 𝘯𝘰𝘵 𝘦𝘷𝘪𝘥𝘦𝘯𝘤𝘦 𝘰𝘧 𝘢𝘣𝘴𝘦𝘯𝘤𝘦” is pure speculation and has no basis in fact in regard to PMI’s studies.
In the spirit of constructive criticism, we note that whilst the authors were investigating the possibility of bias in PMI’s studies, it is possible that their own bias may be affecting their interpretation of results. When disclosing their competing interests, they fail to note that their own affiliation with, and funding from, Bloomberg Philanthropies’ “𝘚𝘛𝘖𝘗: 𝘚𝘵𝘰𝘱𝘱𝘪𝘯𝘨 𝘛𝘰𝘣𝘢𝘤𝘤𝘰 𝘖𝘳𝘨𝘢𝘯𝘪𝘻𝘢𝘵𝘪𝘰𝘯𝘴 𝘢𝘯𝘥 𝘗𝘳𝘰𝘥𝘶𝘤𝘵𝘴” could create a risk of bias. In fact, that potential for bias is plain since the lead author has previously written that “𝘵𝘩𝘦𝘳𝘦 𝘪𝘴 𝘭𝘪𝘵𝘵𝘭𝘦 𝘳𝘰𝘭𝘦 𝘧𝘰𝘳 𝘩𝘦𝘢𝘵𝘦𝘥 𝘵𝘰𝘣𝘢𝘤𝘤𝘰 𝘱𝘳𝘰𝘥𝘶𝘤𝘵𝘴 𝘢𝘵 𝘦𝘪𝘵𝘩𝘦𝘳 𝘪𝘯𝘥𝘪𝘷𝘪𝘥𝘶𝘢𝘭 𝘰𝘳 𝘱𝘰𝘱𝘶𝘭𝘢𝘵𝘪𝘰𝘯 𝘭𝘦𝘷𝘦𝘭” and that “𝘩𝘦𝘢𝘵𝘦𝘥 𝘵𝘰𝘣𝘢𝘤𝘤𝘰 𝘱𝘳𝘰𝘥𝘶𝘤𝘵𝘴 𝘩𝘢𝘷𝘦 𝘯𝘰 𝘱𝘶𝘣𝘭𝘪𝘤 𝘩𝘦𝘢𝘭𝘵𝘩 𝘳𝘰𝘭𝘦.” ¹¹ This potential conflict was not made clear to readers. The reference by Bero ¹² used by the authors in their introduction states that “𝘤𝘰𝘯𝘴𝘪𝘥𝘦𝘳𝘢𝘵𝘪𝘰𝘯 𝘴𝘩𝘰𝘶𝘭𝘥 𝘣𝘦 𝘨𝘪𝘷𝘦𝘯 𝘵𝘰 𝘢𝘧𝘧𝘪𝘭𝘪𝘢𝘵𝘪𝘰𝘯 𝘰𝘳 𝘪𝘯𝘵𝘦𝘳𝘦𝘴𝘵 𝘨𝘳𝘰𝘶𝘱 𝘣𝘪𝘢𝘴.” Bero notes that “[𝘢]𝘯 𝘪𝘯𝘵𝘦𝘳𝘦𝘴𝘵 𝘨𝘳𝘰𝘶𝘱 𝘪𝘴 𝘢𝘯 𝘰𝘳𝘨𝘢𝘯𝘪𝘻𝘦𝘥 𝘨𝘳𝘰𝘶𝘱 𝘸𝘪𝘵𝘩 𝘢 𝘯𝘢𝘳𝘳𝘰𝘸𝘭𝘺 𝘥𝘦𝘧𝘪𝘯𝘦𝘥 𝘷𝘪𝘦𝘸𝘱𝘰𝘪𝘯𝘵, 𝘸𝘩𝘪𝘤𝘩 𝘱𝘳𝘰𝘵𝘦𝘤𝘵𝘴 𝘪𝘵𝘴 𝘱𝘰𝘴𝘪𝘵𝘪𝘰𝘯 𝘰𝘳 𝘱𝘳𝘰𝘧𝘪𝘵𝘴. 𝘛𝘩𝘦𝘴𝘦 𝘨𝘳𝘰𝘶𝘱𝘴 𝘢𝘳𝘦 𝘯𝘰𝘵 𝘦𝘹𝘤𝘭𝘶𝘴𝘪𝘷𝘦𝘭𝘺 𝘣𝘶𝘴𝘪𝘯𝘦𝘴𝘴 𝘨𝘳𝘰𝘶𝘱𝘴 𝘣𝘶𝘵 𝘤𝘢𝘯 𝘪𝘯𝘤𝘭𝘶𝘥𝘦 𝘢𝘭𝘭 𝘬𝘪𝘯𝘥𝘴 𝘰𝘧 𝘰𝘳𝘨𝘢𝘯𝘪𝘻𝘢𝘵𝘪𝘰𝘯𝘴 𝘵𝘩𝘢𝘵 𝘮𝘢𝘺 𝘢𝘵𝘵𝘦𝘮𝘱𝘵 𝘵𝘰 𝘪𝘯𝘧𝘭𝘶𝘦𝘯𝘤𝘦 𝘨𝘰𝘷𝘦𝘳𝘯𝘮𝘦𝘯𝘵𝘴. 𝘐𝘯𝘵𝘦𝘳𝘦𝘴𝘵 𝘨𝘳𝘰𝘶𝘱𝘴 𝘤𝘢𝘯 𝘣𝘦 𝘦𝘹𝘱𝘦𝘤𝘵𝘦𝘥 𝘵𝘰 𝘤𝘰𝘯𝘴𝘵𝘳𝘶𝘤𝘵 𝘵𝘩𝘦 𝘦𝘷𝘪𝘥𝘦𝘯𝘤𝘦 𝘢𝘣𝘰𝘶𝘵 𝘢 𝘩𝘦𝘢𝘭𝘵𝘩 𝘳𝘪𝘴𝘬 𝘵𝘰 𝘴𝘶𝘱𝘱𝘰𝘳𝘵 𝘵𝘩𝘦𝘪𝘳 𝘱𝘳𝘦𝘥𝘦𝘧𝘪𝘯𝘦𝘥 𝘱𝘰𝘭𝘪𝘤𝘺 𝘱𝘰𝘴𝘪𝘵𝘪𝘰𝘯.” We encourage the authors to transparently disclose that their own funding from, and affiliation with, “𝘚𝘛𝘖𝘗: 𝘚𝘵𝘰𝘱𝘱𝘪𝘯𝘨 𝘛𝘰𝘣𝘢𝘤𝘤𝘰 𝘖𝘳𝘨𝘢𝘯𝘪𝘻𝘢𝘵𝘪𝘰𝘯𝘴 𝘢𝘯𝘥 𝘗𝘳𝘰𝘥𝘶𝘤𝘵𝘴”—an interest group that actively campaigns against HTPs, the tobacco industry, and PMI—presents a potential conflict of interest.
(𝟰) 𝗖𝗼𝗻𝗰𝗹𝘂𝘀𝗶𝗼𝗻
There are legitimate concerns about bringing any new nicotine or tobacco product to the market, but these concerns should be considered against the backdrop of the science that is known about smoking. People who smoke and regulators will best be served by informing them of the relative risks of such products compared to continuing to smoke. This requires an unbiased review of the existing science whilst continuing to study the impact on individual and public health. Such actions will help and inform those who currently smoke to transition away from cigarettes and non-smokers not to start to use any nicotine or tobacco product.
(𝟱) 𝗥𝗲𝗳𝗲𝗿𝗲𝗻𝗰𝗲
1.) Braznell S, Van Den Akker A, Metcalfe C, et alCritical appraisal of interventional clinical trials assessing heated tobacco products: a systematic review. Tobacco Control Published Online First: 08 November 2022. doi: 10.1136/tc-2022-057522
2.) Tattan-Birch_H, Hartmann-Boyce_J, Kock_L, Simonavicius_E, Brose_L, Jackson_S, Shahab_L, Brown_J. Heated tobacco products for smoking cessation and reducing smoking prevalence. Cochrane Database of Systematic Reviews 2022, Issue 1. Art. No.: CD013790. https://doi.org/10.1002/14651858.CD013790.pub2
3.) Food and Drug Administration (2020) Scientific Review of Modified Risk Tobacco Product Application (MRTPA) STNs MR0000059 - MR0000061, MR0000133 -Technical Project Lead Document (https://www.fda.gov/media/139796/download)
4.) Food and Drug Administration (FDA) (2012): Modified Risk Tobacco Product Applications. Guidance for Industry (https://www.fda.gov/media/83300/download).
5.) NCT05569005 (https://www.clinicaltrials.gov/ct2/show/NCT05569005?spons=Philip+Morris&...)
6.) NCT05566678 (https://www.clinicaltrials.gov/ct2/show/NCT05566678?spons=Philip+Morris&...)
7.) NCT05385055 (https://www.clinicaltrials.gov/ct2/show/NCT05385055?spons=Philip+Morris&...)
8.) Choi, S., Lee, K., Park, S.M., (2021) Combined associations of changes in noncombustible nicotine or tobacco product ad combustible cigarette use habits with subsequent short-term cardiovascular disease risk among South Korean men. Circulation, 144: 1521-1538. doi: 10.1161/CIRCULATIONAHA.121.054967
9.) van der Plas A, Antunes M, Romero-Kauss A, Hankins M and Heremans A (2022) Ischemic Heart Disease and Chronic Obstructive Pulmonary Disease Hospitalizations in Japan Before and After the Introduction of a Heated Tobacco Product. Front. Public Health 10:909459. doi: 10.3389/fpubh.2022.909459
10.) Philip Morris International 2021 Annual Report (p42) published on 24.03.2022
11.) Gilmore A B, Braznell S. US regulator adds to confusion around heated tobacco products BMJ 2020; 370 :m3528 doi: 10.1136/bmj.m3528
12.) Bero LA. Tobacco industry manipulation of research. Public Health Rep 2005;120:200–8. doi: 10.1177/003335490512000215
Clive Bates’ commentary on our paper repeats claims we previously addressed [1]. Here, we address seven points, the first is contextual and the remaining are raised in his letter.
1. We note the failure of the author to acknowledge Māori perspectives, in particular their support for endgame measures, concerns in relation to harm minimisation [2] as outlined in his “all in” strategy, and ethical publishing of research about Indigenous peoples. [3]
2. We reject the assertion that the basis of our modelling is “weak”. While there is uncertainty around the potential effect of denicotinisation, as this policy hasn’t been implemented, there are strong grounds to believe that it will have a profound impact on reducing smoking prevalence. This is based on both theory and logic (i.e., nicotine is the main addictive component of cigarettes and why most people smoke), and the findings of multiple randomized controlled trials (RCTs) showing that smoking very low nicotine cigarettes (VLNCs) increases cessation rates for diverse populations of people who smoke [4-7].
Our model’s estimated effect on smoking prevalence had wide uncertainty, namely a median of 85.9% reduction over 5 years with a 95% uncertainty interval of 67.1% to 96.3% that produced (appropriately) wide uncertainty in the health impacts. The derivation of this input parameter through expert knowledge elicitation (EKE) is described in the Appendix of our paper. Univariate se...
Clive Bates’ commentary on our paper repeats claims we previously addressed [1]. Here, we address seven points, the first is contextual and the remaining are raised in his letter.
1. We note the failure of the author to acknowledge Māori perspectives, in particular their support for endgame measures, concerns in relation to harm minimisation [2] as outlined in his “all in” strategy, and ethical publishing of research about Indigenous peoples. [3]
2. We reject the assertion that the basis of our modelling is “weak”. While there is uncertainty around the potential effect of denicotinisation, as this policy hasn’t been implemented, there are strong grounds to believe that it will have a profound impact on reducing smoking prevalence. This is based on both theory and logic (i.e., nicotine is the main addictive component of cigarettes and why most people smoke), and the findings of multiple randomized controlled trials (RCTs) showing that smoking very low nicotine cigarettes (VLNCs) increases cessation rates for diverse populations of people who smoke [4-7].
Our model’s estimated effect on smoking prevalence had wide uncertainty, namely a median of 85.9% reduction over 5 years with a 95% uncertainty interval of 67.1% to 96.3% that produced (appropriately) wide uncertainty in the health impacts. The derivation of this input parameter through expert knowledge elicitation (EKE) is described in the Appendix of our paper. Univariate sensitivity analyses comparing the 67.1% and 96.3% estimates (all other input parameters held at their median value) produced HALY gains ranging from 545,000 to 653,000. Our paper presents this uncertainty transparently.
3. The assertion that the effect size estimate of denicotinisation is based on one randomized trial is incorrect. The author has been informed that this assertion is false on several occasions but even so continues to repeat this claim. We used an EKE process, which is described in the Appendix of our paper. The experts considered many ‘inputs’ to their estimation, of which just one was the evidence from the multiple existing RCTs.
4. We disagree with the author’s characterisation of the EKE process as “arbitrary guesswork”. As Bates himself has noted, expert judgement can provide valuable insight in situations of uncertainty and can “provide a risk-perception ‘anchor’ … following assessment of the evidence that exists.” [8] We believe that ≥ 5 RCTs demonstrating a relationship between VLNCs and increased smoking cessation constitute a reasonable evidence base to draw upon, particularly when supported by theory/logic and other lines of evidence.[9]
Policy-making often occurs in a context of uncertainty. Denicotinisation is one such example, as we will not know its ‘real world’ impact until it has been implemented. To inform that policy making, it is astute to have estimates of the likely health impact – which requires EKE. Over time, as evidence accrues, such modelling should be updated.
5. As stated in our paper, we did not explicitly model an illicit market. Tight border security in an island nation with no land borders within 1,000 km, reduces the potential of a significant illicit tobacco market. Furthermore, the Aotearoa/New Zealand (A/NZ) Government announced new measures against tobacco smuggling in preparation for the introduction of its ‘endgame’ legislation. [10] The impact of an illicit tobacco market may be greater in other countries. In A/NZ, the illicit market is small (around 5-6% max) and has not increased greatly despite 10 years of above inflation tobacco excise increases and the introduction of plain packs – interventions which the tobacco industry routinely claims will result in an explosion in the illicit market. This suggests enforcement measures work well in the A/NZ context. Furthermore, given the widespread availability and use by people who smoke of nicotine-containing vaping products in A/NZ, seeking to replace VLNCs with illicit cigarettes is likely to be significantly less common than in jurisdictions where vaping products are not available.
6. It is possible – as Bates asserts – that we have overestimated the health gains from denicotinisation and other endgame policies because the smoking prevalence since 2020, appears to be falling more rapidly than we modelled (meaning the ‘room’ for health gains from an endgame policy is less). We discussed this in our paper.
7. Discussing the public health philosophy of denicotinisation was beyond the scope of our paper. Our focus was only on evaluating the potential health and equity impacts of four interventions included the A/NZ Smoke-free Action Plan 2025.
[2] Waa A, Robson B, Gifford H, Smylie J, Reading J, Henderson JA, Henderson PN, Maddox R, Lovett R, Eades S, Finlay S. Foundation for a smoke-free world and healthy Indigenous futures: an oxymoron?. Tobacco Control. 2020 Mar 1;29(2):237-40.
[3] Maddox R, Drummond A, Kennedy M, et al. Ethical publishing in ‘Indigenous’ contextsTobacco Control Published Online First: 13 February 2023. doi: 10.1136/tc-2022-057702
[4] Donny EC, Denlinger RL, Tidey JW, Koopmeiners JS, Benowitz NL, Vandrey RG, Al’Absi M, Carmella SG, Cinciripini PM, Dermody SS, Drobes DJ. Randomized trial of reduced-nicotine standards for cigarettes. New England Journal of Medicine. 2015 Oct 1;373(14):1340-9.
[5] Smith TT, Koopmeiners JS, Tessier KM, Davis EM, Conklin CA, Denlinger-Apte RL, Lane T, Murphy SE, Tidey JW, Hatsukami DK, Donny EC. Randomized trial of low-nicotine cigarettes and transdermal nicotine. American journal of preventive medicine. 2019 Oct 1;57(4):515-24.
[6] Walker N, Howe C, Bullen C, Grigg M, Glover M, McRobbie H, Laugesen M, Parag V, Whittaker R. The combined effect of very low nicotine content cigarettes, used as an adjunct to usual Quitline care (nicotine replacement therapy and behavioural support), on smoking cessation: a randomized controlled trial. Addiction. 2012 Oct;107(10):1857-67.
[7] Higgins ST, Tidey JW, Sigmon SC, Heil SH, Gaalema DE, Lee D, Hughes JR, Villanti AC, Bunn JY, Davis DR, Bergeria CL. Changes in cigarette consumption with reduced nicotine content cigarettes among smokers with psychiatric conditions or socioeconomic disadvantage: 3 randomized clinical trials. JAMA network open. 2020 Oct 1;3(10):e2019311-.
I have published a summary critique of this modelling exercise on PubPeer. [1] This summarises concerns raised in post-publication reviews of this paper while it was in pre-print form by experts from New Zealand and Canada, and me. [2][3]
By way of a brief summary:
1. All the important modelled findings flow from a single assumption that denicotinisation will reduce smoking prevalence by 85% over five years. Yet the basis for this assumption is weak and disconnected from the reality of the market system being modelled.
2. The central assumption is based partly on a smoking cessation trial that bears no relation to the market and regulatory intervention that is the subject of the simulation. Even so, the trial findings do not support the modelling assumption.
3. The central assumption also draws on expert elicitation. Yet, there is no experience with this measure as it would be novel, and there is no relevant expertise in this sort of intervention. Where experts have been asked to assess the impacts, their views diverge widely, suggesting that their estimates are mainly arbitrary guesswork.
4. The authors have only modelled benefits and have not included anything that might be a detriment or create a trade-off. The modelling takes no account of the black market or workarounds. These are inevitable consequences of such 'endgame' prohibitions, albeit of uncertain size. Though it may be challenging to mo...
I have published a summary critique of this modelling exercise on PubPeer. [1] This summarises concerns raised in post-publication reviews of this paper while it was in pre-print form by experts from New Zealand and Canada, and me. [2][3]
By way of a brief summary:
1. All the important modelled findings flow from a single assumption that denicotinisation will reduce smoking prevalence by 85% over five years. Yet the basis for this assumption is weak and disconnected from the reality of the market system being modelled.
2. The central assumption is based partly on a smoking cessation trial that bears no relation to the market and regulatory intervention that is the subject of the simulation. Even so, the trial findings do not support the modelling assumption.
3. The central assumption also draws on expert elicitation. Yet, there is no experience with this measure as it would be novel, and there is no relevant expertise in this sort of intervention. Where experts have been asked to assess the impacts, their views diverge widely, suggesting that their estimates are mainly arbitrary guesswork.
4. The authors have only modelled benefits and have not included anything that might be a detriment or create a trade-off. The modelling takes no account of the black market or workarounds. These are inevitable consequences of such 'endgame' prohibitions, albeit of uncertain size. Though it may be challenging to model, the simulation does not account for the negative behavioural or perceptual impacts of trying to force people to quit or switch by using the law to remove their regular cigarettes. It should not be assumed that these are zero or immaterial to policy assessment.
5. The real-world progress in reducing smoking in New Zealand through tobacco harm reduction and the rise of vaping has been rapid and highly positive, outpacing both the business-as-usual baseline assumptions in the modelling and the impact of the intervention. This suggests the modelled benefits are greatly overstated.
6. The denicotinisation policy should not be compared to a flawed and inflated hypothetical business-as-usual baseline but to an alternative policy that embraces a different public health philosophy. The denicotinisation measure uses the power of the law to try to force behaviour change onto smokers by removing their regular cigarettes from the market. This may be effective, but it also carries risks of black market activity and a public or political backlash once the consequences are understood by those affected. The alternative would position the state as an enabler, maximising support, encouragement and incentives to switch to smoke-free alternatives or quit. This is not business as usual but would mean going “all in” on tobacco harm reduction, with the goal of reducing smoking as rapidly as possible but without resorting to using the coercive power of the law. Such a policy may prove effective but also have lower risks and be less susceptible to unintended consequences.
[2] Bates, C., Youdan, B., Bonita, R., Laking, G., Sweanor, D., Beaglehole, R. (2022). Review of: “Tobacco endgame intervention impacts on health gains and Māori:non-Māori health inequity: a simulation study of the Aotearoa-New Zealand Tobacco Action Plan.” Qeios. https://doi.org/10.32388/8WXH0J
[3] Bates, C., Youdan, B., Bonita, R., Sweanor, D., & Beaglehole, R. (2022). Review of: “The case for denicotinising tobacco in Aotearoa NZ remains strong: response to online critique.” Qeios. https://doi.org/10.32388/ZZAUQM
¶ 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...
¶ 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 was not yet fully enforced. This could be due to early supply-side responses to the flavor ban (e.g., some businesses discontinuing selling flavored e-cigarettes immediately upon the law’s effective date), or demand for e-cigarettes falling due to publicity related to the flavor ban effective date. The fact that e-cigarette sales continued falling in the latter half of 2018 until full enforcement kicked in on 1/1/2019 does not by itself invalidate Friedman’s model specifically looking at effective date. Therefore, there is nothing flawed about the concept of studying the effect that the flavor ban effective date (which led to a documented decline in flavored e-cigarette sales in San Francisco between July 2018 through the end of August 2018) had on youth cigarette use measured in the San Francisco YRBSS in November to December of 2018 (compared to other locations not adopting flavor bans).
¶ The current TC paper makes many inaccurate statements that appear to undermine most of the paper.
¶ • "Thus, the San Francisco survey preceded the enforcement of its flavoured tobacco sales restriction (January 2019), making the 2019 YRBSS an inappropriate data source for evaluating the effects of the city’s flavoured tobacco sales restriction."
¶ This is not true. The decline in flavored e-cigarette sales between the July 2018 effective date to the end of August 2018 could have clearly resulted in spillover effects in the youth cigarette use marketplace. The authors provide no acknowledgement of this in their paper.
¶ • "If youth smoking rates increased similarly in Oakland following that city’s sales restriction, this would lend credence to the call for caution against flavoured tobacco sales restrictions. However, if the patterns differ, we should identify alternate explanations for the rise in San Francisco’s youth smoking prevalence."
¶ This is faulty logic. It's entirely possible that policies adopted in two separate cities could exhibit different effects (including one having an effect and the other having no effect) depending on the population's underlying preferences for tobacco products and different evasion opportunities. I don’t know if there is a reason that this could be the case or not, but that’s irrelevant. What is relevant is that the loose language as currently written is inaccurate and could lead people to conclude the wrong thing in other contexts. The authors also fail to provide statistical testing of their Oakland model as required by STROBE guidelines, nor do they acknowledge that unlike the original study their own pre-post analysis is limited by not having a counterfactual group of non-treated areas, and so there is no ability to control for trends over time.
¶ • "Since there was no ban on non-menthol cigarettes sales, we would have expected to see an increase in sales of cigarettes if youth had been switching products."
¶ • “The study actually found an overall trend of a reduction in both total tobacco sales and cigarette sales in San Francisco following the flavoured tobacco product sales restriction, further suggesting that flavoured products were not being substituted by other unflavoured tobacco products or cigarettes.”
¶ Assuming for a moment that we can observe cigarette sales sold to youth, it would be entirely possible that these cigarette sales could decline in San Francisco but decline by more in the control areas due to secular trends; therefore, suggesting the flavor ban would need to increase cigarette sales to youth is inaccurate. And of course the authors do not observe who buys these cigarettes (youth or adults), so sales data for the population as a whole does not necessarily refute youth use patterns.
¶ • “However, in order to imply causality, there cannot be ambiguous temporal precedence.”
¶ • “do not include the policy enactment and enforcement dates that are required to avoid erroneous conclusions like those in the recent analysis of the San Francisco flavoured sales restriction.”
¶ The authors state that Friedman is ambiguous about the policy timing, but this is not the case as she clearly states she is studying effective date. That is not ambiguous. The authors also state that Friedman’s study has erroneous conclusions. I do not see anything erroneous about the limited scope of her research question studying effective date.
¶ The authors also refer in their references to conversation with the CDC-Office on Smoking and Health regarding the YRBSS data collection date. This reference is incomplete per STROBE guidelines, and should include a specific individual that the authors spoke with and a date of the conversation. Since this conversation was with a government employee it is especially important that there is not the perception of the government leaking information to certain groups of scientists but not others, so full disclosure is needed here. Other researchers have tried to get effective dates for the YRBSS survey from the CDC before but have been rebuffed, creating concerns regarding inequal access to data, as well as concerns regarding if this communication between the CDC and the researchers was authorized or not.
¶ Additionally, I found the author’s discussion of the tobacco industry promoting Friedman’s study as irrelevant. This discussion has the unfortunate effect of muddying the waters of what is supposed to be a focus on the science of Freidman’s article, and could easily lead people to conclude that Friedman herself has industry funding, which is not true. None of us are impervious to industry attempts to use our research for their own gain; in fact, if we start to attack researchers whose work is used by industry, this gives industry an easy way to discredit the researchers they are most threated by (by finding a way to cite their research in industry reports and publications, etc.). How research is used after the publication process is not relevant to this debate over the merits of the science of Friedman’s original article.
¶ Reference:
¶ Gammon, Doris G., Todd Rogers, Jennifer Gaber, James M. Nonnemaker, Ashley L. Feld, Lisa Henriksen, Trent O. Johnson, Terence Kelley, and Elizabeth Andersen-Rodgers . "Implementation of a comprehensive flavoured tobacco product sales restriction and retail tobacco sales." Tobacco Control (2021).
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...
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 claim that Friedman’s conclusion is still valid despite not being based on any data after the ordinance actually took effect.
In addition to this central issue, Pesko raised some other minor points that we address below.
Pesko criticised the CDC for providing unequal access to data. This is false. We simply used the request form on the CDC public website (https://www.cdc.gov/healthyyouth/data/yrbs/contact.htm) and were directed to reach the San Francisco School District that conducted the YRBSS to confirm these dates.
Pesko argued that our discussion of the tobacco industry promoting Friedman’s study is irrelevant. We disagree. The tobacco industry and its allies and front groups have widely used Friedman’s conclusion “that reducing access to flavored electronic nicotine delivery systems may motivate youths who would otherwise vape to substitute smoking”[5] to oppose local and state flavored tobacco sales restrictions.
References:
1 Liu J, Hartman L, Tan ASL, et al. Youth tobacco use before and after flavoured tobacco sales restrictions in Oakland, California and San Francisco, California. Tob Control 2022;:tobaccocontrol-2021-057135. doi:10.1136/tobaccocontrol-2021-057135
2 Vyas P, Ling P, Gordon B, et al. Compliance with San Francisco’s flavoured tobacco sales prohibition. Tob Control 2021;30:227–30. doi:10.1136/tobaccocontrol-2019-055549
3 Friedman AS. Further Considerations on the Association Between Flavored Tobacco Legislation and High School Student Smoking Rates-Reply. JAMA Pediatr 2021;175:1291–2. doi:10.1001/jamapediatrics.2021.3293
4 Maa J, Gardiner P. Further Considerations on the Association Between Flavored Tobacco Legislation and High School Student Smoking Rates. JAMA Pediatr 2021;175:1289–90. doi:10.1001/jamapediatrics.2021.3284
5 Friedman AS. A Difference-in-Differences Analysis of Youth Smoking and a Ban on Sales of Flavored Tobacco Products in San Francisco, California. JAMA Pediatr 2021;175:863–5. doi:10.1001/jamapediatrics.2021.0922
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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...
NOT PEER REVIEWED
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 the effective date. 1a) The authors state in their abstract: "We also found that 2019 YRBSS data from San Francisco, California cannot be used to evaluate the effect of the sales restriction on all flavoured tobacco products in San Francisco as the YRBSS data for this city were collected prior to enforcement of the sales restriction." This is undercut by the above finding that the policy effective date led to declines in e-cigarette sales. Additionally, for other researchers in this space, I highly recommend the use of effective date in these types of policy evaluation efforts. Only one thing can change the effective date: legislation. In contrast, any number of things can change enforcement dates including government resources and willpower to enforce the laws. Further, enforcement intensity can change over time for many reasons. For these reasons, enforcement is a messy source of variation subject to all kinds of endogeneity concerns. For this reason, the vast majority of quasi-experimental research uses effective date, and I recommend that continue. However, it's reasonable to consider alternative timing points (such as enactment date and/or enforcement date) as sensitivity analyses. 2) The authors state: "Following the sales restriction, high school youth vaping and cigarette use declined between 2017 and 2019 in Oakland. These observations of patterns are purely descriptive and observational and are not statistically significant changes." The authors cannot say that cigarette use 'declined' between 2017 and 2019 if this change is not statistically significant. 3) The authors say in their paper that they received the YRBSS survey collection date from the CDC. In their reply, they appear to acknowledge that this was false and they actually received the data from the San Francisco School District. The reference should be corrected so that people know where to go for this type of information in the future. 4) This statement is not completely accurate: "If youth smoking rates increased similarly in Oakland following that city’s sales restriction, this would lend credence to the call for caution against flavoured tobacco sales restrictions. However, if the patterns differ, we should identify alternate explanations for the rise in San Francisco’s youth smoking prevalence." It's entirely possible smoking rates could continue to fall, just by less than in control groups as a result of flavor bans. That would still be evidence that flavor bans are increasing smoking (by reducing smoking cessation). The loose language the authors use here could lead people to make the wrong conclusion in other contexts.
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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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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, not even after the January 1, 2019 enforcement date that Liu et al. purport as the critical date for a pre-post analytical design. This pattern is normal in sales data analyses of policy change. For example, even after Washington state had temporarily banned sales of flavored e-cigarettes in October 2019, sales of menthol-flavored e-cigarettes in November 2019 were still at 10% of pre-ban volumes. Sales crashed after the policy went into effect but never reached zero. Enforcement was incomplete. But to argue that the policy was not in effect in San Francisco or Washington after it was implemented is flat wrong. By late 2018, as measured in sales, retailer behavior had been affected by the policy.
Second, Liu et al. relying on work from Vyas et al. , argue that the policy was not truly affecting real-life outcomes in late 2018 because there was a low measured compliance rate with the flavored tobacco policy among retailers. Interestingly, in this case, Liu et al. judge whether retailers were affected by the flavored sales ban in a binary manner, favoring an interpretation that any retailer being out of compliance by selling one flavored product counts as not changing behavior at all. They assume that those 82% of retailers who violated the sales ban in San Francisco in December 2018 had not altered their behavior or wares since the policy came into effect in July of that year. Vyas points out that many retailers had questions about which products were covered by the ban, such as capsule cigarettes and cigars with “Sweet” descriptors. Vyas et al. frustratingly do not provide evidence about what it meant for retailers to be out of compliance in December 2018. But, judging from the details of the enforcement survey conducted, selling just one flavored tobacco product, even unknowingly, would make a retailer non-compliant. Further, given the importance of flavored tobacco sales in the US tobacco market, it would be reasonable to assume almost all tobacco retailers sold flavored products before the policy was in effect. So, at least 18% of retailers had changed their behavior to become fully compliant with the policy before the enforcement date, and I strongly suspect that many more reduced the number of non-compliant products on their shelves before enforcement (judging by changes in sales). Real-life changes in retailer behavior were in effect by late 2018.
For Friedman’s pre-post design to be inappropriate, as Liu et al. claim, the flavored tobacco sales ban must have had no effect on any person’s behavior before January 2019, when YBRSS data collection finished. The authors have repeatedly claimed that Friedman is not measuring what they think they are measuring. Still, her rejoinders that she meets the requirements to use a pre-post differences-in-differences analytical design with her chosen data are correct. Friedman should not retract her study.
Liu et al. should continue to look into important policy questions raised by Friedmans’ study. They and the rest of our field should use rigorous and appropriate analytical methods. We should learn as much as we can using all tools and data available. And the answers we find will depend as much as possible on the data and not on the convenience of findings of advocacy groups.
Finally, this case highlights the need for including more precise date of data collection identifiers in publicly available datasets. Had CDC included some of these data in the original YRBSS, this controversy could have been averted.
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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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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 effective date is not at all as unusual as Pesko claims. Pesko and Friedman’s suggestion to use effective date post hoc simply does not make any logical sense in the San Francisco case, where there was an explicit and highly publicised period of non-enforcement as well as documented non-compliance with the policy through the period of survey administration. In fact, all the existing papers on the San Francisco flavour ban,[5–8] including the Friedman paper,[1] have used the January 1, 2019 enforcement date as the cut-off date for evaluating the policy implementation effects.
Friedman rightly points out that the San Francisco Department of Public Health didn’t even begin compliance inspections until December 3rd, 2018. The YRBSS survey was already nearly complete (fielded between November 5th and December 14th, 2018) at that time. In addition, the current smoking question assesses smoking in the past 30 days, meaning that all of the survey respondents would be reporting on their smoking behaviour for a preceding period that encompasses a time before compliance checks began. When compliance checks began in December, only 17% of retailers were found to be compliant with the flavour ban, likely because they were explicitly instructed that there would be no penalties until January 1, 2019. These facts mean that youths’ retail purchase access would not have changed appreciably at that time. Her conclusion in her paper that “reducing access to flavoured electronic nicotine delivery systems may motivate youths who would otherwise vape to substitute smoking”[1] is inconsistent with the fact that e-cigarettes were still widely available in San Francisco in the fall of 2018.
Pesko and Friedman cite Gammon et al. (2021) showing reduced e-cigarette sales[5] to argue that Friedman’s analysis is still valid because the law may have led to a decrease in youth’s demand for e-cigarettes before the enforcement date. In truth, the vaping rate went from 7.1% to 16% in San Francisco between 2017 and 2019. We note that the Friedman paper omitted reporting youth vaping prevalence,[1] stating that “Recent vaping was not considered because of likely confounding. California legalised recreational marijuana use the same year San Francisco’s flavour ban went into effect; in addition, the YRBSS’s vaping questions did not distinguish vaping nicotine vs marijuana.” The decision to not control for vaping in the Friedman analysis is not justified. Friedman wrote in her response[2] to three critiques[3,9,10] of the original paper that the reason was potential misclassification of marijuana vaping due to California’s legalisation of recreational marijuana because the YRBSS questions do not specify the substance being vaped. Marijuana exclusive vapers account for only about 1% of the youth population, making this an inappropriate reason to not control for significant differential changes in vaping over time in different cities.[11–13] For example, vaping rates went down in Oakland after the flavour restriction but were up significantly in the 2018 pre-enforcement period in San Francisco. Initiation of vaping nicotine has been associated with higher rates of subsequent use of cigarettes among adolescents.[14,15] Higher rates of vaping nicotine e-cigarettes may also have been the impetus for passage of the San Francisco flavour ban, making vaping an important confounder. Taken together, these facts make uncontrolled confounders a likely explanation to cigarette use differences across locations and therefore decreases the possibility that the cigarette smoking rate went up due to an unenforced flavour ban.
Pesko and Friedman did not mention that Gammon et al. (2021) reported the predicted flavoured nicotine e-cigarette sales in San Francisco increased from 3439 units per week pre-policy (July 2015-July 2018) to 5906 units per week in the effective period (July-December 2018) and only declined after the enforcement period (January-December 2019) to 16 units per week (Table 1 in their article).[5] Clearly, flavoured e-cigarettes were still widely available in the marketplace during the effective but non-enforced period and in fact, more flavoured e-cigarettes were sold during the effective period than prior to the policy. Furthermore, Friedman also did not mention that Gammon et al. (2021) reported that cigarette sales declined post flavour ban.[5] Predicted total cigarette sales in San Francisco declined from 83424 units per week pre-policy (July 2015-July 2018) to 77370 units per week in the effective period (July-December 2018) and further declined after the enforcement period (January-December 2019) to 64220 units per week (Table 1). [5] This pattern is therefore inconsistent with Friedman’s 2021 paper conclusion that “reducing access to flavoured electronic nicotine delivery systems may motivate youths who would otherwise vape to substitute smoking” in the fall of 2018. The fact is average weekly flavoured e-cigarette sales increased while total cigarette sales decreased in San Francisco between July-December 2018 compared to pre-policy period. [5] The substitution explanation falls apart. Pesko and Friedman cannot selectively use data to have it both ways.
As we described in our paper, after Oakland implemented a convenience store flavoured tobacco sales restriction in July 2018, high school youth vaping declined from 11.2% to 8.0% (p=0.04)[16] and smoking declined from 4.4% to 2.4% (p=0.02)[17] between 2017 and 2019. Our description that vaping and cigarette use prevalence declined was accurate. Upon reviewing the YRBSS data from the CDC, the Oakland data does in fact represent a statistically significant drop in vaping and smoking rate from 2017 to 2019. Friedman objects to our use of the Oakland (neighboring city to San Francisco) data as a comparison because Oakland’s law was less comprehensive than San Francisco’s. We respectfully disagree with Friedman’s objection. The Oakland law that drastically limited youth access to flavoured tobacco products in that city certainly informs the San Francisco case. The idea that the decline in cigarette smoking prevalence after the flavour ban in Oakland was less than the decline of cigarette smoking elsewhere is disproven by the fact that there was a greater drop in current smoking rate in Oakland from 2017 to 2019 (46% decline from 4.4% to 2.4%) compared to the average decrease nationally across the United States (32% decline from 8.8% to 6.0%) based on YRBSS data.[18]
Friedman offered several post hoc explanations for why youth cigarette smoking might increase following a flavour ban. She offers no data from San Francisco to support market responses following the SF flavour ban, nor does she provide data that SF youth had switched to using flavour accessories. These scenarios also assume that flavoured tobacco products were no longer available at the time of the SF YRBSS data collection, but we know products were still largely available as of December 2018 in 83% of the retailers. It is historically inaccurate for Friedman to suggest that the outbreak of EVALI had any bearing on potentially reducing people’s willingness to buy vaping products from informal sellers in 2018 because this outbreak occurred in the fall of 2019, one year after the SF YRBSS data were collected.
Our description about receiving the YRBSS survey collection date through an inquiry from the CDC was accurate.[19] The CDC informed us that the YRBSS in San Francisco was conducted in the fall of 2018 and we used this information in our paper. We wrote to the San Francisco School District to confirm these dates as did Dr. Friedman.
Liber’s points about partial compliance rates are refuted by the availability of flavoured products during the survey administration period and are addressed by our above response. We thank him for agreeing that this case highlights the need for including more precise date of data collection identifiers in publicly available data sets. Given the significance and potential impact of these analyses for public health policy, it behooves all users of publicly available data to pay close attention to dates of data collection in relation to policy effective/enforcement dates when analyzing this information, to seek confirmation if there is any doubt, and not make assumptions about the dates. In this case the dates of the 2019 YRBSS administration ranged widely from fall of 2018 (SF) to fall of 2019 (NYC).[19]
An important benefit of flavour ban legislation is that flavoured combustible tobacco use goes down.[7] The use rates of flavoured combustible little cigars and cigarillos are similar or exceed the combustible cigarette use rate among youth in San Francisco, [11] making flavour bans an important tool in decreasing overall youth combustible tobacco rates.
The results of the 2019-2020 California Student Tobacco Survey, which was conducted after the enforcement of the flavour ban showed that the prevalence of cigarette smoking among San Francisco high schoolers was 1.6% (compared with 4.7% based on the San Francisco 2017 pre-ban YRBSS data).[11] After the enforcement of the flavour ban, we now see historically low smoking rates in San Francisco. This data from the time after the flavour ban was actually implemented by retailers further calls into question the conclusion of the Friedman paper.
References
1 Friedman AS. A Difference-in-Differences Analysis of Youth Smoking and a Ban on Sales of Flavoured Tobacco Products in San Francisco, California. JAMA Pediatr 2021;175:863–5. doi:10.1001/jamapediatrics.2021.0922
2 Friedman AS. Further Considerations on the Association Between Flavoured Tobacco Legislation and High School Student Smoking Rates—Reply. JAMA Pediatr 2021;175:1291–2. doi:10.1001/jamapediatrics.2021.3293
3 Maa J, Gardiner P. Further Considerations on the Association Between Flavoured Tobacco Legislation and High School Student Smoking Rates. JAMA Pediatr 2021;175:1289–90. doi:10.1001/jamapediatrics.2021.3284
4 Liu J, Hartman L, Tan ASL, et al. In reply: Youth tobacco use before and after flavoured tobacco sales restrictions in Oakland, California and San Francisco, California. Tob Control Published Online First: 16 March 2022. doi:10.1136/tobaccocontrol-2021-057135
5 Gammon DG, Rogers T, Gaber J, et al. Implementation of a comprehensive flavoured tobacco product sales restriction and retail tobacco sales. Tob Control Published Online First: 4 June 2021. doi:10.1136/tobaccocontrol-2021-056494
6 Guydish JR, Straus ER, Le T, et al. Menthol cigarette use in substance use disorder treatment before and after implementation of a county-wide flavoured tobacco ban. Tob Control 2021;30:616–22. doi:10.1136/tobaccocontrol-2020-056000
7 Yang Y, Lindblom EN, Salloum RG, et al. The impact of a comprehensive tobacco product flavour ban in San Francisco among young adults. Addict Behav Rep 2020;11:100273. doi:10.1016/j.abrep.2020.100273
8 Holmes LM, Lempert LK, Ling PM. Flavoured Tobacco Sales Restrictions Reduce Tobacco Product Availability and Retailer Advertising. Int J Environ Res Public Health 2022;19:3455. doi:10.3390/ijerph19063455
9 Mantey DS, Kelder SH. Further Considerations on the Association Between Flavoured Tobacco Legislation and High School Student Smoking Rates. JAMA Pediatr 2021;175:1290. doi:10.1001/jamapediatrics.2021.3287
10 Leas EC. Further Considerations on the Association Between Flavoured Tobacco Legislation and High School Student Smoking Rates. JAMA Pediatr 2021;175:1290–1. doi:10.1001/jamapediatrics.2021.3290
11 Zhu S-H, Braden K, Zhuang Y-L, et al. Results of the Statewide 2019-2020 California Student Tobacco Survey. https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/CTCB/CDPH%20Document%20Lib...
12 Zhu S-H, Zhuang Y-L, Braden K, et al. Results of the Statewide 2017-2018 California Student Tobacco Survey. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUK...
13 Monitoring the Future (MTF) Public-Use Cross-Sectional Datasets. https://www.icpsr.umich.edu/web/NAHDAP/series/35 (accessed 1 Jul 2022).
14 Chan GCK, Stjepanović D, Lim C, et al. Gateway or common liability? A systematic review and meta-analysis of studies of adolescent e-cigarette use and future smoking initiation. Addiction 2021;116:743–56. doi:10.1111/add.15246
15 Soneji S, Barrington-Trimis JL, Wills TA, et al. Association Between Initial Use of e-Cigarettes and Subsequent Cigarette Smoking Among Adolescents and Young Adults: A Systematic Review and Meta-analysis. JAMA Pediatr 2017;171:788–97. doi:10.1001/jamapediatrics.2017.1488
16 Centers for Disease Control and Prevention. Youth Online: High School YRBS - Oakland, CA 2017 and 2019 Results Current Electronic Vapor Product Use. https://nccd.cdc.gov/Youthonline/App/Results.aspx?TT=A&OUT=0&SID=HS&QID=... (accessed 1 Jul 2022).
17 Centers for Disease Control and Prevention. Youth Online: High School YRBS - Oakland, CA 2017 and 2019 Results Current Cigarette Smoking. https://nccd.cdc.gov/Youthonline/App/Results.aspx?TT=A&OUT=0&SID=HS&QID=... (accessed 1 Jul 2022).
18 Centers for Disease Control and Prevention. Trends in the Prevalence of Tobacco Use National YRBS: 1991—2019. 2021.https://www.cdc.gov/healthyyouth/data/yrbs/factsheets/2019_tobacco_trend... (accessed 20 Jun 2022).
19 Centers for Disease Control and Prevention. Data Request and Contact Form- YRBSS. 2021.https://www.cdc.gov/healthyyouth/data/yrbs/contact.htm (accessed 1 Jul 2022).
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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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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 considered to be reasonable counterfactuals for the adopters’ trends. The corresponding multivariable regression explicitly controls for other policy changes that may affect the outcome, common time trends, and time-invariant differences between jurisdictions (i.e., absorbing ⍺ in Figure). In that context, changes in the adopting jurisdictions’ trends relative to non-adopters— β-⍺ in Figure 1 — can be attributed to the policy change. Such analyses use the policy’s official effective date as the pre- vs post-policy cut point to avoid confounding from endogenous delays in a policy’s implementation (e.g., as retailer or consumer behavior can contribute to implementation delays). In other words, a DD analysis based on realized enforcement dates risks introducing bias. Thus, official/legislated effective dates are used to ensure that resulting estimates capture unconfounded responses to the policy change.
While DD estimates are valid even when the official effective date precedes full implementation, claims about their generalizability may need to be constrained. In the case of San Francisco’s flavor ban, the implementation history suggests that the effects I estimated should be interpreted as responses to the partially implemented policy, as both the policy timeline and empirical data show responses to the policy in late-2018. Specifically, voters approved San Francisco’s ban on sales of flavored tobacco products via referendum on June 5th, 2018. While the policy’s legal effective date was July 21, 2018, the San Francisco Department of Public Health (SFDPH) announced that retailer violation penalties would not be enforced until January 1, 2019, so retailers could liquidate their existing stocks of flavored products. In the interim, SFDPH conducted retailer education and outreach starting in September 2018, and began compliance inspections on December 3rd, 2018. Retailers still selling flavored products at that point were informed that the flavor ban was in effect and they would face suspension of their tobacco sales permit if they continued to offer flavored products; and they were issued a Compliance Notification Letter with instructions to text a particular number to confirm compliance. Accordingly, San Francisco’s flavored tobacco product sales fell markedly in the second half of 2018: weekly averages for November and December 2018 were both well below those for the four weeks preceding July 21, 2018, a pattern not evident in comparison districts. [3] Retailer compliance was measured at 17% in December 2018 which, while low, still evinces a retailer response to the law before 2019. [4] Prior work showing that consumers respond to anticipated tobacco policy changes, not merely those already in effect, offers further ways San Francisco’s law could have affected consumer behavior during this period. [5]
Indeed, evidence on retailer behavior shows that enforcement per se was not necessary to induce retailer compliance. Specifically, despite SFDPH’s plan to begin enforcing retailer penalties in January 2019, the flavor policy’s Rules and Regulations were not finalized until August 16, 2019, meaning that non-compliant retailers did not face suspension of their tobacco sales permits in the first half of 2019 (Jennifer Callewaert, Principal Environmental Health Inspector at SFDPH, personal communication, 5/19/2022). Yet Vyas et al. (2021) document retailer compliance rates of 77%, 85%, and 100% in January, February, and March of 2019, respectively. [4] Thus, while expected penalties may have driven compliance during this period, enforcement per se could not have.
Liu et al.’s (2022) article cannot refute these mechanisms: beyond its failure to present any statistically significant evidence, the authors overlook the fact that youth cigarette smoking also declined in California districts without a flavor restriction during this period: from 2017 to 2019, YRBSS smoking rates dropped from 4.2% to 3.2% in San Diego, and 2.7% to 2.3% in Los Angeles. Thus, common time trends could explain Oakland’s nonsignificant trend, as opposed to its flavor policy. Perhaps more importantly, Oakland’s law was substantively different from San Francisco’s: the former allowed retailer exemptions and thus may have created different incentives for illicit suppliers—e.g., if a lack of legal sources for adults makes illicit sales of menthol cigarettes more profitable—yielding different effects on underage access. In this context, even if perfect estimates of the Oakland and San Francisco policies’ effects differed, one would not constitute evidence against the other because the policies themselves are different.
It is worth exploring conceptually why youth cigarette smoking might increase in response to a comprehensive flavor ban. Informal market responses to this policy offer one potential mechanism: if flavor bans make flavored products more profitable for illicit sellers, they could increase underage access to flavored combustible products (e.g., if illicit sellers stock up on menthol loosies, combustible menthol products may have actually become more accessible post-ban for youth who rely on unlicensed sellers). Alternatively, youth who preferred flavored products might turn to flavor accessories primarily designed for use with combustible products (e.g., flavor cards, crush balls), making smoking more attractive relative to vaping once flavored vapes were not offered by licensed retailers (particularly if the 2019 outbreak of vaping-associated lung injuries reduced people’s willingness to buy vaping products from informal sellers).
Youth substitution from exclusive cigar use towards cigarettes might explain a portion but not all of the results: as the majority of youth cigar users already smoke, the effect size I estimated is too large to be fully explained by youth who previously smoked cigars. While substitution could not be assessed directly (as San Francisco’s YRBSS data did not cover cigar use in 2015-2019), over 70% of San Francisco minors responding to the 2013 YRBSS who reported past 30 day cigar use already smoked cigarettes. Rescaling these numbers based on 2013 to 2017 reductions in cigar use observed in other California districts suggests that about 0.7% of San Francisco youths smoked cigars but not cigarettes in 2017. If all of them switched to cigarettes in response to the flavor ban, it would account for less than 15% of my effect estimate. (I derived these estimates based on YRBSS data).
Finally, it is possible that San Francisco youth who took up smoking in late 2018 were already addicted to nicotine, and simply switched to cigarettes as the most accessible substitute once flavored ENDS were no longer on the market. In that case, flavor restrictions’ long-run effects might differ from the short run if the lack of flavored ENDS reduces youth nicotine uptake. This is an important possibility that calls for further study.
My paper certainly is not the final say on flavor restrictions’ effects. As the original article noted, its findings may not generalize in the long run, to other jurisdictions, or to heterogeneous flavor restrictions. It provides one piece of evidence on how minors’ cigarette smoking changed under one partially implemented flavor policy in a distinctive urban center. We need more research on longer run outcomes across many different jurisdictions’ policies, considering both youth and adult behavior as well as effects on the illicit market, to fully understand flavor restrictions’ implications for public health.
Funding Statement: This research was supported by the National Institute on Drug Abuse of the National Institutes of Health (grant 3U54DA036151-08S2) and the US Food and Drug Administration Center for Tobacco Products. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
References
[1] Liu J, Hartman L, Tan ASL, et al. Youth tobacco use before and after flavoured tobacco sales restrictions in Oakland, California and San Francisco, California. Tob Control 2022 [Published Online First]. 17 March 2022 [cited 2022 June 16] http://dx.doi.org/10.1136/tobaccocontrol-2021-057135.
[2] Friedman AS. A difference-in-differences analysis of youth smoking and a ban on sales of flavored tobacco products in San Francisco, California. JAMA Pediatr 2021;175(8):863-865.
[3] Gammon DG, Rogers T, Gaber J, et al. Implementation of a comprehensive flavoured tobacco product sales restriction and retail tobacco sales. Tob Control, 2021 [Published Online First]. 4 June 2021 [cited 2022 June 16] http://dx.doi.org/10.1136/tobaccocontrol-2021-056494.
[4] Vyas P, Ling P, Gordon B, et al. Compliance with San Francisco’s flavoured tobacco sales prohibition. Tob Control 2021;30:227-230.
[5] Gruber J, Köszegi B. Is addiction "rational"? Theory and evidence. Q J Econ 2001;116(4): 1261-1303.
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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.
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...
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 Announcement). The release noted that “the companies have agreed to focus on launching IQOS in the U.S.” PMI is listed on the New York Stock Exchange and is therefore subject to the rules of the NYSE and the Securities and Exchange Commission, including requirements for the disclosure of material events such as the PMI/Altria Announcement. We estimate that during a date range similar to that used by the authors, of the total number of stories retrieved using the authors’ search terms, >85% were reporting on the above noted PMI/Altria Announcement. The authors failed to mention this and other confounders in their discussion.
The authors state that “the original PMI press release (sic) was republished (including editing or revisions to make the republication consistent with the publisher’s format) in 14 additional news outlets.” We performed a full text review of the 14 articles mentioned and of those that were still accessible, none mentioned IQOS. The authors’ conclusion that “PMI capitalised on EVALI by using an earned news media strategy to market their IQOS brand of heated tobacco for free across scores of news outlets that reached millions of readers. This marks the first known case where a tobacco company used the EVALI outbreak to promote tobacco products” is therefore completely unsupported by their own data.
These facts, and other errors detected in this article, were communicated to the authors on 23rd April 2021. In summary, we believe that the article is unreliable, and that urgent substantial revision or retraction is warranted to prevent other studies citing the currently published inaccuracies.
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...
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 not necessarily guarantee the full reporting of all specified outcomes. This unfortunately holds true throughout the reporting of clinical research. [3, 4]
Additionally, we showed that for the conference posters identified by our searches there was a clear risk of unreported outcomes for these short-format publications. Potentially making some studies only available as posters or abstracts risks further outcome reporting issues or delays.
In Footnote 9 of the comment, Dr. Mishra states that “Section 801 of the Food and Drug Administration Amendments Act of 2007 (FDAAA) and implementing regulations issued by the National Institutes of Health (NIH) do not require registration of clinical trials involving tobacco products”
The Final Rule is entirely silent on the specific coverage status of tobacco products. Searching the Final Rule document for the word “Tobacco” reveals 0 results.[5] Another Final Rule issued well after the Sottera decision, 21 CFR 201, 801, and 1100, and an FDA guidance document both make clear that under certain circumstances tobacco products can be considered covered under the FDAAA.[6, 7]
To quote the FDA Guidance:
“If an ENDS product is marketed for tobacco cessation or for any other therapeutic purpose, the product is a drug or device, rather than a tobacco product, under the authorities of FDA’s Center for Drug Evaluation and Research or Center for Devices and Radiological Health, and appropriate approval must be sought to market a product as a drug or device.” (Page 9)
And 21 CFR 201, 801, and 1100:
“Whether the product, as used in the study, is subject to regulation as a drug depends on whether the product is being investigated for any of the purposes described in § 1100.5(a) or (b) of this rule. To determine if a product made or derived from tobacco is being investigated for one of these purposes, FDA generally would review the protocol for the study, including the proposed methods and measures. In the Agency’s experience, the proposed methods and measures for a study can provide insight into the purposes for which a product is being investigated.” (Page 2213)
We also note that the FDAAA Final Rule requires trials of drugs and devices to report regardless of whether or not they plan to seek any approvals with the FDA [5]:
“The final rule maintains the proposal to require the submission of results information for applicable clinical trials of unapproved, unlicensed, or uncleared products, regardless of whether FDA approval, licensure, or clearance is or will be sought or obtained.” (Page 64995)
We discuss the relevant legal frameworks, and their unfortunate ambiguity, in more depth in the manuscript.
Our determination of potential FDAAA coverage was based on public registration information directly provided by Juul and matched to official published criteria for determining FDAAA coverage. As stated in their comment, Juul Labs have now updated many of their registrations to no longer match these criteria. However the registered trials we assessed contained outcomes related to the uptake and pharmacokinetics of nicotine in the body, a key feature of addiction, and measures directly relevant to smoking cessation like product use, dependency, urge to smoke, and aspects of withdrawal. It is, however, ultimately up to the FDA to make official determinations about which trials are covered under the FDAAA based on their assessment of the purpose and outcomes of a given study.
Regardless of the exact regulatory status of these trials, a matter we hope the FDA will offer further clarity on, we strongly encourage Juul Labs to consider amending their existing registrations with the results of these trials. ClinicalTrials.gov offers a rapid, public, open source repository for trial results that enhances their availability, transparency, and discoverability and should not preclude subsequent peer reviewed publications.[8] It is clear from their response that Juul Labs understands the importance of trial registration and reporting to the public and scientific community, and we welcome this recognition. ClinicalTrials.gov allows for full results to be reported, without space limitations or delays associated with journal publication, and with a clear public link to all prespecified outcomes and other registered details. While the FDAAA compels this type of reporting, there is no limitation on voluntary submission of results if trials are not covered under the law. We strongly believe it is in the public interest that all outcomes for all trials that form PMTA applications should be fully and publicly reported in a timely manner. Currently this does not appear to be the case even if it may have improved since our evaluation.
Whether compelled to report by legal requirements or not, we hope Juul will consider setting a strong precedent for transparency in tobacco-industry e-cigarette research by adhering to global ethical standards [9] and reporting their full trial results for these, and future, trials to ClinicalTrials.gov and assuage any doubts about selective reporting of results or outcomes.
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...
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 are outdated references to publication or presentation of the five studies included by the authors in their analysis. While the article asserts that just one of the five studies that was incorrectly registered as an “applicable device clinical trial” has been published, as of this writing, results from three of the five studies have been published. (8) Across our research program, we have published a total of 17 articles (all publicly available on our science website www.juullabsscience.com) and are working on additional publications.
Finally, although not obligated to do so (9), Juul Labs voluntarily submitted registration information for ten studies to the ClinicalTrials.gov registry. As voluntary submissions, all of the studies should have been registered as a “voluntary other trial.” Due to an administrative error at Juul Labs, six of those studies were instead registered as an “applicable device clinical trial.” These errors are in the process of being corrected and, in fact, four of the studies have been formally updated on ClinicalTrials.gov to reflect this change. (10, 11, 12, 13)
We look forward to continuing to share results from our science and research program with the scientific and public health community as we work to advance harm reduction for adults who smoke, and to support the scientific basis for the category.
Sincerely, Snigdha Mishra, SVP Regulatory Science
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...
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 press and would likely include a discussion of consequences for iQOS.
So, an analysis that tries to measure media interest in PMI and iQOS for cynical publicity purposes at that time would be heavily confounded by other unrelated but newsworthy developments concerning the same company and product. A check of the press releases by the company should have raised the alarm. PMI also states that it did not seek any publicity for its safety notice about iQOS, which PMI says the authors:
"falsely describe as a “press release”, despite it never being published through a press release distribution service"
Now that it has been pointed out, it is quite clear that a serious error has been made here that undermines the foundations of the study and renders the allegation made in the title baseless. The simple way to deal with this is to acknowledge the error, retract the article, apologise, and resolve to be more careful in future. That should take a couple of hours, not several months and there would be no shame in it. That this has not happened is troubling.
[1] Moira Gilchrist (PMI) Review of: Philip Morris International used the e-cigarette, or vaping, product use associated lung injury (EVALI) outbreak to market IQOS heated tobacco. Qeios. [https://www.qeios.com/read/NLZDBR}
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...
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 articles is not supported by our replication analysis.
We recognize that for any observational data analysis there are alternative explanations. However, Gilchrist’s alternative explanations are debatable. First, she argues the materials published by PMI on EVALI and IQOS (3) were not a “press release” and therefore could not have engendered a change in media coverage. We now refer to the materials published by PMI on EVALI and IQOS as a “public statement” published on PMI’s website. Yet, PMI has not provided any verifiable disclosure about how they circulated these materials beyond their publication and availability on internet search engines and social media, a concern we raised in our study (2). Regardless, PMI’s public statement was potentially consumed and amplified by other media makers. Second, she assumes the increase in news coverage was due to a PMI publication entitled “Philip Morris International Inc. and Altria Group, Inc. End Merger Discussions” (4) which does not mention EVALI. While a sizable percentage of the news articles we studied mention the merger, their inclusion of IQOS and EVALI suggests the possibility of additional source material for these stories. It is plausible that information from the published materials we studied tying IQOS and EVALI and the larger merger story were discussed in tandem.
There were factual errors in our report that we missed during the copy edit of our piece: the date of PMI’s materials being published was misstated (25 versus 24 September), the date of another reference was misstated, and references were misordered. Additionally, the date we submitted our piece was misstated due to a production system issue created by a delay in submitting the revised version. Last, in light of PMI stating that the 25 September publication was not a press release, the article has been amended accordingly. We have provided Tobacco Control with an errata to correct these errors. However, the principal conclusion of our work was unaffected by any error.
While we can measure the potential spillover effect of published claims, we cannot know PMI’s intent. It is paramount that the earned media strategies of the tobacco industry come under closer inspection. The tobacco industry has used varied tactics to sow misimpressions that favor them and their products, a fact well documented in both the scientific literature and courts of law (5); earned media campaigns may be yet another.
References
1. Gilchrist M. Study alleging Philip Morris International used the EVALI outbreak to market IQOS requires substantial methodological revision and further peer review, or retraction. Tob Control Rapid Response.
2. Ayers JW, Leas EC, Dredze M, et al. Tob Control. Epub ahead of print: doi:10.1136/ tobaccocontrol-2021-056661.
3. Philip Morris International. Lung illnesses associated with use of vaping products in the US. Available: https://www.pmi.com/media-center/news/lung-illnesses-associated-with-use... [Accessed 10 Mar 2021].
4. Philip Morris International. Philip Morris International Inc. and Altria Group, Inc. End Merger Discussions. https://philipmorrisinternational.gcs-web.com/static-files/78a6afb3-107d... Accessed 11 June 2021.
5. Ong EK, Glantz SA. Constructing "sound science" and "good epidemiology": tobacco, lawyers, and public relations firms. Am J Public Health. 2001;91.
NOT PEER REVIEWED
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...
NOT PEER REVIEWED
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 claim
The headline finding is not, however, even remotely plausible. The company has made it clear that it made its iQOS-EVALI statement available passively for information purposes. If it had generated even one story among 384 the authors say that matched their keyword search in the 30 days after publication, the authors could have produced it. If they had a good case and wanted to avoid a retraction, they could have looked through these results (or to save time, articles published in the two weeks after PMI's statement) and shown at least some articles clearly derive from the statement. Though searching only with Google, I have been unable to identify a single article. That doesn't mean there aren't any, but it's not me making the allegations. The authors are making the allegations and the burden of evidence is with them. They should now respond with examples of articles that support their critique and publish the list of 384 articles captured in their search as a supplementary file that is open to anyone to examine
3. Confounding by other news is a fatal problem for this study
The problem of confounding by other news related to the company, product and sector at around the same time is overwhelming. PMI published its iQOS-EVALI statement on 24 September 2019 [3]. This period coincided with; the end of merger talks between Altria and PMI on 25 September [4]; also on the same day, Juul announced the departure of its CEO and new corporate practices (Juul is part-owned by Altria) [5]; a new iQOs product was launched by PMI on 26 September [6]; there was an ongoing controversy with high news value developments on a lung injury outbreak in the United States, which was at the time often falsely attributed to nicotine vaping. For example, a significant CDC press release on 27 September [7].
4. Many news media will have covered several issues at once
The timing in question was a crisis period for products and companies making low-risk alternatives to cigarettes. It will have generated many news pieces that would have covered specific stories but also rounded up the other news. For example, Reuters reported both the PMI-Altria merger news and Juul restructuring in the same piece on 25 September 2019 with references to both lung injures and to iQOS, but without any reference to PMI's 24 September 2019 statement. [8]
5. The study method has no credible approach to confounding
Much of the response seems to be devoted to discussing sloppy though trivial errors in the original paper. This is a distraction from addressing the fundamental flaw, on which the response has relatively little to say. Without some sort of strategy to address confounding by other news and thereby to isolate from the signal (of PMI cynical opportunism) from the cacophonous noise of the news flow at the time, the authors have no basis for their claim. On top of this, the failure to produce a single article that appears to be derived in whole or even in part from the allegedly cynical communication suggests the authors have nothing.
6. Failure to put findings to the company
There is no sign here that the authors contacted the company or made any efforts to verify their story or check for alternative explanations. Why not? Why is it acceptable to avoid this most basic of journalistic practices simply because the authors are writing in an academic journal and about an organisation they do not like?
Just because the object of this research is the tobacco industry, it doesn't mean scientific standards or research and investigative ethics should be jettisoned. Precisely because the target of this research is a tobacco company, it makes a good test of scientific integrity and ‘white hat bias’. [9]
“White Hat Bias is bias leading to distortion of research-based information in the service of what may be perceived as righteous ends.”
[9]. The concept originates with: Cope MB, Allison DB. White Hat Bias: Examples of its Presence in Obesity Research and a Call for Renewed Commitment to Faithfulness in Research Reporting. Int J Obes (Lond) 2010;34(1):84. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2815336/
NOT PEER REVIEWED
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...
NOT PEER REVIEWED
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 marked as “additional coverage” of the PMI News Article. Of the total, 5 of the “duplicate articles” were no longer accessible online and none of the remaining 9 mentioned IQOS at all. All of them were reporting on the EVALI outbreak and flavor ban proposals, a fact that we raised in our April letter to the Authors.
The Authors note that Tobacco Watcher is “a dynamic resource with continuous data collection and processing”. We could not find any information about the computational environment of the database, nor does there appear to be any public information about factors that can impact reproducibility and replicability. Specifically, we could not find any published information about how it collects, processes, and analyzes data, how it is version controlled and what data management plans are in place. However, a poster presentation by some of the Authors indicates that media articles are “automatically coded” using “natural language processing, trained on human-coded data” [4]. It is therefore difficult to understand why results relating to media articles from 2019—generated from an automatic coding process—could abruptly change over the course of two months in 2021. Of course, it is entirely plausible that the 14 articles had been falsely coded, and that this error was manually addressed at some point between April 20th and June 10th, 2021. The Authors should explain if this was the case, or whether changes to the underlying Tobacco Watcher algorithms caused the change—and if so, how. They should also provide an explanation of why they remain confident in the rest of their trend analyses, given the apparent instability of Tobacco Watcher over time.
Because of the Authors’ failure to replicate this important aspect of their study, there is no valid evidence to show any direct link between the PMI News Article and the increase in media coverage of IQOS and EVALI. The Authors’ invalid assumption that the PMI News Article was “republished” was presumably relied upon to support their title and conclusions and yet the evidence for this has now been shown to be nonexistent—not just by our analysis, but also by the Authors’ subsequent failure to replicate their initial finding.
Confounding Factors Ignored:
Given that the Authors have now shown that they do not have any evidence to support a direct, causal relationship between the PMI News Article and subsequent news coverage including both the terms IQOS and EVALI, potential confounders become central to the question of whether their title and conclusions are supported or not. Whilst they now concede that their evidence merely demonstrates that a causal relationship is “plausible”, they continue to ignore or dismiss other more likely explanations. Many confounding factors were laid out in our April letter—with sources beyond those emanating solely from PMI—and they provide important information about the news media environment that could credibly have caused a rise in articles mentioning IQOS and EVALI (including in particular the official press releases [5] by PMI and Altria on 25th September 2019—announcing that their proposed merger talks were over and that the companies would focus on launching IQOS in the U.S.— as well as a press release from the U.S. Centers for Disease Control related to EVALI). Generally, in epidemiology, sociology and other fields, there are at least three main criteria that should be met in order to establish a causal relationship: the cause occurs before the effect; the cause and the effect covary; and a lack of plausible alternative explanations [6]. By dismissing the most plausible explanations for the increase in media coverage, and failing to provide any credible alternative evidence to explain their hypothesis, the overall analysis and conclusion presented by the Authors fails to meet these criteria for causality.
Attempt to Shift the Burden of Proof:
The Authors make logical errors in defense of their Article. They state that “PMI has not provided any verifiable disclosure about how they circulated these materials [the PMI News Article] beyond their publication and availability on internet search engines and social media”. Any perceived lack of disclosure on the part of PMI does not render the Authors’ claims any more valid. To the contrary, the burden of proof is on them to provide evidence for their assertions. In the three months since we first wrote to the Authors to express our concerns, it would have been perfectly possible for them to: (a) list which news articles actually refer to the PMI News Article and/or use the phrases ‘IQOS’ AND ‘EVALI’ (rather than ‘vaping’ and ‘illness’, which are not identical search terms); and (b) rapidly and independently verify whether any of the journalists writing about both IQOS and EVALI had seen the PMI News Article by simply asking them.
Unsubstantiated, Yet Definitive Language:
The title “Philip Morris International used the e-cigarette, or vaping, product use associated lung injury (EVALI) outbreak to market IQOS heated tobacco” is a statement purporting to be factual. However, the Authors now state that their original findings and conclusions are merely “plausible” and admit “we cannot know PMI’s intent”. Plausibility is not a statement of fact or truth. Instead, it implies that an argument is not fully formed, appears specious, superficially fair or reasonable, but in fact could be either right or wrong. As such, the title and other conclusory allegations in the Article are—by the Author’s own admission—not supported. Having ignored or discounted evidence that makes the Author’s conclusions implausible, the final paragraph of their response makes clear that in the absence of evidence, their conclusion rests solely on the Author’s distrust of the industry.
Summary:
In summary, the conclusion that “Philip Morris International used the e-cigarette, or vaping, product use associated lung injury (EVALI) outbreak to market IQOS heated tobacco” can be disproven using the authors’ own tool, an analysis method that actually takes into account concomitant news events, the Authors’ acknowledgment that they failed to replicate an important aspect of their findings, and their concession that their title is merely “plausible”. The entire premise of the EVALI/IQOS Article is patently invalid and substantial revision or retraction of this paper remains urgently warranted.
NOT PEER REVIEWED
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.
NOT PEER REVIEWED
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 of the PMI’s public statement is available in the appendix of our original piece (the version available presently on the PMI website has been changed) and we analyze excerpts to make our case below.
PMI’s statement recounted the EVALI outbreak beginning: “Skepticism and fear around vaping has emerged following the cases of respiratory illness and deaths in the US associated with the use of e-cigarettes.” PMI then contrasted this against their IQOS heated tobacco product, writing “on April 30 2019, the FDA authorized IQOS for sale in the US, finding that marketing of the product would be ‘appropriate for the protection of public health’ [quotes used in the original release].” As we previously argued, some readers (especially novice consumers) can interpret this as implying the FDA endorses IQOS and such statements are not allowed. The Food, Drug and Cosmetic Act prohibits ‘any expressed or implied statement...that either conveys, or misleads or would mislead consumers into believing that [a tobacco] product is approved by the Food and Drug Administration’ (ACT 21 U.S.C. § 331(tt)). The same “appropriate for the protection of public health” statement also implies that IQOS is safer than vaping, a claim disallowed by the FDA.
While Bates and Gilchrist may still object to our assertions that PMI’s intent in publishing their statement was to promote IQOS using EVALI, this objection contrasts with public statements PMI executives have made that are perhaps even clearer in their intent. For example, a Wall Street Journal article began “tobacco giant Philip Morris International Inc. says vaping fears in the U.S. should give a boost to the recent launch of its IQOS smoking alternative” and cited PMI executives discussing how EVALI could be a boon for IQOS promotion just days after PMI published the materials we studied (6).
Bates and Gilchrist may similarly still object that other events (such as the failed merger talks between Altria and PMI (7)) may be responsible for news coverage of IQOS and EVALI. However, generating earned media about an issue is not a one-shot game. Any public relations expert could attest that a multi-modal strategy is required to get an issue in the news media agenda including a media statement, follow-up interviews, case studies, activations, integrations, etc.
Our assertion is that the EVALI outbreak was used by PMI as part of an overall strategy to promote IQOS - a fact we discovered in our Industry Watch piece. For example, the Irish Times reported that PM had called off merger talks with Altria, “…after it became apparent the US government crackdown on vaping could have a negative impact given Altria’s stake in Juul.” André Calantzopoulos, PMI’s chief executive, said that they had decided to focus on its launch of IQOS, which was not a vaping product (8) --thereby again leveraging EVALI to promote its new product.
We echo our previous call for the FDA to investigate the statement PMI published and subsequent news coverage for compliance and if a violation has occurred appropriate regulatory actions be taken. We call on the tobacco control community to invest in surveillance of industry speech and research on the potential impacts of industry speech that can inform additional regulations governing marketing channels such as websites, online news sources and other digital media.
We thank Cummings and colleagues for their interest in and comments on our umbrella review published recently in Tobacco Control.[1] The authors criticize us for not including the latest studies. Yet, for an umbrella review, those studies need to be in a published review to be included, as we indicated in our methods and limitations. Generally, given the lengthy review and publication processes, any review will not be inclusive of all studies in a field that has as high a publication breadth and intensity as tobacco regulatory science. In addition, the authors mentioned that our meta-analysis was not available in PROSPERO pre-registration. This is because the review registration was completed in the very early stages of the review. We have updated this information in PROSPERO now to include the meta-analysis. The issue of overlap was addressed in our limitations, as we had to screen over 3,000 studies included in our selected reviews. However, given the importance of this issue for the meta-analysis, we performed a new meta-analysis that included the individual studies in each domain instead of using the odds ratio reported by the review to eliminate the effect of including the same study more than one time on our results. We confirm that the results of the new meta-analysis, which includes each study only once, are similar to the original meta-analysis (Supplement A: https://www.publichealth.me...
We thank Cummings and colleagues for their interest in and comments on our umbrella review published recently in Tobacco Control.[1] The authors criticize us for not including the latest studies. Yet, for an umbrella review, those studies need to be in a published review to be included, as we indicated in our methods and limitations. Generally, given the lengthy review and publication processes, any review will not be inclusive of all studies in a field that has as high a publication breadth and intensity as tobacco regulatory science. In addition, the authors mentioned that our meta-analysis was not available in PROSPERO pre-registration. This is because the review registration was completed in the very early stages of the review. We have updated this information in PROSPERO now to include the meta-analysis. The issue of overlap was addressed in our limitations, as we had to screen over 3,000 studies included in our selected reviews. However, given the importance of this issue for the meta-analysis, we performed a new meta-analysis that included the individual studies in each domain instead of using the odds ratio reported by the review to eliminate the effect of including the same study more than one time on our results. We confirm that the results of the new meta-analysis, which includes each study only once, are similar to the original meta-analysis (Supplement A: https://www.publichealth.med.miami.edu/_assets/pdf/meta-analysis.pdf).
The authors also accuse us of not being transparent about our adopted classification of evidence strategy, while a careful check of the reference we provided shows it (Morton et al. Page 131 (Box 4-2).[2] This classification is also adopted by the National Academies of Sciences.[3] Our assessment of the gateway effect as high evidence is consistent with this classification (National Academies of Sciences, Engineering, and Medicine 2018; Page 5, Box S-2: High evidence (including conclusive and substantial) (Supplement B: https://www.publichealth.med.miami.edu/_assets/pdf/level-of-evidence.pdf).[3] Generally, we object to the authors’ characterization that observational studies cannot imply causality. In fact, carefully designed observational studies led to most of what we know about major risks to health, such as smoking, hypertension, diabetes, and high cholesterol levels.[4-7]
We excluded research supported by the tobacco industry, given the ample evidence of the industry's fraudulent scientific behavior, which prompts objective scientists to question the extent to which industry-sponsored authors report methods and results accurately.[8, 9] We note that our stance regarding industry-supported publications is also consistent with the policy of Tobacco Control. Contrary to the commentary’s critique, the message about nicotine’s effect on the developing brain is supported by evidence from human and animal studies and endorsed by the CDC as well as major credible public health bodies.[10-13]
The authors state that comparing ENDS to cigarette smoking is needed, given their potential to help addicted smokers quit. Alas, an accurate comparison of these products is currently not feasible. Unlike cigarettes, which were suspected of causing lung cancer as far back as the late 19th century and for which we have more than a half-century of robust evidence of the health effects, we have much more modest literature on ENDS health effects, spanning less than two decades.[14] Also, unlike today’s combustible cigarette, a rather standardized tobacco use method with a standardized pattern of use and standardized assessment tools, ENDS are not standardized. The heterogeneity of ENDS products, their use patterns, and still nascent long-term ENDS exposure assessment tools make accurate comparisons impossible. In fact, even the same product, manufactured by the same maker, can have variability in its liquid content and ingredient proportions.[15] While the commentary criticized our review based on the acknowledged lack of long-term data about ENDS effects on health, they make an unsubstantiated claim that the group most likely to use ENDS on a persistent basis are smokers.
To navigate the complexity of ENDS, we adopted a consumer rights stand that recognizes that every consumer needs to be aware of the potential risks and benefits of the products they are using. So, although the evidence is inconclusive about the real-world effects of ENDS in helping smokers quit, and the fact that the FDA has not yet approved any of them as a cessation device, we have created some messages to support this based on evidence from randomized clinical trials.[16] We agree that it will take more time before robust scientific evidence about the long-term effects of ENDS accumulates, but this lack of knowledge should not be an excuse for failing to alert users of potential adverse health consequences of ENDS use. The public has a right to know whether any novel product that was being used by a significant proportion of the population contains known toxicants, despite lacking robust evidence of long-term effects on health. Why should ENDS be any different?
References
1. Asfar, T., et al., Risk and safety profile of electronic nicotine delivery systems (ENDS): an umbrella review to inform ENDS health communication strategies. Tobacco Control, 2022: p. tobaccocontrol-2022-057495.
2. Morton, S., et al., Finding what works in health care: standards for systematic reviews. 2011.
3. National Academies of Sciences, E., Medicine., Public health consequences of e-cigarettes. 2018.
4. Mahmood, S.S., et al., The Framingham Heart Study and the epidemiology of cardiovascular disease: a historical perspective. The lancet, 2014. 383(9921): p. 999-1008.
5. Doll, R., et al., Mortality in relation to smoking: 50 years' observations on male British doctors. Bmj, 2004. 328(7455): p. 1519.
6. Kannel, W.B. and D.L. McGee, Diabetes and cardiovascular disease: the Framingham study. Jama, 1979. 241(19): p. 2035-2038.
7. Castelli, W.P., et al., Incidence of coronary heart disease and lipoprotein cholesterol levels: the Framingham Study. Jama, 1986. 256(20): p. 2835-2838.
8. Kessler, G., Amended Final Opinion. USA v. Philip Morris, 2006.
9. Pisinger, C., N. Godtfredsen, and A.M. Bender, A conflict of interest is strongly associated with tobacco industry-favourable results, indicating no harm of e-cigarettes. Prev Med, 2019. 119: p. 124-131.
10. Centers for Disease Control and Prevention. It’s not like you can buy a new brain. 2019 [cited 2022 November 29th]; Available from: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/Quick-Facts-o...
11. Goriounova, N.A. and H.D. Mansvelder, Short-and long-term consequences of nicotine exposure during adolescence for prefrontal cortex neuronal network function. Cold Spring Harbor perspectives in medicine, 2012. 2(12): p. a012120.
12. England, L.J., et al., Nicotine and the developing human: a neglected element in the electronic cigarette debate. American journal of preventive medicine, 2015. 49(2): p. 286-293.
13. Surgeon General, U., E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon General. 2016, Retrieved from Atlanta, GA: https://ecigarettes. surgeongeneral. gov ….
14. Proctor, R.N., The history of the discovery of the cigarette–lung cancer link: evidentiary traditions, corporate denial, global toll. Tobacco control, 2012. 21(2): p. 87-91.
15. Yassine, A., et al., Did JUUL alter the content of menthol pods in response to US FDA flavour enforcement policy? Tobacco control, 2022. 31(Suppl 3): p. s234-s237.
16. Hajek, P., et al., A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy. N Engl J Med, 2019. 380(7): p. 629-637.
The paper by Asfar et al (1) had a noble objective, which was to inform ENDS health risk communications by updating the 2018 evidence review by the US. National Academies of Sciences, Engineering and Medicine (NASEM) (2). The need for improved risk communications about ENDS is reinforced by a recent study which found that only 17.4% of US smokers believe that nicotine vaping is safer than smoking (3). While ENDS use is not safe, the evidence from toxicant exposure studies does show that ENDS use is far safer than smoking cigarettes and may benefit public health by assisting those who smoke to quit smoking (4, 5).
An important limitation of the umbrella review method utilized by the authors is that it does not directly attempt to systematically characterize new research. This is a concern because the marketplace of ENDS products used by consumers has evolved since the 2018 NASEM report (4, 5). Furthermore, the authors have included some meta-analyses of selected reviews for some domains, but these meta-analyses were not in the Prospero pre-registration (6), nor explained in the paper. It’s thus unclear how or why certain reviews were selected for meta-analysis, and also whether the comparators are the same for these reviews. More importantly, these meta-analyses risk single studies contributing multiple times to the same pooled estimate. The authors noted this as a limitation commenting inaccurately that ‘it was impossible to identify articles that were included in...
The paper by Asfar et al (1) had a noble objective, which was to inform ENDS health risk communications by updating the 2018 evidence review by the US. National Academies of Sciences, Engineering and Medicine (NASEM) (2). The need for improved risk communications about ENDS is reinforced by a recent study which found that only 17.4% of US smokers believe that nicotine vaping is safer than smoking (3). While ENDS use is not safe, the evidence from toxicant exposure studies does show that ENDS use is far safer than smoking cigarettes and may benefit public health by assisting those who smoke to quit smoking (4, 5).
An important limitation of the umbrella review method utilized by the authors is that it does not directly attempt to systematically characterize new research. This is a concern because the marketplace of ENDS products used by consumers has evolved since the 2018 NASEM report (4, 5). Furthermore, the authors have included some meta-analyses of selected reviews for some domains, but these meta-analyses were not in the Prospero pre-registration (6), nor explained in the paper. It’s thus unclear how or why certain reviews were selected for meta-analysis, and also whether the comparators are the same for these reviews. More importantly, these meta-analyses risk single studies contributing multiple times to the same pooled estimate. The authors noted this as a limitation commenting inaccurately that ‘it was impossible to identify articles that were included in multiple reviews’. In our view this serious methodological flaw merits removal of all pooled estimates from their analyses. Additionally in several places, association is conflated with causality (e.g. “ENDS use impedes smoking cessation”) when based on observational data. The classification of evidence is also not transparent, cannot be found in the source the authors cited, and in places does not follow from the evidence presented (e.g. gateway evidence classified as high when based on observational studies).
The review also excludes research reviews supported by ENDS manufacturers. While we recognize and agree with the authors’ concerns about possible bias in industry publishing, we also believe that the exclusion of such research without any analysis of the scientific merits of the research itself precludes a comprehensive assessment of the scientific literature regarding the health risks of ENDS. Also, excluding industry publications necessarily eliminates from consideration evidence that the Center for Tobacco Products may be asked to consider when it is reviewing product applications for product marketing authorizations and modified risk claims.
The paper falls short, as well, in addressing the risk communication implications of the findings since the authors’ recommendations often do not match the evidence of what is known and not known about the risks of using ENDS. A careful analysis of suggested risk messages contained in supplementary material to the paper finds messages that do not appear to be supported by the evidence reviewed in the paper. For example, the suggested risk messages that "nicotine in vapes can harm memory, concentration, and learning in young people," "vaping nicotine can harm learning ability in young people," and "exposure to nicotine during adolescence can interfere with brain development" do not appear to be derived from a comprehensive review of scientific evidence. The evidence of nicotine having adverse effects on brain development or learning in adolescents comes primarily from rodent studies where dosing of nicotine is not necessarily analogous to exposure from ENDS.
For most of the topics reviewed, the umbrella review reveals that the health risks of ENDS remain unsettled at this time. Whilst biomarker exposure data clearly indicate reduced risk compared to tobacco cigarettes (4), we would suggest restraint is needed in communicating absolute risk information to the public (7). Also we would go one step further in noting that whatever the health risks of ENDS may be, they are going to be most observable in those persons using ENDS on a persistent basis for months or years at a minimum. For example, the health risks of cigarette smoking do not reliably emerge until after smokers exceed 10 pack-years or more of exposure (87). Few studies of ENDS health risks have actually focused on the likely higher risk group of persistent ENDS users (4).
We also take issue with the paper’s main conclusion that direct comparison between the harms of cigarettes and ENDS should be avoided (1). In fact, such comparisons are likely unavoidable and necessary since the group most likely to use ENDS on a persistent basis are those who have a history of cigarette use. Moreover, ENDS were originally developed as a cessation aid and evaluations of cessation aids almost always incorporate evidence on the relative harms compared to continuing to smoke. We do recognize that accounting for a person’s smoking history complicates evaluations of the health risks of ENDS, but dismissing such comparisons simply ignores the fact that ENDS are existing or potential cigarette substitutes for many smokers (4, 5). A recent review of biomarker studies found that compared to smoking, using ENDS leads to a substantial reduction in biomarkers of toxicant exposure associated with cigarette smoking, while also acknowledging that the degree of any residual risk from smoking remains unclear because of the lack of comparisons between long-term former smokers, and with those who have never smoked or used ENDS (4).
Communicating health risk information about ENDS has to have some context to be meaningful to consumers. A common misconception about tobacco use is that the most dangerous component of the product is nicotine (9-14). However, while nicotine can be addictive, it is the other toxicants in tobacco, especially burned tobacco, that are the true culprits of tobacco-related diseases (2, 4). Thus, when communicating information about the health risks of tobacco products, it makes sense to provide consumers with information about the relative health dangers from burned compared to unburned tobacco products. The example risk messages included in the supplementary materials to the paper appear to be developed with a goal of discouraging anyone from using a vaping product rather than to inform potential users about risks.
Public health authorities can reduce the risk of misinforming or confusing the public by acknowledging when evidence is incomplete or based on statistical association rather than clear evidence of causality, and by updating any statements or recommendations quickly when plausibly causal evidence becomes available (7).
References
1. Asfar T, Jebai R, Li W, et al. Risk and safety profile of electronic nicotine delivery systems (ENDS): an umbrella review to inform ENDS health communication strategies. Tob Control Epub ahead of print: [please include Day Month Year]. doi:10.1136/ tobaccocontrol-2022-057495
2. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on the Review of the Health Effects of Electronic Nicotine Delivery Systems. Public Health Consequences of E-Cigarettes. Eaton DL, Kwan LY, Stratton K, editors. Washington (DC): National Academies Press (US); 2018 Jan 23.
3. Kim S, Shiffman S, Sembower MA. US adult smokers' perceived relative risk on ENDS and its effects on their transitions between cigarettes and ENDS. BMC Public Health. 2022 Sep 19;22(1):1771. doi: 10.1186/s12889-022-14168-8.
4. McNeill, A, Simonavičius, E, Brose, LS, Taylor, E, East, K, Zuikova, E, Calder, R and Robson, D (2022). Nicotine vaping in England: an evidence update including health risks and perceptions, September 2022. A report commissioned by the Office for Health Improvement and Disparities. London: Office for Health Improvement and Disparities.
5. Balfour DJK, Benowitz NL, Colby SM, Hatsukami DK, Lando HA, Leischow SJ, Lerman C, Mermelstein RJ, Niaura R, Perkins KA, Pomerleau OF, Rigotti NA, Swan GE, Warner KE, West R. Balancing Consideration of the Risks and Benefits of E-Cigarettes. Am J Public Health. 2021 Sep;111(9):1661-1672.
6. Rime Jebai, Wei Li, Oluwole Olusanya Joshua, Beck Graefe, Celia Rubio. Systematic Review of Reviews on the Harmful Effects of Electronic Nicotine Delivery Systems: Building Evidence for Health Communication Messaging. PROSPERO 2021 CRD42021241630 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021241630
7. United States Surgeon General. Confronting Health Misinformation: The U.S. Surgeon General’ s Advisory on Building a Healthy Information Environment [Internet]. 2021 [cited 2022 Aug 9]. Available from: https://www.hhs.gov/sites/default/files/surgeon-general-misinformation-a...
8. Doll R, Peto R, Boreham J, Sutherland I. Mortality from cancer in relation to smoking: 50 years observations on British doctors. Br J Cancer. 2005 Feb 14;92(3):426-9. doi: 10.1038/sj.bjc.6602359.
9. O’Brien EK, Nguyen AB, Persoskie A, Hoffman AC. U.S. adults’ addiction and harm beliefs about nicotine and low nicotine cigarettes. Prev Med. 2017;96:94-100.
10. Steinberg MB, Bover-Manderski MT, Wackowski OA, Singh B, Strasser AA, Delnevo CD. Nicotine Risk Misperception Among US Physicians. J Gen Intern Med. 2021, 36(12):3888-3890.
11. Elton-Marshall T, Driezen P, Fong GT, et al. Adult perceptions of the relative harm of tobacco products and subsequent tobacco product use: Longitudinal findings from waves 1 and 2 of the population assessment of tobacco and health (PATH) study. Addict Behav. doi:10.1016/j.addbeh.2020.106337.
12. Parker MA, Villanti AC, Quisenberry AJ, Stanton CA, et al. Tobacco Product Harm Perceptions and New Use. Pediatrics. 2018 Dec;142(6):e20181505. doi: 10.1542/peds.2018-1505.
13. Yong HH, Gravely S, Borland R, Gartner C, et al. Perceptions of the Harmfulness of Nicotine Replacement Therapy and Nicotine Vaping Products as Compared to Cigarettes Influence Their Use as an Aid for Smoking Cessation? Findings from the ITC Four Country Smoking and Vaping Surveys. Nicotine Tob Res. 2022 Aug 6;24(9):1413-1421. doi: 10.1093/ntr/ntac087.
14. National Cancer Institute. Health Information National Trends Survey. HINTS 5 cycle 3, 2019. Available at: https://hints.cancer.gov/view-questions-topics/question-details.aspx?PK_...
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...
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 parents are unaware of their children’s e-cigarette use[3]. Young participants who receive the questionnaire from their parents, in suspicion of their parents might know, may be unwilling to fill out honestly.
2. A clearer definition of stop smoking/quitting. In Table 3, when asking participants quitting plans, it is better to clarify the quitting of traditional tobacco products or quitting nicotine products. As some youth may treat vaping itself as quitting and some may not, the survey result might therefore, be ambiguous.
3. Seasonality. Previous studies have indicated seasonal variations in the initiation of smoking among adolescents[4], Unsupervised time out of school during the first months of summer vacation is a period of increased smoking behavior. However, significantly lower rates during September were observed which seem to be related to the beginning of school. Survey for this study were conducted July/August in 2017, August/September in 2018 and 2019. As cross-sectional study only offers a snapshot of the situation, to conduct surveys at different months with fluctuating trends would inevitably lower the liability of the result.
[1] Hammond, D., Reid, J. L., Rynard, V. L., Fong, G. T., Cummings, K. M., McNeill, A., Hitchman, S., et al. (2019). Prevalence of vaping and smoking among adolescents in Canada, England, and the United States: repeat national cross sectional surveys. BMJ (Clinical Research Ed.), 365, l2219.
[2] Hammond D, Reid JL, White CM. ITC Youth Tobacco and E-Cigarette Survey:
Technical Report – Wave 3 (2019. Waterloo, ON: University of Waterloo, 2020. http://
davidhammond.ca/wp-content/uploads/2020/05/2019_P01P3_W3_TechnicalReport_updated202005.pdf
[3] Wu T and Chaffee BW. Parental Awareness of Youth Tobacco Use and the Role of Household Tobacco Rules in Use Prevention. Pediatrics. 2020;146(5): e20194034
[4] Colwell, B., Ramirez, N., Koehly, L., Stevens, S., Smith, D. W., & Creekmur, S. (2006). Seasonal variations in the initiation of smoking among adolescents. Nicotine & Tobacco Research, 8(2), 239–243.
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...
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 Monitoring the Future (MTF) survey—three of the most widely cited sources of data for youth vaping.[5,6,7]
Mr. Wang questioned whether the process for ascertaining parental consent may bias the survey responses. Ascertaining parental consent among minors is a common and required practice in most jurisdictions. To the extent that young respondents may not have provided honest responses due to concerns about confidentiality, the likely impact would be to under-report smoking and vaping status. However, the recruitment process has not changed over the course of the study; thus, this is unlikely to account for the trends over time reported in our paper. In addition, the trends in the ITC Youth Tobacco and Vaping Surveys are very similar to the trends in vaping reported by national surveillance surveys in the US,[5] Canada, [8,9,10] and England.[11]
Regarding Mr. Wang’s assertion that “when asking participants quitting plans, it is better to clarify the quitting of traditional tobacco products or quitting nicotine products”, we can confirm that questions about intentions to quit and cessation were indeed asked separately for smoking and vaping. Thus, if a youth reported smoking cigarettes and vaping e-cigarettes, they would have been asked cessation-related questions in different sections of the survey for each of cigarettes and e-cigarettes/vaping.
Finally, Mr. Wang has noted seasonal variation in smoking and vaping rates. Despite some variations in the exact survey timing, the ITC Youth Tobacco and Vaping Surveys have been conducted over a similar time period in each year. For example, across the first three waves of the survey, 64%, 79% and 74% of surveys, respectively, were conducted in the month of August. As noted above, trends in vaping prevalence over time from the ITC surveys align very closely with other national surveys over the same period. With respect to specific findings reported in our Tobacco Control manuscript, we would not expect any material differences in levels of dependence, cessation-related outcomes or vaping brands due to the minor variation in data collection periods.
We hope this additional information will provide context for interpreting the study results and feedback on the manuscript.
References
1. Hammond D, Reid JL, Rynard VL, Fong GT, Cummings KM, McNeill A, Hitchman S, et al. Prevalence of vaping and smoking among adolescents in Canada, England, and the United States: repeat national cross sectional surveys. BMJ. 2019; 365: l2219. doi: 10.1136/bmj.l2219.
2. Hammond D, Rynard V, Reid JL. Changes in prevalence of vaping among youth in the United States, Canada, and England, 2017 to 2019. JAMA Pediatr. 2020;174(8):797-800. doi: 10.1001/jamapediatrics.2020.0901.
3. Published Erratum: Prevalence of vaping and smoking among adolescents in Canada, England, and the United States: repeat national cross sectional surveys. BMJ. 2020 Jul 10;370:m2579. doi: 10.1136/bmj.m2579.
4. Hammond D, Reid JL, Rynard VL, Burkhalter R. ITC Youth Tobacco and E-Cigarette Survey:
Technical Report – Wave 3 (2019). Waterloo, ON: University of Waterloo, 2020. http://davidhammond.ca/wp-content/uploads/2020/05/2019_P01P3_W3_Technica...
5. Park-Lee E, Ren C, Sawdey MD, et al. Notes from the Field: E-Cigarette Use Among Middle and High School Students — National Youth Tobacco Survey, United States, 2021. MMWR Morb Mortal Wkly Rep 2021;70:1387–1389. DOI: http://dx.doi.org/10.15585/mmwr.mm7039a4.
6. Hyland A, Kimmel HL, Borek N, on behalf of the PATH Study team. Youth and young adult acquisition and use of cigarettes and ENDS: The latest findings from the PATH Study (2013-2019). Society for Research on Nicotine & Tobacco Annual Conference, March 2020
7. Miech R, Johnston L, O’Malley PM, Bachman JG, Patrick ME. Trends in adolescent vaping, 2017-2019. N Engl J Med. 2019;381(15):1490-1491. doi:10.1056/NEJMc1910739.
8. Government of Canada. Detailed tables for the Canadian Student Tobacco, Alcohol and Drugs Survey 2016-17. Available from https://www.Canada.ca/en/health-Canada/services/canadian-student-tobacco...
9. Government of Canada. Canadian Tobacco, Alcohol and Drugs Survey (CTADS): Summary of Results for 2017. 2017. Available from https://www.Canada.ca/en/health-Canada/services/canadian-tobacco-alcohol....
10. Statistics Canada. Canadian Tobacco and Nicotine Survey, 2019. Available from https://www150.statcan.gc.ca/n1/daily-quotidien/200305/dq200305a-eng.htm.
11. Action on Smoking and Health UK. Use of e-cigarettes among young people in Great Britain, 2021. June 2021. Available from https://ash.org.uk/wp-content/uploads/2021/07/Use-of-e-cigarettes-among-...
¶ 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...
¶ 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 population health (not just to youth tobacco use). This study provides evidence from a single state that may not be generalizable to other states without preemption policies. Other studies have found unintended negative effects of flavor policies, and these studies should be referenced to balance the discussion section.
¶ I applaud the authors for providing an early data point on the effect of these policies, but certainly more work in this space is needed before policy recommendations can be made. The authors may also wish to consider for future difference-in-difference papers whether there is evidence in support of the parallel trends assumption , which is a crucial assumption underpinning the reliability of the model.
¶ References:
¶ Friedman, Abigail S. "A difference-in-differences analysis of youth smoking and a ban on sales of flavored tobacco products in San Francisco, California." JAMA pediatrics 175, no. 8 (2021): 863-865.
¶ Xu, Yingying, Lanxin Jiang, Shivaani Prakash, and Tengjiao Chen. "The Impact of Banning Electronic Nicotine Delivery Systems on Combustible Cigarette Sales: Evidence From US State-Level Policies." Value in Health (2022).
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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.
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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 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, because the number of menthol smokers across the seven provinces in our evaluation study was low (N=138). However, we did report that there were no statistically significant differences in smoking cessation outcomes between menthol and non-menthol smokers across the seven provinces, consistent with the possibility that there were no differences between a characterizing flavour ban and an additive ban. Hagen's comment did prompt us to do the explicit analysis, comparing the four provinces with characterizing flavour bans to the three provinces with menthol additive bans.
Consistent with our previously reported findings of no differences across the seven provinces, the explicit comparison found no significant differences in smoking cessation outcomes among daily and among all smokers between menthol smokers and non-menthol smokers in provinces with menthol additive bans vs provinces with menthol characterizing flavour bans. Thus, the findings do indeed, as Hagen aimed to highlight, point to the positive impact of the characterizing flavour ban, being not different from that of the national menthol additive ban ─ with the caution that the small sample sizes afforded low statistical power to test for differences.
Our follow-up analysis also showed that a significantly higher percentage of pre-ban menthol smokers reported that they still smoked menthols at follow-up in provinces with menthol characterizing flavour bans, compared with provinces with menthol additive bans (25.3% vs 8.4%, p=0.02). We will describe these results more fully in a forthcoming paper.
There are complexities in the distinctions between a characterizing flavour ban and an additive ban. Each would call upon different kinds of regulatory oversight. For example, the European Union's characterizing flavour ban under the 2016 Tobacco Products Directive [4] required the establishment of an Independent Advisory Panel to determine whether a particular tobacco product has a characterizing flavour, with input from a technical group of sensory and chemical assessors, whose methodology is "based on a comparison of the smelling properties of the test product with those of reference products." [5] In contrast, regulating an additive ban requires product testing to determine the presence of a banned additive.
As jurisdictions consider measures to eliminate the well-documented impact of menthol in increasing attractiveness and reducing harshness of combustible tobacco products [6], these differences in regulatory capacity need to be considered.
3. Chung-Hall J, Fong GT, Meng G, et al. Evaluating the impact of menthol cigarette bans on cessation and smoking behaviours in Canada: longitudinal findings from the Canadian arm of the 2016–2018 ITC Four Country Smoking and Vaping Surveys. Tobacco Control Published Online First: 05 April 2021. doi: 10.1136/tobaccocontrol-2020-056259
6. Tobacco Products Scientific Advisory Committee. Menthol cigarettes and public health: review of the scientific evidence and recommendations. Rockville, MD: Food and Drug Administration, 2011.
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.
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We object to the framing of Association of Vapers India (AVI), erroneously referred to as ‘Vape India’ in the paper, as a tobacco industry front group, without providing any basis for the claim except our membership of International Network of Nicotine Consumer Organisations (INNCO).
AVI was organised in August 2016, when consumers of low-risk alternatives came together to arrest the tide of state bans in India, which were being lobbied for by the Bloomberg Philanthropies network the authors belong to.[1] Though one of our directors is the current president of INNCO’s governing board, elected through a member vote in the 2020 General Assembly, he is serving in unpaid, honorary capacity.
AVI has not received funding from INNCO, nor from the Foundation for Smoke-free World (FSFW), and neither from the tobacco industry. Our work is financed through voluntary contributions, and like INNCO, the affairs are conducted by a governing board comprising unpaid consumer volunteers.
It is scurrilous to cast AVI as a tobacco industry group or anything other than a consumer-led movement that is seeking access to harm reduction avenues for India’s nearly 270 million tobacco users, among whom cancers are rising[2] even as most have meagre means to deal with the health consequences, which makes harm prevention a vital mitigation strategy. We are product agnostic and advocate access to lower-risk alternatives for both smokers and smokeless tobacco...
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We object to the framing of Association of Vapers India (AVI), erroneously referred to as ‘Vape India’ in the paper, as a tobacco industry front group, without providing any basis for the claim except our membership of International Network of Nicotine Consumer Organisations (INNCO).
AVI was organised in August 2016, when consumers of low-risk alternatives came together to arrest the tide of state bans in India, which were being lobbied for by the Bloomberg Philanthropies network the authors belong to.[1] Though one of our directors is the current president of INNCO’s governing board, elected through a member vote in the 2020 General Assembly, he is serving in unpaid, honorary capacity.
AVI has not received funding from INNCO, nor from the Foundation for Smoke-free World (FSFW), and neither from the tobacco industry. Our work is financed through voluntary contributions, and like INNCO, the affairs are conducted by a governing board comprising unpaid consumer volunteers.
It is scurrilous to cast AVI as a tobacco industry group or anything other than a consumer-led movement that is seeking access to harm reduction avenues for India’s nearly 270 million tobacco users, among whom cancers are rising[2] even as most have meagre means to deal with the health consequences, which makes harm prevention a vital mitigation strategy. We are product agnostic and advocate access to lower-risk alternatives for both smokers and smokeless tobacco users, adhering to harm reduction and human rights principles laid out in UN drug policies and in Article 1(d) of the FCTC charter.
We find these accusations especially mischievous in light of our Indian government owning a major 28% stake in the country’s cigarette monopoly and gaining directly from the e-cigarette ban,[3] despite which it was invited to chair COP8 proceedings, whereas consumer advocates, including from AVI, who were there to seek deliberations on their right to access lower-risk alternatives, and whom the FCTC policies affect most severely, were ousted after the plenary session on the pretext of preventing industry influence, left to protest outside the venue and use social media to make ourselves heard.
We strongly oppose this unfair application of Article 5.3 of FCTC which covets tobacco-trading governments but forcefully excludes consumers and attempts to delegitimize them under the garb of the same provision.
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We appreciate the authors’ concern about industry “astroturfing.” We believe astroturf activities undermine the genuine consumer movement that INNCO and its members represent. But the conclusions that the authors draw from their research are attenuated and inaccurate. In particular, we object strenuously to the authors’ conclusion that because INNCO has received funding from the Foundation for a Smoke-Free World (the Foundation), we are a tobacco front group.
INNCO was formed in 2016, a year before the Foundation was established. All of INNCO’s members are autonomous, independent consumer organisations, and with rare exception are run by volunteers on a shoe-string budget. These organisations joined forces to create INNCO, and they nominate and elect INNCO’s Governing Board members, who serve without compensation.
INNCO only accepts funding from sources where our independence as an organisation run by and for consumers is assured. INNCO operated for more than two years with only volunteer efforts and no funding. (Funding from the Foundation was received in December of 2018, which is after the period this paper covers.)
As the authors note, INNCO was formed in large part to ensure the consumer voice is heard on international platforms. However, we question the authors’ intent in casting our desire to engage as legitimate stakeholders as nefarious.
While the authors have cited numerous references on the motivations of t...
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We appreciate the authors’ concern about industry “astroturfing.” We believe astroturf activities undermine the genuine consumer movement that INNCO and its members represent. But the conclusions that the authors draw from their research are attenuated and inaccurate. In particular, we object strenuously to the authors’ conclusion that because INNCO has received funding from the Foundation for a Smoke-Free World (the Foundation), we are a tobacco front group.
INNCO was formed in 2016, a year before the Foundation was established. All of INNCO’s members are autonomous, independent consumer organisations, and with rare exception are run by volunteers on a shoe-string budget. These organisations joined forces to create INNCO, and they nominate and elect INNCO’s Governing Board members, who serve without compensation.
INNCO only accepts funding from sources where our independence as an organisation run by and for consumers is assured. INNCO operated for more than two years with only volunteer efforts and no funding. (Funding from the Foundation was received in December of 2018, which is after the period this paper covers.)
As the authors note, INNCO was formed in large part to ensure the consumer voice is heard on international platforms. However, we question the authors’ intent in casting our desire to engage as legitimate stakeholders as nefarious.
While the authors have cited numerous references on the motivations of the tobacco industry, they appear to not understand the tobacco harm reduction consumer space, relying solely on the previous work of their own organisation to draw inferences. Consumer advocates are passionate about alternatives that have helped them wean off smoking, and are committed to ensuring continued access for these potentially life-saving products.
Consumers are aligned with FCTC’s goals of mitigating tobacco-related death and disease, although our approach differs in that we reject prohibitionism and stigmatisation in favour of pragmatic, humane and ultimately more effective policies that recognise human rights and the agency of users to become proactive participants in improving their health. INNCO thus brings a unique, ear-to-the-ground perspective to tobacco control efforts, and should be welcomed as FCTC observers.
By encouraging governments, policymakers and others to view consumers and consumer groups as fronts for the tobacco industry, the authors deplatform and disenfranchise an already unfairly marginalised group. We urge the authors to consider the ethical implications of nudging decisionmakers to dismiss the consumer voice. This disregard of the most profoundly affected stakeholders occurs in no other health or policy arena.
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It’s surprising finding oneself involuntarily part of a research study. Given no chance to contribute, perhaps I can offer privileged insight into the processes the authors seek to describe.
Analysis of tweets around the COP8 meeting show that nicotine consumer advocates were the most active, followed by public health advocates and the tobacco industry. My company – Knowledge Action Change – also tweeted, at the Geneva launch of our tobacco harm reduction report. [1] Tweeting by tobacco harm reduction advocates out-shadowed “official” FCTC messaging (and if the authors had searched #FCTCCOP8 and #COP8 as well as #COP8FCTC, they would have uncovered more).
The article asserts that tobacco industry money is behind this activity. But it is beyond this study’s narrow methodological reach to illuminate why nicotine consumer advocates tweet. My discussions with nicotine consumer advocates – the majority of whom are volunteers - demonstrate passionate interest in the policymaking that influences their lives. Having found safer alternatives to smoking, they fear that inappropriate regulation including bans will see their options disappear. They are frustrated that they are ignored by tobacco control policymakers, regulators and researchers. Barred from COP8 along with the public and press, consumer organisations are also barred from the NGO coalition Framework Convention Alliance. No other field of health policy excludes the affected. Consu...
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It’s surprising finding oneself involuntarily part of a research study. Given no chance to contribute, perhaps I can offer privileged insight into the processes the authors seek to describe.
Analysis of tweets around the COP8 meeting show that nicotine consumer advocates were the most active, followed by public health advocates and the tobacco industry. My company – Knowledge Action Change – also tweeted, at the Geneva launch of our tobacco harm reduction report. [1] Tweeting by tobacco harm reduction advocates out-shadowed “official” FCTC messaging (and if the authors had searched #FCTCCOP8 and #COP8 as well as #COP8FCTC, they would have uncovered more).
The article asserts that tobacco industry money is behind this activity. But it is beyond this study’s narrow methodological reach to illuminate why nicotine consumer advocates tweet. My discussions with nicotine consumer advocates – the majority of whom are volunteers - demonstrate passionate interest in the policymaking that influences their lives. Having found safer alternatives to smoking, they fear that inappropriate regulation including bans will see their options disappear. They are frustrated that they are ignored by tobacco control policymakers, regulators and researchers. Barred from COP8 along with the public and press, consumer organisations are also barred from the NGO coalition Framework Convention Alliance. No other field of health policy excludes the affected. Consumers use social media to speak out, asking others to do likewise. Picking on a tiny unfunded Mexican organisation for encouraging peers to tweet misunderstands how social media works: the FCA itself recently exhorted members to tweet in the week of the postponed COP9.
Prior assumptions about tobacco industry interference dominate this article (as with much of the Bath group’s work). The authors assert that ‘vaping consumer advocacy groups’ receive industry funding, but provide no evidence for this for any national or local group cited. Net result – the article both smears and further disempowers a disenfranchised population.
Do the authors apply their ‘theory of external influence’ to their own work? The Bath group shares over $20m from the anti-nicotine and anti-tobacco harm reduction Bloomberg Philanthropies. [2] Philanthro-capitalism comes with its own strings attached. [3]
Perhaps more productive would be social science insights into the views of consumer advocates and the narratives that both drive and divide a field in which all parties ostensibly share a common outcome - an end to smoking.
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Freedom of speech is a fundamental right in a free society. There is no justification to either interfere with the right of stakeholders to participate in the public debate regarding tobacco harm reduction policy, or to malign those that exercise that right. Given that the outcome of these policy discussions will affect the lives of more than one billion people on the planet who smoke, everyone must be free to advance arguments for and against any policy, and each argument must be scrutinized and evaluated on its evidence base and merits. Unfortunately, the recent paper in Tobacco Control—Exploring the Twitter activity around the eighth meeting of the Conference of the Parties to the WHO Framework Convention on Tobacco Control—missed the opportunity to do this.
Instead of engaging in a discussion on the key issues and arguments put forth in the public discussion around the eighth meeting of the Conference of the Parties (COP8), the authors employ diversionary ad hominem tactics. They mischaracterize Philip Morris International’s (PMI’s) legitimate participation in the public debate on the role that products with the potential to reduce the risk of harm compared to smoking can play in global public health policy. Using phrases like ‘tobacco industry actors’ and ‘front groups’ the authors falsely imply that any person or organization who publicly supports tobacco harm reduction are paid to do so by the tobacco industry, and specifically PMI....
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Freedom of speech is a fundamental right in a free society. There is no justification to either interfere with the right of stakeholders to participate in the public debate regarding tobacco harm reduction policy, or to malign those that exercise that right. Given that the outcome of these policy discussions will affect the lives of more than one billion people on the planet who smoke, everyone must be free to advance arguments for and against any policy, and each argument must be scrutinized and evaluated on its evidence base and merits. Unfortunately, the recent paper in Tobacco Control—Exploring the Twitter activity around the eighth meeting of the Conference of the Parties to the WHO Framework Convention on Tobacco Control—missed the opportunity to do this.
Instead of engaging in a discussion on the key issues and arguments put forth in the public discussion around the eighth meeting of the Conference of the Parties (COP8), the authors employ diversionary ad hominem tactics. They mischaracterize Philip Morris International’s (PMI’s) legitimate participation in the public debate on the role that products with the potential to reduce the risk of harm compared to smoking can play in global public health policy. Using phrases like ‘tobacco industry actors’ and ‘front groups’ the authors falsely imply that any person or organization who publicly supports tobacco harm reduction are paid to do so by the tobacco industry, and specifically PMI.
We fundamentally disagree with the authors’ approach. However, if they wish to pursue it in a robust way, we invite them to address an obvious inconsistency, and lack of rigor, in their present publication: the failure to explore the funding or linkages of individuals or organizations they deemed not to have tobacco industry links. By excluding this analysis, the authors have ignored the potential bias of almost one third of the Twitter accounts that they say engaged in the debate around COP8, including many who have links to their own funders (Bloomberg Philanthropies’ STOP: Stopping Tobacco Organizations and Products), and who have their own agendas (1-4) . Completing this analysis would be a useful way to shift from ad hominem attacks and move forward to a robust, science-based debate about tobacco harm reduction in the context of the next Conference of the Parties (COP9).
The importance of tobacco harm reduction policy to hundreds of millions of the world’s population means that it deserves a reasoned, fact-based dialogue between all parties, with science and consumers at the centre of discussion. It is legitimate to disagree, but ad hominem attacks have nothing to do with the argument at hand and simply serve to undermine progress. Dismissing views that differ from one’s own, or—worse still—attempting to intimidate dissenters into silence, will not move the debate forward. Emotions should not be allowed to dictate what and who does and does not get heard—truth and accuracy should be the only considerations.
For more than a decade, PMI has been at the forefront of researching, developing and scientifically assessing products that have the potential to reduce the risk of harm compared to smoking for adults who would otherwise continue to smoke. We are convinced that such products can contribute to improving public health. We are confident in the robustness of our scientific findings and the arguments in favor of tobacco harm reduction. We are proud of our scientists who have developed products that have the potential to reduce the risks of harm compared to smoking for those adults who do not quit. These products are precisely the ones which can make the policy of tobacco harm reduction work. We are open to discuss our strategies, actions and achievements with everyone who has a role to play in shaping public policy to reach better outcomes for men and women who smoke. If the authors of the recent paper—or anyone else—would like to engage in a factual discussion on the issues that really matter, we are ready and willing to debate with them.
(1) https://www.who.int/tobacco/about/partners/bloomberg/en/ (accessed 20 Nov 2020)
(2) https://www.fctc.org/about-us/ (accessed 23 Nov 2020)
(3) https://untobaccocontrol.org/kh/article-53/bloomberg-philanthropies-sele... (accessed 23 Nov 2020)
(4) https://www.tobaccofreekids.org/what-we-do/global/bloomberg (accessed 20 Nov 2020)
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It is disappointing to see the BMJ publishing a research paper which smears consumer advocates for tobacco harm reduction by attempting to link consumer activity on social media with the tobacco industry. One can only conclude that the goal was to devalue the opinions of former smokers who have found safer nicotine products to have been beneficial to their lives.
I write as chair of the UK New Nicotine Alliance and as it is highly likely that tweets from our supporters have been included in this research, so we welcome the right to reply to the article.
The attempt to paint consumers as part of some mythical tobacco industry plot is offensive to individuals and organisations promoting tobacco harm reduction. We and our supporters, along with many other vapers, are systematically excluded from the FCTC conferences and yet have a strong stake in the outcomes of the meeting. Social media is one of the few opportunities we have to get our views across. Consumers of safer nicotine products have been acutely aware of an increasing warfare against the products which have helped them to stop smoking.
In 2018, there were clear threats being expressed by the WHO FCTC in advance of COP8 towards products that vaping consumers value highly for helping them to quit smoking. Many vapers travelled to Geneva in 2018 at their own expense, but as ‘members of the public’ were excluded from the meeting.
The article by Robertson et al was funded b...
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It is disappointing to see the BMJ publishing a research paper which smears consumer advocates for tobacco harm reduction by attempting to link consumer activity on social media with the tobacco industry. One can only conclude that the goal was to devalue the opinions of former smokers who have found safer nicotine products to have been beneficial to their lives.
I write as chair of the UK New Nicotine Alliance and as it is highly likely that tweets from our supporters have been included in this research, so we welcome the right to reply to the article.
The attempt to paint consumers as part of some mythical tobacco industry plot is offensive to individuals and organisations promoting tobacco harm reduction. We and our supporters, along with many other vapers, are systematically excluded from the FCTC conferences and yet have a strong stake in the outcomes of the meeting. Social media is one of the few opportunities we have to get our views across. Consumers of safer nicotine products have been acutely aware of an increasing warfare against the products which have helped them to stop smoking.
In 2018, there were clear threats being expressed by the WHO FCTC in advance of COP8 towards products that vaping consumers value highly for helping them to quit smoking. Many vapers travelled to Geneva in 2018 at their own expense, but as ‘members of the public’ were excluded from the meeting.
The article by Robertson et al was funded by Bloomberg Philanthropies: an organisation set up to distribute funds from an American multi-billionaire with antipathy to tobacco harm reduction.
In reality the article shows how successful THR consumer advocates are in dominating the Twittersphere around COP, and rightly so, because it is they are who are most affected by the outcome of COP meetings. Instead of attempting to denigrate these opinions, an altruistic approach would be to welcome the fact that consumers are engaging with the process and studying how consumer experience can help enhance public health outcomes. Sadly, this has not been considered by the authors of this report.
When doing scientific research, following the scientific method, you have a hypothesis (question) that you are going to investigate - in this case: Does xxx consumer organisation have any direct ties to tobacco companies that influence their advocacy?
After you have chosen your method, you then gather your evidence, make an objective analysis and state your findings and make a conclusion.
Your method SHOULD be thorough and your research should be objective in order to maintain the integrity of your research (and yourself). The evidence will either prove/disprove your original hypothesis.
Instead, the authors have chosen to not only demonise the participation of consumers in the narrative of their own health, one has lobbied false claims about tobacco industry connections that do not exist.
It is very concerning that the authors find it necessary to disenfranchise the very people who are fighting for their right to make informed choices about their health. It defies logic, and the principles of fairness and decency.
It perhaps would have been more helpful to all concerned if the authors had done due diligence beyond looking at a website that does not have verified information, to cast aspersions on consumer advocacy organisations.
It definitely would be more productive to welcome the voices of the people for whom felt impassioned enough to get involved in consumer advocacy to help smokers not only hav...
When doing scientific research, following the scientific method, you have a hypothesis (question) that you are going to investigate - in this case: Does xxx consumer organisation have any direct ties to tobacco companies that influence their advocacy?
After you have chosen your method, you then gather your evidence, make an objective analysis and state your findings and make a conclusion.
Your method SHOULD be thorough and your research should be objective in order to maintain the integrity of your research (and yourself). The evidence will either prove/disprove your original hypothesis.
Instead, the authors have chosen to not only demonise the participation of consumers in the narrative of their own health, one has lobbied false claims about tobacco industry connections that do not exist.
It is very concerning that the authors find it necessary to disenfranchise the very people who are fighting for their right to make informed choices about their health. It defies logic, and the principles of fairness and decency.
It perhaps would have been more helpful to all concerned if the authors had done due diligence beyond looking at a website that does not have verified information, to cast aspersions on consumer advocacy organisations.
It definitely would be more productive to welcome the voices of the people for whom felt impassioned enough to get involved in consumer advocacy to help smokers not only have the choices they need switch to less harmful alternative, but to be informed consumers of safer nicotine products.
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I am writing as co-founder of Pro-Vapeo Mexico, a non-profit consumer association affiliated with the International Network of Nicotine Consumer Organisations (INNCO), explicitly mentioned in the article “Exploring the Twitter activity around the eighth meeting of the Conference of the Parties to the WHO Framework Convention on Tobacco Control”. The authors of this article explicitly recognize that “We found no evidence that the individuals affiliated with INNCO or its member organizations were themselves funded by FSFW [Foundation for a Smoke Free World] or by the TI [Tobacco Industry] directly”. While this statement is correct, it still leaves missing information that we believe it is necessary and useful, for the benefit of your readers, to fully clarify: not only has Pro Vapeo Mexico never received any funding (direct or indirect) from any industry sector (tobacco, e-cigarettes or pharmaceutical) or from INNCO or the FSFW, we are a fully independent NGO whose activities are not (and have never been) directed by the TI or the FSFW or INNCO. Our affiliation with INNCO stems from its role as an umbrella organization grouping consumer associations worldwide united in advocating for Tobacco Harm Reduction, a strategy to improve global health by providing adult smokers the option to consume nicotine without having to inhale toxic cigarette smoke.
Regrettably, the authors of the above-mentioned article claim that our twitter activity in the...
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I am writing as co-founder of Pro-Vapeo Mexico, a non-profit consumer association affiliated with the International Network of Nicotine Consumer Organisations (INNCO), explicitly mentioned in the article “Exploring the Twitter activity around the eighth meeting of the Conference of the Parties to the WHO Framework Convention on Tobacco Control”. The authors of this article explicitly recognize that “We found no evidence that the individuals affiliated with INNCO or its member organizations were themselves funded by FSFW [Foundation for a Smoke Free World] or by the TI [Tobacco Industry] directly”. While this statement is correct, it still leaves missing information that we believe it is necessary and useful, for the benefit of your readers, to fully clarify: not only has Pro Vapeo Mexico never received any funding (direct or indirect) from any industry sector (tobacco, e-cigarettes or pharmaceutical) or from INNCO or the FSFW, we are a fully independent NGO whose activities are not (and have never been) directed by the TI or the FSFW or INNCO. Our affiliation with INNCO stems from its role as an umbrella organization grouping consumer associations worldwide united in advocating for Tobacco Harm Reduction, a strategy to improve global health by providing adult smokers the option to consume nicotine without having to inhale toxic cigarette smoke.
Regrettably, the authors of the above-mentioned article claim that our twitter activity in the period 9-18 October 2018 -somehow- proves our alleged participation in a lobbying effort coordinated by the TI to disrupt the COP-8 WHO-FCTC meeting taking place at the time. This is ludicrous. Our tweets do not prove this claim, but instead reveal our effort to mobilize our community of consumers to claim our right to attend and participate in that COP WHO-FCTC meeting as a legitimate part of the civil society. We were only protesting against the unjustified exclusion from this event of INNCO and its affiliated consumer associations under the false contention that we formed a TI front. In fact, we intend to keep protesting until our right to attend and participate in COP WHO-FCTC meetings as part of the civil society is fulfilled.
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Thank you for the opportunity to clarify and correct some of the recent statements about our research article, ‘Exploring the Twitter activity around the eighth meeting of the Conference of the Parties to the WHO Framework Convention on Tobacco Control’.
Mr Sarangapani, Director of the Association of Vapers India (AVI), is incorrect in claiming that our article makes “false allegations” and “unsubstantiated claims”, and that it frames AVI as a tobacco industry (TI) front group. We categorise his organisation as a ‘next generation product (NGP) advocate’ and we state that AVI is a member of the International Network of Nicotine Consumer Organisations (INNCO). We also report that INNCO has received funding from the Foundation for a Smoke-Free World (FSFW),[1] which is an organisation that continues to be funded solely by Philip Morris International.[2] Thus, AVI is a member of an organisation that receives indirect funds from Philip Morris International, via the FSFW. Those statements are factual and substantiated; readers can locate further details and references to the FSFW’s grantees and tax returns via our Tobacco Tactics pages, as referenced in our article. In his letter, Mr Sarangapani points out that the Founder-Director of AVI is the current President of INNCO’s Governing Board; however, our research article makes no mention of that fact. We clearly state that: “We found no evidence that the individuals affiliated with INNCO or its mem...
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Thank you for the opportunity to clarify and correct some of the recent statements about our research article, ‘Exploring the Twitter activity around the eighth meeting of the Conference of the Parties to the WHO Framework Convention on Tobacco Control’.
Mr Sarangapani, Director of the Association of Vapers India (AVI), is incorrect in claiming that our article makes “false allegations” and “unsubstantiated claims”, and that it frames AVI as a tobacco industry (TI) front group. We categorise his organisation as a ‘next generation product (NGP) advocate’ and we state that AVI is a member of the International Network of Nicotine Consumer Organisations (INNCO). We also report that INNCO has received funding from the Foundation for a Smoke-Free World (FSFW),[1] which is an organisation that continues to be funded solely by Philip Morris International.[2] Thus, AVI is a member of an organisation that receives indirect funds from Philip Morris International, via the FSFW. Those statements are factual and substantiated; readers can locate further details and references to the FSFW’s grantees and tax returns via our Tobacco Tactics pages, as referenced in our article. In his letter, Mr Sarangapani points out that the Founder-Director of AVI is the current President of INNCO’s Governing Board; however, our research article makes no mention of that fact. We clearly state that: “We found no evidence that the individuals affiliated with INNCO or its member organisations were themselves funded by FSFW or by the TI directly” (p4). I acknowledge that on page 5 of the article, we have referred to AVI by their Twitter handle (vapeindia), as opposed to the organisation’s full name.
Mr Cullip’s interpretation of our article as a “smear” against vaping consumer advocates is an inaccurate representation of our research. As set out in our research objectives (p2), we examined the main themes and sentiment of tweets about WHO FCTC COP8, identified and classified the most active tweeters, explored how people who tweeted about COP8 engaged with one another and, lastly, explored the presence of TI links among the most active tweeters. Our article makes no statements that denigrate vapers’ opinions. Rather, we conclude there was an extensive online presence by Philip Morris International (PMI) executives, and by organisations and individuals funded directly and indirectly by PMI (e.g. Consumer Choice Center, Foundation for a Smoke-Free World, INNCO, Knowledge-Action-Change). We conclude that our findings are consistent with PMI’s 2014 corporate affairs strategy, which was leaked as part of an exposé by Reuters.[3] Far from being a “mythical tobacco industry plot” as Mr Cullip claims, PMI’s corporate affairs strategy described engaging tobacco harm reduction advocates to “amplify and leverage the debate on harm reduction” around events such as the WHO FCTC COP.[3]
Dr Gilchrist’s letter contains several inaccurate assertions. Our research does not “malign” either the individuals or the organisations that participated in the Twitter debate during COP8. We do not use the term “front group” in relation to any of the organisations supporting tobacco harm reduction referred to in our article. Nor do we imply that “any person or organisation who publicly supports tobacco harm reduction are paid to do so by the industry”. Our research article presents a factual account of the most common topics and sentiment of tweets that used #COP8FCTC, the categories of individuals and organisations tweeting, and their networks and patterns of engagement with one another. Around one-fifth of the most active tweeters were either tobacco companies, third-party organisations that have received direct tobacco industry funding, or employees of those organisations. We refer (accurately) to those tweeters as ‘tobacco industry actors’; we provide a detailed definition of our inclusion criteria and provide references to evidence tobacco industry funding. The only specific criticism Dr Gilchrist makes about our study is that we did not explore links between the most active tweeters and non-tobacco industry sources of funding. Given the irreconcilable conflict between the tobacco industry’s interests and tobacco control policy interests, and given tobacco companies’ repeated attempts to influence policy via third parties and intermediaries,[4] our focus on documenting tobacco industry involvement in FCTC debates is justified. Unlike tobacco companies, public health advocacy groups do not stand to generate or lose billions of dollars in profit as a result of decisions made at WHO FCTC COP. Neither do they have a history of obfuscating their funding sources.
Professor Stimson’s letter incorrectly states that we claim tobacco industry money is behind all the activity on Twitter by harm reduction advocates; in fact, on page 4 we state: “…for 23 of the 50 NGP [next generation product] advocates, we found no publicly available evidence of any link with the TI”. Professor Stimson is correct that we state: “…vaping consumer advocacy groups that receive TI funding are emerging and attempting to influence the WHO.” He insinuates this claim is unsubstantiated, yet we provide clear evidence that factasia.org and INNCO, each of whom describe themselves as a vaping consumer advocacy organisation, receive funding from PMI (directly and indirectly, respectively).[1,5] We do not claim TI links with national vaping advocacy groups and, as already noted, we state: “We found no evidence that the individuals affiliated with INNCO or its members organisations were themselves funded by FSFW or by the TI directly” (p4). As Professor Stimson points out, our article includes a paragraph where we report that a member of INNCO, ProVapeo Mexico, encouraged vapers to tweet during COP8. Professor Stimson interprets our research as “picking on” that organisation, yet we make no criticism of ProVapeo Mexico’s activities. Our article documents only the facts about the number of tweets using #COP8FCTC that appear to have been posted as a result of ProVapeo Mexico’s appeal.
In response to Julie Woessner’s letter, at no point does our article state that INNCO is a tobacco front group. As I note above, our article documents substantial activity on Twitter during COP8 both by PMI, and by organisations (and people affiliated with those organisations) that have received money from PMI either directly, or indirectly via the FSFW. We believe this activity is consistent with proposed actions laid out in PMI’s leaked 2014 corporate affairs strategy, which included plans to: “Establish the concept of harm reduction as legitimate public policy in tobacco regulation”, “Identify and engage non-traditional 3rd party stakeholders/allies (e-cigarette manufacturers and retailers, adult consumers of RRP products, tobacco harm reduction advocates…” and “Amplify and leverage the debate on harm reduction around global events (eg, COP6)”.[3] We believe our findings raise important questions about PMI’s claims of transformation, as the activity we have documented appears part of a long-standing corporate affairs plan. Our article presents the facts that some harm reduction-related organisations receive PMI (or FSFW) funds. We do not cast those funded organisations as “nefarious”.
Our research aims to increase transparency in tobacco control policy-making. Making known any links between tobacco companies and individuals and organisations that participate in tobacco control policy debates, even if those links are indirect and occur through intermediaries, is in the public interest and consistent with the principles of WHO FCTC Article 5.3.[6] Vapers who belong to INNCO-affiliated organisations are also entitled to know the network (or “umbrella organization”) to which their organisation belongs receives tobacco industry funding via the FSFW. It is encouraging therefore to observe that following our publication, INNCO appears to have added a statement declaring its FSFW funding onto its homepage (that development appears to have occurred between 1 and 16 November 2020).[7,8]
We are transparent about our research funders. The researchers working on this paper were funded by Bloomberg Philanthropies through the STOP initiative, and by Cancer Research UK; neither funder, nor any of the STOP partners, had any role in the research conceptualisation, study design, data collection, analysis, decision to publish, or preparation of the manuscript.
Lindsay Robertson, MPH, PhD
Conflict of Interest: None declared
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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.
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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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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 have a share of the blame, such a construct fails to recognise the ground reality experienced by most of the world’s tobacco users, diverts attention from drawing up effective policies and shields some of the biggest contributors to the problem.
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Ruth Malone's pursuit of common ground in the tobacco control and broader public health communities is most welcome. As I emphasize in a new commentary that has received wide circulation (https://drive.google.com/file/d/1C1nk1XEZ8WhnOXtCGTqHdeqomc9HOuko/view), we must collectively climb out of our bunkers, come to the table and genuinely work together. Everyone, on all sides of the concurrent debates over tobacco harm reduction and protecting youth must stop skirting the truth when it feels inconvenient and open our minds and ears to all of the science that is before us, while discouraging and abandoning studies and pronouncements that are demonstrably biased or inadequate. We must move beyond the adversarial nature of the debate and transparently acknowledge areas of ambiguity or concern.
Combating the smoking epidemic is a social justice issue, as too little attention is now being given in many places, including the U.S., to prioritizing the importance of promoting adult smoking cessation and, for those adults addicted to smoking who cannot or are unwilling to quit nicotine -- many of whom are socially marginalized, poor, less educated, experience serious mental health conditions, or are members of the military or veterans -- helping them switch to less-hazardous, noncombustible forms of nicotine.
Regardless of ideology and policy preferences, we...
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Ruth Malone's pursuit of common ground in the tobacco control and broader public health communities is most welcome. As I emphasize in a new commentary that has received wide circulation (https://drive.google.com/file/d/1C1nk1XEZ8WhnOXtCGTqHdeqomc9HOuko/view), we must collectively climb out of our bunkers, come to the table and genuinely work together. Everyone, on all sides of the concurrent debates over tobacco harm reduction and protecting youth must stop skirting the truth when it feels inconvenient and open our minds and ears to all of the science that is before us, while discouraging and abandoning studies and pronouncements that are demonstrably biased or inadequate. We must move beyond the adversarial nature of the debate and transparently acknowledge areas of ambiguity or concern.
Combating the smoking epidemic is a social justice issue, as too little attention is now being given in many places, including the U.S., to prioritizing the importance of promoting adult smoking cessation and, for those adults addicted to smoking who cannot or are unwilling to quit nicotine -- many of whom are socially marginalized, poor, less educated, experience serious mental health conditions, or are members of the military or veterans -- helping them switch to less-hazardous, noncombustible forms of nicotine.
Regardless of ideology and policy preferences, we must at the very least tell the public as well as health care practitioners the truth about nicotine. That means that all of the major national and international messengers in this area -- NGOs and government, alike -- should do everything possible to educate the world about the continuum of risk of nicotine products, as clearly described by the U.S. Food and Drug Administration in its comprehensive plan released in July 2017, and not sweepingly demonize nicotine, which devastatingly causes widespread dependence on cigarettes but itself does not cause the illnesses suffered by the users of tobacco and is, in fact, a drug approved by the FDA as being safe and effective when used for smoking cessation.
We won’t come together if we don’t come together with openness, honesty and integrity. The time for that is now.
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I appreciated the editorial by Ruth Malone on finding "common ground" on the topic of product regulation and more broadly the role of tobacco control. I would certainly agree that the current climate in smoking harm reduction has become toxic and emotional, non-scientific, and counterproductive to achieving the public health goal of reducing premature deaths caused by using smoked tobacco (i.e., mainly cigarettes). I also agree that the cigarette companies are likely using this as a wedge to advance their own financial interests - what else would you expect? I don't think anyone interested in public health is suggesting that we dismiss the past bad actions of the cigarette manufacturers, nor accept the claims of manufacturers of alternative nicotine products. Rather, we need to heed the lessons of the past so as not to make the same mistakes going forward. The United States, the Tobacco Control Act created a framework that should incentivize manufacturers to move away from profiting from the sale of cigarettes that causes so much harm to consumers. Promoting dialogue summits would allow for participants to engage in a civil manner, educate one another about challenges and opportunities and agree to specific measurable goals and objectives. Bringing stakeholders together will not resolve all differences but it will allow serious and responsible stakeholders the opportunity to bring ideas forward and find areas of common ground...
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I appreciated the editorial by Ruth Malone on finding "common ground" on the topic of product regulation and more broadly the role of tobacco control. I would certainly agree that the current climate in smoking harm reduction has become toxic and emotional, non-scientific, and counterproductive to achieving the public health goal of reducing premature deaths caused by using smoked tobacco (i.e., mainly cigarettes). I also agree that the cigarette companies are likely using this as a wedge to advance their own financial interests - what else would you expect? I don't think anyone interested in public health is suggesting that we dismiss the past bad actions of the cigarette manufacturers, nor accept the claims of manufacturers of alternative nicotine products. Rather, we need to heed the lessons of the past so as not to make the same mistakes going forward. The United States, the Tobacco Control Act created a framework that should incentivize manufacturers to move away from profiting from the sale of cigarettes that causes so much harm to consumers. Promoting dialogue summits would allow for participants to engage in a civil manner, educate one another about challenges and opportunities and agree to specific measurable goals and objectives. Bringing stakeholders together will not resolve all differences but it will allow serious and responsible stakeholders the opportunity to bring ideas forward and find areas of common ground that can more rapidly advance population health. As an example, issues and concerns related to adolescent use of tobacco and nicotine products should be a major topic of concern, not only by the public health and tobacco control communities but by federal, state, and local policy makers and regulators, parents and teachers, responsible retailers and distributers, and many of those associated with the manufacturing businesses. While many stakeholders share common ground in this area, the polarizing and media driven approach that has been taken over the last several years has caused what has become a war of rhetoric, with a lot of finger pointing and a failure to bring interested parties together to discuss how to collectively deal with the issue and find workable solutions to protect youth while allowing smokers to have access to cleaner alternative nicotine products. It is often said that it should be good science that drives the implementation of sound policies. However, I fear that is not happening today. Finding "common ground" will be impossible so long as there remains an unwillingness to support civil dialogue on issues of smoking harm reduction. I hope that public health/ medial organizations like WHO, ACS, FDA, CDC and others will do more to facilitating real and open dialogue on how to accelerate a reduction of smoking caused disease and death than has been the case over the past decade.
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Professor Malone’s call for a better understanding of the context of the tobacco epidemic is timely. For tobacco as for sugar and alcohol, the extent of population harm is linked to the historic growth of an oligopoly which has used economies of scale, aggressive sales tactics and ingredient modification to transform commodities into highly-processed, convenient and affordable artefacts1-3. At a time when the pandemic has brought the role of governments in protecting the public into greater focus, the implementation of market restrictions which we know to be effective in reducing demand (higher tax, minimum price, minimum pack size)4 should receive a new impetus.
Professor Malone’s call to unite opponents and proponents of ‘newer and novel nicotine and tobacco products’ (NNNTPs) around opposition to the tobacco industry should be heeded. Imperial Brands’s recent decision to turn back to ‘neglected’ cigarettes after being ‘overly focused’ on alternative nicotine products shows that profits, not smokers’ lives, will always be the tobacco companies’ priority5. The enormous influence exercised by the tobacco industry over governments worldwide is perhaps the most pressing tobacco control issue today, with countries including the US continuing to score highly on the Global Index of Tobacco Industry Interference6.
As to whether NNNTPs represent a ‘breakthrough’, it is not so much the products themselves that are disruptive, but rather the...
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Professor Malone’s call for a better understanding of the context of the tobacco epidemic is timely. For tobacco as for sugar and alcohol, the extent of population harm is linked to the historic growth of an oligopoly which has used economies of scale, aggressive sales tactics and ingredient modification to transform commodities into highly-processed, convenient and affordable artefacts1-3. At a time when the pandemic has brought the role of governments in protecting the public into greater focus, the implementation of market restrictions which we know to be effective in reducing demand (higher tax, minimum price, minimum pack size)4 should receive a new impetus.
Professor Malone’s call to unite opponents and proponents of ‘newer and novel nicotine and tobacco products’ (NNNTPs) around opposition to the tobacco industry should be heeded. Imperial Brands’s recent decision to turn back to ‘neglected’ cigarettes after being ‘overly focused’ on alternative nicotine products shows that profits, not smokers’ lives, will always be the tobacco companies’ priority5. The enormous influence exercised by the tobacco industry over governments worldwide is perhaps the most pressing tobacco control issue today, with countries including the US continuing to score highly on the Global Index of Tobacco Industry Interference6.
As to whether NNNTPs represent a ‘breakthrough’, it is not so much the products themselves that are disruptive, but rather the fact that the most popular product i.e. the electronic cigarette did not originate with the tobacco industry, and that independent, non-tobacco companies have carved out a significant, perhaps even the largest slice of the market 7. The independent sector is routinely underreported because it is made up of a multitude of small to medium-sized companies rather than a few big players8, and because of market analysts’ outdated reliance on sales data from tobacco retail outlets rather than specialist shops. As Professor Malone says, the world is changing; the need to implement the provisions of the Framework Convention on Tobacco Control is as pressing as ever, but to fight tobacco harm in the new nicotine landscape, we need to move on from a simplistic conflation of tobacco and NNNTP industries. More sophisticated research is required to discern and illuminate the various strategies being employed by both tobacco and non-tobacco industry players in promoting combusted, smokeless or new nicotine products in different national markets, and to tease out the implications for population health and regulatory regimes.
1. Mintz SW. Sweetness and power. New York: Viking; 1985.
2. Schudson M. The Emergence of New Consumer Patterns: the case of the cigarette. In: Miller D, ed. Consumption: critical concepts in the social sciences: Routledge; 2001: 475-501.
3. Benson P. Commentary: Biopolitical injustice and contemporary capitalism. American Ethnologist 2012; 39(3): 488-90.
4. World Health Organization. WHO Framework Convention on Tobacco Control. Geneva: WHO 2004.
5. Nilsson P. Imperial Brands turns focus back to tobacco. Financial Times. 2021 27 January 2021.
6. Assunta M. Global Tobacco Industry Interference Index 2020. Bangkok, Thailand: Global Center for Good Governance in Tobacco Control (GGTC), 2020.
7. Brown R. Scaring the Giants: Vaping Category Report 2020. The Grocer. 2020 14 February 2020.
8. Levy DT, Lindblom EN, Sweanor DT, et al. An Economic Analysis of the Pre-Deeming US Market for Nicotine Vaping Products. Tobacco Regulatory Science 2019; 5(2): 169-81.
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We thank Tobacco Control for the opportunity to respond to the comment above. Our study was obviously not looking into the harms of secondhand aerosol from e-cigarettes (SHA). Our paper departs from previous compelling research on the harms of SHA and assesses the prevalence and duration of such exposure among e-cigarette non-users, i.e., bystanders who are potentially exposed to the aerosols emitted by e-cigarette users.
Firstly, it is clear that we conducted the study on the basis of knowledge that bystanders were involuntarily exposed to potentially hazardous SHA in many places. We have clearly mentioned the growing evidence that supports our assertion about the potential harms of SHA in the Introduction and Discussion sections of the paper. SHA contains many toxicants, including nicotine, particulate matter and carcinogens (e.g., volatile organic compounds, polycyclic aromatic hydrocarbons, formaldehyde, acetaldehyde and tobacco specific nitrosamines-TSNAs). As mentioned, this evidence comes from previous scientific research (please, foresee the references 11 to 14 of our paper). Of special interest, fine particulate matter (PM2.5) concentration increased during e-cigarette use sessions with human volunteers in settings such as a room[1–3], during vapers’ conventions[4,5], and in vape shops and their neighbouring businesses[6]. Some TSNAs, such as N-nitrosonornicotine and nicotine-derived nitrosamine ketone, which are carcinogenic[7], hav...
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We thank Tobacco Control for the opportunity to respond to the comment above. Our study was obviously not looking into the harms of secondhand aerosol from e-cigarettes (SHA). Our paper departs from previous compelling research on the harms of SHA and assesses the prevalence and duration of such exposure among e-cigarette non-users, i.e., bystanders who are potentially exposed to the aerosols emitted by e-cigarette users.
Firstly, it is clear that we conducted the study on the basis of knowledge that bystanders were involuntarily exposed to potentially hazardous SHA in many places. We have clearly mentioned the growing evidence that supports our assertion about the potential harms of SHA in the Introduction and Discussion sections of the paper. SHA contains many toxicants, including nicotine, particulate matter and carcinogens (e.g., volatile organic compounds, polycyclic aromatic hydrocarbons, formaldehyde, acetaldehyde and tobacco specific nitrosamines-TSNAs). As mentioned, this evidence comes from previous scientific research (please, foresee the references 11 to 14 of our paper). Of special interest, fine particulate matter (PM2.5) concentration increased during e-cigarette use sessions with human volunteers in settings such as a room[1–3], during vapers’ conventions[4,5], and in vape shops and their neighbouring businesses[6]. Some TSNAs, such as N-nitrosonornicotine and nicotine-derived nitrosamine ketone, which are carcinogenic[7], have been identified in e-cigarette aerosol (reference 12 of our paper). Airborne nicotine concentration was found to increase after e-cigarette use in an experimental study in a room[1], in an observational study conducted in users’ and non-users’ homes (reference 13 of our paper), and in a study of vapers’ conventions[8]. Also, nicotine in SHA was found to be systematically absorbed by bystanders at levels comparable to secondhand tobacco smoke (references 10 and 42 of our paper), which is worrisome. Additionally, SHA may cause reduced lung function and asthma exacerbations among non-users exposed to it (references 15 and 16). Unfortunately, we are unable to review the study conducted by the California Department of Public Health that was mentioned in the comment, as the source is a blogsite without any specific reference to the scientific publication. Personal blogsites tend to be subjective and are dominantly used to express the bloggers’ personal views, even when these blogsites are maintained by academics. It is worth mentioning, our work was published in a peer-reviewed journal, developed by a team of researchers devoted to public health, and, importantly, who have no conflict of interests.
Secondly, the evidence available at the time of the writing of our paper shows that e-cigarette use and seeing e-cigarette use may renormalise tobacco smoking, induce relapse to smoking among former smokers and trigger initiation of e-cigarette use among non-smokers, particularly young people, by decreasing the harm perception of e-cigarettes (references 17 to 21, and 57). This means the concern around SHA is not only about the air quality but also the social norm it might shape.
In conclusion, based on the evidence mentioned, we wanted to know to what extent e-cigarette exposure was perceived among the general population in European countries; consequently, our study estimates the prevalence of passive exposure to SHA from e-cigarettes. Perhaps the “fear” (we prefer to say “concern”) should exist for selling or using products that may harm the health of people who use them and bystanders who are involuntarily exposed to their aerosols. Based on our results, current evidence, and arguments previously discussed[9], we continue to believe that governments should include e-cigarettes use in smoke-free laws.
References mentioned in this response:
1 Schober W, Szendrei K, Matzen W, et al. Use of electronic cigarettes (e-cigarettes) impairs indoor air quality and increases FeNO levels of e-cigarette consumers. Int J Hyg Environ Health 2014;217:628–37. doi:10.1016/j.ijheh.2013.11.003
2 van Drooge BL, Marco E, Perez N, et al. Influence of electronic cigarette vaping on the composition of indoor organic pollutants, particles, and exhaled breath of bystanders. Environ Sci Pollut Res 2019;26:4654–66. doi:10.1007/s11356-018-3975-x
3 Volesky KD, Maki A, Scherf C, et al. The influence of three e-cigarette models on indoor fine and ultrafine particulate matter concentrations under real-world conditions. Environ Pollut 2018;243:882–9. doi:10.1016/j.envpol.2018.08.069
4 Chen R, Aherrera A, Isichei C, et al. Assessment of indoor air quality at an electronic cigarette (Vaping) convention. J Expo Sci Environ Epidemiol 2018;28:522–9. doi:10.1038/s41370-017-0005-x
5 Soule EK, Maloney SF, Spindle TR, et al. Electronic cigarette use and indoor air quality in a natural setting. Tob Control 2017;26:109–12. doi:10.1136/tobaccocontrol-2015-052772
6 Li L, Nguyen C, Lin Y, et al. Impacts of electronic cigarettes usage on air quality of vape shops and their nearby areas. Sci Total Environ 2021;760:143423. doi:10.1016/j.scitotenv.2020.143423
7 Hecht SS. Biochemistry, Biology, and Carcinogenicity of Tobacco-Specific N -Nitrosamines. Chem Res Toxicol 1998;11:559–603. doi:10.1021/tx980005y
8 Johnson JM, Naeher LP, Yu X, et al. A biomonitoring assessment of secondhand exposures to electronic cigarette emissions. Int J Hyg Environ Health 2019;222:816–23. doi:10.1016/j.ijheh.2019.04.013
9 Wilson N, Hoek J, Thomson G, et al. Should e-cigarette use be included in indoor smoking bans? Bull World Health Organ 2017;95:540–1. doi:10.2471/BLT.16.186536
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I wish to express my dismay with the clear and obvious intention to promote an agenda of fear. One might ask why you are not looking to see whether there actually are any harms from second hand aerosol as the study clearly acts upon a preface that this is the case. I would point you to the CDC's own testing of the air quality found here. Something smells a lot less like science and a lot more like virtue signalling funded by an agenda eager to skip the important part of knowing what you're dealing with before searching for potential victims. https://tobaccoanalysis.blogspot.com/2017/05/vape-shop-air-sampling-by-c...
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Recent work from Ilies et al. (1) is very informative toward understanding the degree to which heated tobacco products might confer less health risk than combusted cigarettes. This publication extends well beyond the existing HTP emissions evidence base, much of which was not conducted by independent groups. The authors should be commended for leveraging strong methodology, and for their comprehensive evaluation of toxicants generated by these products.
While the methodology and results of this publication appear sound, there are a number of inaccurate claims that warrant criticism in the second paragraph of the Introduction section:
• The second paragraph discusses nicotine vaping products (e-cigarettes), however citation #2 (Centers for Disease Control and Prevention (CDC). Use of cigarettes and other tobacco products among students aged 13-15 years--worldwide, 1999-2005. MMWR Morb Mortal Wkly Rep 2006;55:553) utilize data from 1999 through 2005, which mostly spans a time frame prior to the invention of the first e-cigarette in 2004 (2), and certainly spans a timeframe prior to their widespread marketing in the United States. The citation follows the sentence “However, the death toll provoked by their [e-cigarettes] consumption has increased significantly, reaching 650,000 annually, and it is likely to rise over the coming year…” This citation is clearly inapplicable to the unfounded claim being made about deaths attributable to e-ci...
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Recent work from Ilies et al. (1) is very informative toward understanding the degree to which heated tobacco products might confer less health risk than combusted cigarettes. This publication extends well beyond the existing HTP emissions evidence base, much of which was not conducted by independent groups. The authors should be commended for leveraging strong methodology, and for their comprehensive evaluation of toxicants generated by these products.
While the methodology and results of this publication appear sound, there are a number of inaccurate claims that warrant criticism in the second paragraph of the Introduction section:
• The second paragraph discusses nicotine vaping products (e-cigarettes), however citation #2 (Centers for Disease Control and Prevention (CDC). Use of cigarettes and other tobacco products among students aged 13-15 years--worldwide, 1999-2005. MMWR Morb Mortal Wkly Rep 2006;55:553) utilize data from 1999 through 2005, which mostly spans a time frame prior to the invention of the first e-cigarette in 2004 (2), and certainly spans a timeframe prior to their widespread marketing in the United States. The citation follows the sentence “However, the death toll provoked by their [e-cigarettes] consumption has increased significantly, reaching 650,000 annually, and it is likely to rise over the coming year…” This citation is clearly inapplicable to the unfounded claim being made about deaths attributable to e-cigarette use.
• Citation #3 also supports claims about e-cigarette use, however the cited paper (Sinha DN, Kumar A, Bhartiya D, et al. Smokeless tobacco use among adolescents in global perspective. Nicotine Tob Res 2017;19:1395–6) references non-combusted tobacco products in general, as opposed to the many publications which have looked explicitly at e-cigarette use in a more comprehensive fashion. After reading the Sinha et al. research letter, I am not sure that e-cigarettes were considered at all.
• Citation #4 (US Department of Commerce CB. National cancer Institute and centers for disease control and prevention Co-Sponsored tobacco use supplement to the current population survey 2007) does not provide a direct link to any supporting data/publication. It appears the authors are generally referring to the 2006-2007 Tobacco Use Supplement to the Current Population Survey (CPS-TUS), which was conducted in April 2006, August 2006, and January 2007 (3). The first report of an e-cigarette being imported to the United States is from August 2006 (https://rulings.cbp.gov/ruling/M85579), and the 2006-2007 CPS-TUS did not include any survey items related to e-cigarettes. As such, there is no data from the 2006-2007 CPS-TUS that supports the claim “[e-cigarettes] are highly addictive and can cause serious health problems”.
• The claim “More than 30 carcinogenic compounds in high concentrations were identified, leading to severe health hazards such as oral, pharyngeal, oesophageal and pancreatic cancers” is unfounded, as there is no longitudinal data linking e-cigarettes and cancer to date, nor am I aware of evidence that over 30 carcinogenic compounds in “high concentrations” have been identified in any studies of e-cigarette emissions. Additionally, the provided citation (citation #5: Hatsukami D, Zeller M, Gupta P, et al. Smokeless tobacco and public health: a global perspective 2014) does not talk about e-cigarettes even once.
• Citation #6 (Gupta R, Gupta S, Sharma S, et al. Risk of coronary heart disease among smokeless tobacco users: results of systematic review and meta-analysis of global data. Nicotine and Tobacco Research 2019;21:25–31) also does not pertain to e-cigarettes at all, and the accompanying claim “Cardiovascular death risks and stillbirths were also shown to increase up to four times, signalling real concerns regarding human health safety” is baseless with respect to the epidemiological literature on e-cigarettes.
While these concerns do not directly impact the study results or conclusions, e-cigarettes have become a polarizing topic in the tobacco control community and beyond. As such, claims about e-cigarettes must be made with the utmost care, based on rigorous scientific evidence and sound, balanced interpretations of relevant findings. This publication will be read and cited many times over as heated tobacco products continue to proliferate in tobacco markets across the globe, making it that much more important to address these misleading, and at times, blatantly false claims.
References:
1. Ilies BD, Moosakutty SP, Kharbatia NM, et al. Identification of volatile constituents released from IQOS heat-not-burn tobacco HeatSticks
using a direct sampling method. Tobacco Control. Published Online First: 26 May 2020. doi: 10.1136/tobaccocontrol-2019-055521
2. Henningfield JE & Zaatari GS. Electronic nicotine delivery systems: emerging science foundation for policy. Tobacco Control
2010;19:89e90. doi:10.1136/tc.2009.035279
3. US Department of Commerce, Census Bureau (2006-2007). National Cancer Institute and Food and Drug Administration co-sponsored
Tobacco Use Supplement to the Current Population Survey. 2006-2007. https://cancercontrol.cancer.gov/brp/tcrb/tus-cps/
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The meta-analysis by Khouja et al. confirms the strong association in young people between e-cigarette use and subsequent smoking.[1] The critical issue is whether the relationship is causal. If there is a causal relationship, there are several factors which diminish its impact.
Firstly, most of the studies used ‘ever smoking’ as the outcome. Ever smoking is a poor marker for smoking-related harm as most smoking by vapers who later smoke is experimental and infrequent and few progress to established smoking (100+ lifetime cigarettes). Shahab et al. found that only 2.7% of youth who tried e-cigarettes first progressed to established smoking. Only established smoking is linked to significant smoking-related death and disease.[2]
Secondly, the absolute number of non-smokers who progress from vaping to smoking is small as smoking precedes vaping in the vast majority of cases (70-85%).[3] If there is a gateway from vaping to smoking, this only affects a minority of young vapers.
Thirdly, the authors use Bradford Hill’s dose-response and specificity criteria to assess whether the association between vaping and subsequent smoking is likely to be causal.
They acknowledge that the dose-response criterion is mostly based on nicotine dependence, indicating that that nicotine dependent vapers are more likely to progress to smoking. However, nicotine dependence in non-smoking vapers is rare, less than 4% in the 2018 National Youth T...
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The meta-analysis by Khouja et al. confirms the strong association in young people between e-cigarette use and subsequent smoking.[1] The critical issue is whether the relationship is causal. If there is a causal relationship, there are several factors which diminish its impact.
Firstly, most of the studies used ‘ever smoking’ as the outcome. Ever smoking is a poor marker for smoking-related harm as most smoking by vapers who later smoke is experimental and infrequent and few progress to established smoking (100+ lifetime cigarettes). Shahab et al. found that only 2.7% of youth who tried e-cigarettes first progressed to established smoking. Only established smoking is linked to significant smoking-related death and disease.[2]
Secondly, the absolute number of non-smokers who progress from vaping to smoking is small as smoking precedes vaping in the vast majority of cases (70-85%).[3] If there is a gateway from vaping to smoking, this only affects a minority of young vapers.
Thirdly, the authors use Bradford Hill’s dose-response and specificity criteria to assess whether the association between vaping and subsequent smoking is likely to be causal.
They acknowledge that the dose-response criterion is mostly based on nicotine dependence, indicating that that nicotine dependent vapers are more likely to progress to smoking. However, nicotine dependence in non-smoking vapers is rare, less than 4% in the 2018 National Youth Tobacco Survey (NYTS).[4]
They point out that studies with ‘negative control outcomes’ would reduce specificity but do not cite any studies to demonstrate this. A number of studies have found that vaping also predicts other risky behaviors such as alcohol, marijuana and other substance use.[5,6] There is no biologically plausible mechanism for e-cigarette use being a causal factor for these other behaviours. We think that, like smoking, these associations are best explained by a common liability.[7]
Finally, the recent study by Shahab et al. using NYTS data found that nicotine vaping appears to be protective against future smoking.[2] Teens who vaped first were significantly less likely to subsequently become established smokers than 1) those who smoked first and 2) a matched group of non-vapers.
Their findings suggest that, if there is a gateway from vaping to smoking it is very small and is outweighed by a much larger effect of diverting youth away from cigarette smoking.
References
1. Khouja JN, Suddell SF, Peters SE, et al. Is e-cigarette use in non-smoking young adults associated with later smoking? A systematic review and meta-analysis. Tobacco control 2020 doi: 10.1136/tobaccocontrol-2019-055433 [published Online First: 2020/03/12]
2. Shahab L, Beard E, Brown J. Association of initial e-cigarette and other tobacco product use with subsequent cigarette smoking in adolescents: a cross-sectional, matched control study. Tobacco control 2020 doi: 10.1136/tobaccocontrol-2019-055283
3. Berry KM, Reynolds LM, Collins JM, et al. E-cigarette initiation and associated changes in smoking cessation and reduction: the Population Assessment of Tobacco and Health Study, 2013-2015. Tobacco control 2018;28(1):42-49. doi: 10.1136/tobaccocontrol-2017-054108
4. West R, Brown J, Jarvis M. Epidemic of youth nicotine addiction? What does the National Youth Tobacco Survey reveal about high school ecigarette use in the USA? 2019 [Available from: https://www.qeios.com/read/article/391 accessed 24 February 2020.
5. Park E, Livingston JA, Wang W, et al. Adolescent E-cigarette use trajectories and subsequent alcohol and marijuana use. Addictive behaviors 2020;103:106213. doi: 10.1016/j.addbeh.2019.106213 [published Online First: 2019/12/22]
6. Rigsby DC, Keim SA, Adesman A. Electronic Vapor Product Usage and Substance Use Risk Behaviors Among U.S. High School Students. J Child Adolesc Psychopharmacol 2019;29(7):545-53. doi: 10.1089/cap.2019.0047 [published Online First: 2019/07/26]
7. Vanyukov MM, Tarter RE, Kirillova GP, et al. Common liability to addiction and "gateway hypothesis": theoretical, empirical and evolutionary perspective. Drug and alcohol dependence 2012;123 Suppl 1:S3-17. doi: 10.1016/j.drugalcdep.2011.12.018 [published Online First: 2012/01/21]
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This is a well written original research about the burning issue of tobacco manufacturer lobbying. These manufacturing industries have developed strategies to undercut minimum price laws. By increasing tobacco taxes an effective policy has been designed to decrease tobacco use. In Pakistan currently, 209 million people smoke and about 83 billion cigarettes are smoked per year. As Pakistan has not ratified any anti-smoking policies, there should be great effort made to raise excise duties and taxes on tobacco companies to reduce the demand for cigarettes. In 2017 the local price of cigarettes was about 75 rupees of which half was excise duties [1].
With this expansion of taxes, there will be responses of reducing tobacco consumption, but the cigarette manufacturing industries developed specific promotions and lobbies to encourage their consumers to purchase lower taxed or lower priced tobacco products. It is the responsibility of health authorities to regulate the prices and promotion of such hazardous products [2]. According to WHO, “MPOWER” was the slogan in 2015, according to which M= monitor tobacco usage, P= Protect people from tobacco smoke, O= offering help to quit tobacco use, W= warning about its hazards, E= enforce to ban its advertisement, R = Raise tobacco taxes [3].
For smoke free Pakistan and all over the world four key factors should be instruments: Education, legislation, quitting support and financial policies.
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This is a well written original research about the burning issue of tobacco manufacturer lobbying. These manufacturing industries have developed strategies to undercut minimum price laws. By increasing tobacco taxes an effective policy has been designed to decrease tobacco use. In Pakistan currently, 209 million people smoke and about 83 billion cigarettes are smoked per year. As Pakistan has not ratified any anti-smoking policies, there should be great effort made to raise excise duties and taxes on tobacco companies to reduce the demand for cigarettes. In 2017 the local price of cigarettes was about 75 rupees of which half was excise duties [1].
With this expansion of taxes, there will be responses of reducing tobacco consumption, but the cigarette manufacturing industries developed specific promotions and lobbies to encourage their consumers to purchase lower taxed or lower priced tobacco products. It is the responsibility of health authorities to regulate the prices and promotion of such hazardous products [2]. According to WHO, “MPOWER” was the slogan in 2015, according to which M= monitor tobacco usage, P= Protect people from tobacco smoke, O= offering help to quit tobacco use, W= warning about its hazards, E= enforce to ban its advertisement, R = Raise tobacco taxes [3].
For smoke free Pakistan and all over the world four key factors should be instruments: Education, legislation, quitting support and financial policies.
1. Bate R. Large cigarette tax hikes, illicit producers, and organized crime: Lessons from Pakistan. AEI Paper & Studies. 2018 Jun 1:1.
2. Apollonio DE, Glantz SA. Tobacco industry promotions and pricing after tax increases: An analysis of internal industry documents.
3. World Health Organization. WHO report on the global tobacco epidemic 2015: raising taxes on tobacco. World Health Organization; 2015 Jul 31.
The atomizer used for testing has a maximum rating of 80 watts.
200 watts was applied. Needless to say, horrible results occurred.
This is not reputable science, it is a failed experiment, it should never have been published.
It should be noted that the Aspire Cleito coils used in this study have a manufacturer stated operating power range of between 55 and 75 watts. This is noted both on the box and laser etched into the side of the coil housing proper. it should be noted that the first data points in the graph ( to demonstrate the presence of CO in both liquid samples are in excess of the stated power range of the element.
"Strawnana" at 80 watts
"Black Ice" at 100 watts
This leads me to question the normalizing curve for the black ice sample as there are no data points in the graph (Figure 2) within the manufacturer noted operating range for that coil.
Furthermore, while this statement " ...though the bulk liquid temperature is controlled by boiling limits of the e-liquid component" would be accurate were the coil to be completely submerged in liquid, the mechanics of coil design will confound that principle. The resistance coils in electronic cigarettes are not, by design, submerged in liquid, they are in contact with a liquid saturated wick. Any heat energy applied to the coil whether in magnitude or duration, that exceeds the supply of liquid saturating the wick will result in a temperature spike which could cause the temperature to spike causing thermal degradation of what liquid does remain, and the singeing of the cotton wick.
It can be expected that where combustion occurs, carbon compounds will...
It should be noted that the Aspire Cleito coils used in this study have a manufacturer stated operating power range of between 55 and 75 watts. This is noted both on the box and laser etched into the side of the coil housing proper. it should be noted that the first data points in the graph ( to demonstrate the presence of CO in both liquid samples are in excess of the stated power range of the element.
"Strawnana" at 80 watts
"Black Ice" at 100 watts
This leads me to question the normalizing curve for the black ice sample as there are no data points in the graph (Figure 2) within the manufacturer noted operating range for that coil.
Furthermore, while this statement " ...though the bulk liquid temperature is controlled by boiling limits of the e-liquid component" would be accurate were the coil to be completely submerged in liquid, the mechanics of coil design will confound that principle. The resistance coils in electronic cigarettes are not, by design, submerged in liquid, they are in contact with a liquid saturated wick. Any heat energy applied to the coil whether in magnitude or duration, that exceeds the supply of liquid saturating the wick will result in a temperature spike which could cause the temperature to spike causing thermal degradation of what liquid does remain, and the singeing of the cotton wick.
It can be expected that where combustion occurs, carbon compounds will be present.
I would be interested in seeing the data sets to better understand exactly how far out of operating range CO began to manifest in the study.
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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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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 “risk behaviors”) can be modeled as a latent factor that predisposes an adolescent to use of multiple substances, delinquency, and other health risk behaviors.2,3 The latent factor is influenced by the environment at multiple levels. We rely on this framework in two recent papers that demonstrate that that US declines in tobacco use, other substance use, substance use disorders, delinquency, and sexual promiscuity among adolescents are consistent with a population-level reduction in a latent factor that predisposes to risk for all of these outcomes.4,5 Similarly, the externalizing spectrum of personality and psychopathology is postulated to arise from a common liability to multiple substance use and other disinhibitory disorders.6 Externalizing liability has been shown to change in response to specific environmental stressors such as minority stress and child maltreatment.7–10
Although common liability models do not invoke causal gateway effects, they are consistent with commonly observed gateway patterns, in which easily available drugs such as alcohol, cigarettes and marijuana are usually used prior to use of other drugs.5 Thus, trends observed by Miech and colleagues do not contradict the common liability model.
1. Miech R, Keyes KM, O’Malley PM, Johnston LD. The great decline in adolescent cigarette smoking since 2000: consequences for drug use among US adolescents. Tob Control. January 2020:tobaccocontrol-2019-055052.
2. Jessor R, Jessor SL. Problem Behavior and Psychosocial Development: A Longitudinal Study of Youth. Academic Press; 1977.
3. Jessor R. Risk behavior in adolescence: A psychosocial framework for understanding and action. Journal of adolescent Health. 1991;12(8):597-605.
4. Grucza RA, Krueger RF, Agrawal A, et al. Declines in prevalence of adolescent substance use disorders and delinquent behaviors in the USA: a unitary trend? Psychological Medicine. 2018;48(9):1494-1503.
5. Borodovsky JT, Krueger RF, Agrawal A, Grucza RA. A Decline in Propensity Toward Risk Behaviors Among U.S. Adolescents. Journal of Adolescent Health. 2019;65(6):745-751.
6. Krueger RF, Markon KE, Patrick CJ, Benning SD, Kramer MD. Linking antisocial behavior, substance use, and personality: an integrative quantitative model of the adult externalizing spectrum. J Abnorm Psychol. 2007;116(4):645-666.
7. Lehavot K, Simoni JM. The impact of minority stress on mental health and substance use among sexual minority women. Journal of Consulting and Clinical Psychology. 2011;79(2):159-170.
8. Eaton NR. Transdiagnostic psychopathology factors and sexual minority mental health: Evidence of disparities and associations with minority stressors. Psychology of Sexual Orientation and Gender Diversity. 2014;1(3):244-254.
9. Rodriguez-Seijas C, Stohl M, Hasin DS, Eaton NR. Transdiagnostic Factors and Mediation of the Relationship Between Perceived Racial Discrimination and Mental Disorders. JAMA Psychiatry. 2015;72(7):706.
10. Vachon DD, Krueger RF, Rogosch FA, Cicchetti D. Assessment of the Harmful Psychiatric and Behavioral Effects of Different Forms of Child Maltreatment. JAMA Psychiatry. 2015;72(11):1135.
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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.
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...
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 significantly associated with any respiratory symptom among persons with no previous cigarette smoking history. The secondary analysis strongly suggests that if a measure capturing extent of former smoking was entered as a covariate in the main model, the primary reported finding of an association between e-cigarette use and pulmonary symptoms would have been null.
Second, the analyses did not adjust for conditions that exacerbate wheeze (chronic obstructive pulmonary disease, congestive heart failure and certain cardiac medications), another potential source of residual confounding. These conditions may also cause declining health, prompting the person to quit smoking or switch from smoking to vaping, adding to a cross sectional association through reverse causality.
While addressing this last issue requires longitudinal data, we believe adding former smoking status and marijuana smoking to the main analysis should be done. The inclusion of these covariates would provide a less biased estimate of the cross-sectional association between vaping and respiratory symptoms and perhaps reach entirely different conclusions. We hope the authors will publish updated results in their response to this comment.
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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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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 cessation, I believe their proposed alternative problem-definition is overly simplistic and that it will not serve smokers of any ethnicity well. The appropriate approach is to take a ‘system view’, in which the system includes individuals, community, tobacco industry and supply chain, technology and innovation, information, regulation, taxation and enforcement - and to recognise this system is undergoing a significant disruption. A focus on ‘harm reduction’ should not be misunderstood as an individualist perspective. It requires careful engineering of incentives through ‘risk-proportionate’ policies that bear down hard on the cigarette trade but encourage smokers to switch to lower risk products. It is not an alternative to conventional MPOWER techniques, but a way of widening and improving the responses available to smokers.
4. No analysis is provided of the Centre's mission or work programme and how this will, somehow, harm the interests of indigenous people. No consideration is given to the implications of NOT having the Centre, of NOT doing its work and NOT producing its intellectual property. What is gained by NOT trying to reduce the smoking-related harms among indigenous people? Why is it better for this money to be spent elsewhere or returned to PMI's shareholders than spent on improving the life-chances of New Zealand’s indigenous populations?
5. Instead of dispassionate analysis of the Centre's work programme and the Foundation's aims, an array of irrelevant arguments and innuendo about the original funder is deployed in an effort to discredit the Centre and its work. It amounts to a superficial analysis of business motivations and the incentives of tobacco firms and fails to grasp how these have been fundamentally changed by the ongoing technology disruption created by new forms of non-combustible products. Yet, that is precisely why such a centre has such an important role in the rapidly evolving environment.
6. Indigenous people's smoking rates in New Zealand remain far higher than the European origin population (daily smoking prevalence was 31.2% among Māoris compared to 13.5% among the European population in 2018). Clearly, the standard tobacco control playbook has not been a conspicuous success in this population, yet Māoris suffer a disproportionate burden from the key tobacco policy: tobacco taxes set at a high level. Māoris account for 26% of national expenditure on tobacco, but only account for 15% of the adult population and around 70% of their expenditure is tax (approximately $NZ 700m). The harm reduction approach should also be seen as a way to mitigate the economic inequities that arise from tobacco use and tobacco taxation - there are large savings to smokers who switch from smoking to vaping.
7. Given the relative failure of conventional tobacco control in reducing smoking prevalence in indigenous populations, surely it makes sense to try new approaches - including the 'harm reduction' approach that aims help smokers switch from combustible to non-combustible nicotine products. For many, this will be an easier transition than complete cessation because it involves giving up less (i.e. it does not involve giving up nicotine, sensory impacts, behavioural ritual etc) but for almost the same health gain.
8. There is some support for this in New Zealand’s parliament. A joint House of Representatives Māori Affairs and Health Committee inquiry noted in December 2018 that New Zealand was off-track to meet the Aotearoa 2025 goal and that regularising the market for vaping products should be recognised as part of the policy response:
"We recommend that legislation be enacted to recognise and regulate vaping and e-cigarettes as a pathway to help smokers to quit".
9. Emotive rhetoric about a 'new colonisation' may help to fire up activists but it adds little of practical value to the debate. Nicotine is one of several drugs in widespread and longstanding use in most societies. As a drug, nicotine is relatively benign and does not cause intoxication, overdose, violence, accidents, sexual vulnerability, job losses, family breakdown etc. We now have an opportunity to address its ‘dirty’ delivery system, the inhalation of tobacco smoke, and so to reduce the great harm that arises from how nicotine is administered. How does a Centre trying to reduce smoking-related harm among indigenous people colonise anyone?
10. There is a far more imaginative way to see the Centre, the Foundation and PMI. This is how I see it: due to a major technology disruption in the consumer nicotine marketplace, some tobacco companies are now repositioning themselves in a way that will be beneficial for public health despite their ongoing participation in the cigarette business. A valuable by-product of that has been the release of $1 billion to support research and programmes that reduce smoking and related harms and facilitate a transition from combustible nicotine products to non-combustible. Committed public health advocates and academics should at least keep an open mind about this, while others seize the opportunity to do good and reduce harm with these funds, especially in disadvantaged communities. In this case, the Centre and its leadership have done exactly that and, in my view, they should be given time and some encouragement to prove their worth to indigenous communities.
Note: I have no relationship with the Centre, the Foundation or PMI, and I do not speak on their behalf or at their behest. The views stated here are my own. I have been a public health advocate for tobacco harm reduction since 1998.
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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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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.
Addressing conflicts of interest is fundamentally important for ethical practice. Conflicts of interest are commonly described in ethical principles, including specific Indigenous codes 6-8. The Tri-Council Policy Statement describes a COI as:
“when activities or situations place an individual or institution in a real, potential or perceived conflict between the duties or responsibilities related to research, and personal, institutional or other interest. These interests include, but are not limited to, business, commercial or financial interests pertaining to the institution and/or the individual, their family members, friends, or their former, current or prospective professional associates.” 6, page 93
A clear COI is created when the tobacco industry’s role is purported to support health research, while also profiting from the sale and promotion of tobacco products–all while smoking continues to be identified as the single greatest avoidable cause of death and disease worldwide 9 10. In other words, there is a COI when health professionals accept funding from the tobacco industry 9 10. This COI was also identified in the United Nations General Assembly, when they recognised the “fundamental conflict of interest between the tobacco industry and public health” 11, page 5. The Foundation was launched with a 12-year funding commitment from PMI of $1 billion 12. There has been financial dependence on PMI as well as conflicting commercial and business interests 2-4 12. Further, analysis of the Foundation’s tax return indicated that the Foundation remains solely funded by PMI. 3 The Foundation and subsequently the Centre have received PMI funding. As Yach and Bettcher stated in an earlier time, “tobacco is at the centre of the contradictions... …It is where the goals of a set of multinationals are clearly in conflict with public health and welfare.” 13, page 6
The COI, actual and perceived, and the inherent conflict of duty can manifest in additional ways:
1) the PMI-funded Foundation’s harm reduction role serves PMI’s agenda of moving into the Alternative Nicotine Devices market, while PMI continues to promote and sell tobacco 14. Therefore, the Foundation serves PMI’s Alternative Nicotine Devices market aspirations 14-16.
2) The Foundation serves a public relations role for PMI. The PMI-funded Foundation’s mission of progressing toward ending smoking through health, science, and technology for smoking cessation and tobacco harm reduction tools, supports PMI’s corporate responsibility agenda. Therefore, it could be argued that the Foundation contributes a veneer of credibility to PMI. This veneer provides public relations opportunities for PMI to frame themselves as “good” global corporate citizens 17-19. Further, Legg et al. 3 provide additional analysis of the relationship between PMI and the Foundation, highlighting that the Foundation’s expenditure on public relations was more than their expenditures on research, challenging the Foundation’s purported image as a “scientific body” and supporting the growing consensus that they serve as a PMI public relations function 3 20.
As Mr. Bates highlights, the tobacco industry continues to directly and indirectly fund foundations, centers, and researchers. Funding foundations, centers, and researchers can be used in its effort to gain credibility 3 21. The tobacco industry has marketed global corporate responsibility with attractive research funding and courted prominent scientists. This has included epidemiologists including Dr. Ernst Wynder, an early proponent of tobacco harm reduction 17, and Dr. Alvan R. Feinstein, editor of the Journal of Clinical Epidemiology 18. Feinstein critiqued the “atmosphere [in which a tobacco industry] consultant’s stature, credibility, and integrity become instantly impugned and tarnished by the depravity of associating with the tobacco ‘bad guy’” 18. However, Feinstein failed to declare that he, too, was a tobacco industry consultant 22-24. The Foundation’s director has also previously detailed such industry strategies as “buying scientists” to serve commercial objectives and undermine effective tobacco control 25. In 2007, Yach and Bettcher stated, “As the vector of the tobacco epidemic, the tobacco industry's actions fall far outside of the boundaries of global corporate responsibility” 13, page 207.
The tobacco industry has a long and productive history of colluding in covering up, denying, confusing, and questioning the science on smoking and smoking-related morbidity and mortality 26. Given the long and comprehensive history of the tobacco industry using public relations firms and scientists in its manipulation of research 27 28, the connections between the Foundation and bodies with long-standing tobacco industry links continues to raise significant concerns about the legitimacy of the PMI-funded Foundation, the Centre, and their research messages.
3) the Foundation and its protagonists create divisions both real and perceived. For example, the Foundation and its protagonists can frame institutions and various peoples as “for” or “against” harm reduction in a binary fashion, but in fact there are many aspects and diverse views on harm reduction 29-32. The arguments about who to trust and who researchers should accept funding from can dilute the health sectors’ efforts, sow confusion and doubt, and generate opportunities to promote the tobacco industry agenda 16 33. As outlined, this echoes a common colonisation tool - divide and conquer. 10 34 This credibility dilemma over who the public should engage with, believe, and trust creates a false dichotomy of “us vs. them”. In reality, views lie on a diverse continuum. Such divisions, real or perceived, do not help progress constructive debate about reducing tobacco use or tobacco related harms, and disrupt knowledge production processes in public health and medicine. 28 Indigenous processes are about inclusivity and our right to the enjoyment of the highest attainable standard of health. 35 We want to have fora that promote that standard, where different perspectives can be heard and discussed free from externally imposed agendas. 32 35
Harm reduction and a comprehensive approach to reducing tobacco use among Indigenous peoples
The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) 32, and others 29-31, have outlined the need for a comprehensive and multifaceted systems approach to reducing commercial tobacco use, including preventing tobacco uptake. 29-32 A comprehensive systems approach emphasises that there is no single solution to addressing smoking disparities; by definition, the solutions are complex. 9 30-32 In addition, the FCTC guiding principles recognize the particular needs and challenges experienced by Indigenous peoples, and the importance of facilitating Indigenous participation in developing, implementing, and evaluating tobacco control. 32 Indigenous peoples should be able to engage in tobacco reduction debates, including about forms of harm reduction, free from external or tobacco industry agendas. 32 35 While Mr. Bates states, “There is a far more imaginative way to see the Centre, the Foundation and PMI”, our interests are clear. We are interested in reducing tobacco use, and consequently tobacco-related death and disease. We are interested in improving our health and wellbeing. “For the tobacco epidemic, the vector is not a virus, bacterium, or other microorganism – it is an industry and its business strategy.” 36, page 71
Conclusion
There is a need for evidence-based debate to reduce tobacco-related death and disease, and we encourage constructive debate that strengthens and advances tobacco control programs and policies. But this science must be ethical and independent from the tobacco industry. 2 5 25 27 28 32 37 We must reinforce the calls from WHO, the public health community, and Indigenous peoples to reject collaborations with the Foundation 3 10 20 32 38. We encourage centers and researchers not to accept Foundation funds, and we urge the Foundation to return its funding to PMI. Tobacco-related death and disease is completely preventable 9, and the “health and well-being of Indigenous peoples is too critical, the promise of future Indigenous generations too important.” 10, page 3
References
1. Chapman S. Tobacco giant wants to eliminate smoking: British Medical Journal Publishing Group, 2017.
2. Daube M, Moodie R, McKee M. Towards a smoke-free world? Philip Morris International’s new Foundation is not credible. The Lancet 2017;390(10104):1722-24.
3. Legg T, Peeters S, Chamberlain P, et al. The Philip Morris-funded Foundation for a Smoke-Free World: tax return sheds light on funding activities. The Lancet doi: 10.1016/S0140-6736(19)31347-9
4. van der Eijk Y, Bero LA, Malone RE. Philip Morris International-funded ‘Foundation for a Smoke-Free World’: analysing its claims of independence. Tobacco Control 2018 doi: 10.1136/tobaccocontrol-2018-054278
5. J. Liberman. The new Philip Morris-funded Foundation for a Smoke-Free World: independent or not?, McCabe Centre for Law & Cancer, 30 January 2018, accessed June 2019 2018 [
6. Canadian Tri-Council. Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS2): Ottawa, ON: Canadian Institutes of Health Research, Natural Sciences and …, 2010.
7. Hudson M, Milne M, Reynolds P, et al. Te ara tika. Guidelines for Māori research ethics: a framework for researchers and ethics committee members 2010
8. Ermine W, Sinclair R, Jeffery B. The ethics of research involving Indigenous peoples: Indigenous Peoples' Health Research Centre Saskatoon, Saskatchewan 2004.
9. Health UDo, Services H. The health consequences of smoking—50 years of progress: a report of the Surgeon General: Atlanta, GA: US Department of Health and Human Services, Centers for Disease …, 2014.
10. Waa A, Robson B, Gifford H, et al. Foundation for a Smoke-Free World and healthy Indigenous futures: an oxymoron? Tobacco Control 2019:tobaccocontrol-2018-054792. doi: 10.1136/tobaccocontrol-2018-054792
11. Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, A/RES/66/2 (24 January 2012), para. 38; 2012.
12. Foundation for a Smoke-Free World. Media advisory: Foundation forming to eliminate smoking worldwide, 2017.
13. Yach D, Bettcher D. Globalisation of tobacco industry influence and new global responses. Tobacco Control 2000;9(2):206-16. doi: 10.1136/tc.9.2.206
14. Philip Morris International. Philip Morris International, 2018 Annual Report, 2018.
15. Foundation for a Smoke-Free World. Our Vision: Foundation for a Smoke-Free World; 2018 [Available from: https://www.smokefreeworld.org/our-vision accessed 18 September 2018.
16. Foundation for a Smoke-Free World. Strategic Plan 2019-2021 The Foundation for a Smoke-Free World: Foundation for a Smoke-Free World, 2018.
17. Fields N, Chapman S. Chasing Ernst L Wynder: 40 years of Philip Morris’ efforts to influence a leading scientist. Journal of Epidemiology & Community Health 2003;57(8):571-78.
18. Mukherjee A, Ekanayake E. Epistemic communities and the global alliance against tobacco marketing. Thunderbird International Business Review 2009;51(3):207-18.
19. Malone RE. On tobacco industry cultural appropriation. Tobacco Control 2009;18(6):425-26. doi: 10.1136/tc.2009.034488
20. Global Center for Good Governance in Tobacco Control. An open letter to the Director General and Executive Board of the World Health Organization, 2019.
21. Smith KE, Fooks G, Collin J, et al. “Working the system”—British American tobacco's influence on the European union treaty and its implications for policy: an analysis of internal tobacco industry documents. PLoS Medicine 2010;7(1):e1000202.
22. Nixon L, Mejia P, Cheyne A, et al. Big Soda’s long shadow: news coverage of local proposals to tax sugar-sweetened beverages in Richmond, El Monte and Telluride. Critical Public Health 2015;25(3):333-47.
23. Etter JF. Secondhand smoke in Geneva, 1996–2006: changes in exposure, opinions, and workplace smoking bans in the absence of national legislation. International journal of occupational and environmental health 2009;15(2):159-65.
24. Dockrell M. Eye and heart at mortal war: coronaries and controversy in a smoke-free Scotland. Expert review of pharmacoeconomics & outcomes research 2009;9(1):23-27.
25. Yach D, Bialous SA. Junking science to promote tobacco. American journal of public health 2001;91(11):1745-48.
26. Francey N, Chapman S. “Operation Berkshire”: the international tobacco companies' conspiracy. BMJ: British Medical Journal 2000;321(7257):371.
27. Bero LA. Tobacco industry manipulation of research. Public health reports 2005;120(2):200.
28. Brandt AM. Inventing conflicts of interest: a history of tobacco industry tactics. American journal of public health 2012;102(1):63-71.
29. Carson KV, Brinn MP, Labiszewski NA, et al. Interventions for tobacco use prevention in Indigenous youth. Cochrane Database of Systematic Reviews 2012(8)
30. Chamberlain C, Perlen S, Brennan S, et al. Evidence for a comprehensive approach to Aboriginal tobacco control to maintain the decline in smoking: an overview of reviews among Indigenous peoples. Systematic reviews 2017;6(1):135.
31. Minichiello A, Lefkowitz AR, Firestone M, et al. Effective strategies to reduce commercial tobacco use in Indigenous communities globally: a systematic review. BMC Public Health 2015;16(1):21.
32. World Health Organization. WHO Framework Convention on Tobacco Control. Geneva: WHO Document Production Services, 2003:44.
33. Friedman LC, Cheyne A, D G, et al. Tobacco Industry Use of Personal Responsibility Rhetoric in Public Relations and Litigation: Disguising Freedom to Blame as Freedom of Choice. American Journal of Public Health 2015;105(2):250-60.
34. Banerjee SB. The Practice of Stakeholder Colonialism: National Interest and Colonial Discourses in the Management of Indigenous Stakeholders. In: Prasad A, ed. Postcolonial Theory and Organization Analysis: A Critical Engagement. New York: Palgrave Macmillan 2003:255-82.
35. UN General Assembly. United Nations Declaration on the Rights of Indigenous peoples. UN Wash 2007;12:1-18.
36. Leung CM-K, Leung AKC, Hon K-LE, et al. Fighting tobacco smoking--a difficult but not impossible battle. International journal of environmental research and public health 2009;6(1):69-83. doi: 10.3390/ijerph6010069 [published Online First: 2009/01/05]
37. Cohen JE, Zeller M, Eissenberg T, et al. Criteria for evaluating tobacco control research funding programs and their application to models that include financial support from the tobacco industry. Tobacco control 2009;18(3):228-34.
38. World Health Organization. WHO Statement on Philip Morris funded Foundation for a Smoke-Free World: WHO Geneva, 2017.
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/
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.
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.
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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.
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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 time series analysis, estimates the declining trend in cigarette use over time, then tests whether this trend changes (in this case, they generally tested for a slope change) after the advent of e-cigarettes.
Interrupted time series is a well-established method for analyzing changes in trends. Indeed Lauren Dutra and I (1) used interrupted time series to do a similar analysis of the effect that the advent of e-cigarettes had on cigarette smoking among youth using the National Youth Tobacco Survey from 2004 to 2014. Based on data over that time, we found that the advent of e-cigarettes (using a start date of 2009 for e-cigs) did not affect the declining trend in cigarette smoking, but led to an increase in total tobacco product use (Figure 1 in our paper).
Lauren and I also used individual-level data (something Levy and colleagues did not consider in their analysis) and found that about one-third of the kids using e-cigarettes had risk profiles that made them unlikely to start using nicotine with conventional cigarettes. Thus, e-cigarettes are expanding the tobacco market.
Levy and colleagues expand the time period of analysis up to 2016 or 2017 (depending on the data source). This is an important addition because, as they note, e-cigarette use has continued to grow since 2014 (their Figure 1).
I have several concerns about the analysis and interpretation of the data that Levy and colleagues present.
The assumption in interrupted time series analysis as they (and we) do it is that the underlying trend is linear (a straight line). The figures in the supplementary file suggest that many of the time histories are curved. Failing to account for this curvature can distort the results and also make the results highly sensitive to the break year (i.e., where the line bends) in the analysis.
A related concern because of the curvature in the data is that the break year they use in their analysis is 2014. They justify this by arguing that 2014 is when e-cigarette use took off. But, if you look at their Figure 1, you could also argue for using 2009 as the break year because that is where the data they have on e-cig use extrapolated back to zero. While e-cig use was lower before 2014, an increasing effect of e-cigs would be captured in the slope change in an interrupted time series model (assuming that the linear assumption is met).
The specific shape of the data curve is especially important in most recent years where e-cigarette use has increased so much among youth and young adults. This fact, combined with the gateway effect, would lead one to predict that historical drops in cigarette smoking would stop or even reverse. Indeed, looking at the detailed data in the supplementary figures shows this in several (but not all) cases:
• The Monitoring the Future (MTF) data showed increases in 10th grade 30 day and daily cigarette smoking (Supplementary Figures 1 and 8) and essentially flat 12th grade smoking between 2016 and 2017 (Supplementary Figure 2).
• The National Youth Tobacco Survey showed flat 30 day cigarette smoking from 2014 to 2017 (Supplementary Figure 3), the first time that there was not a drop in cigarette smoking since NYTS started in 2004. (I also do not understand why Levy and colleagues did not use the NYTS back to 2004; they started in 2011.)
• The National Health Interview Survey showed flat young adult smoking prevalence from 2015 to 2016 for both males and females (Supplementary Figures 13 and 14).
Another important omission in Levy and colleagues’ paper is that they only present data on cigarette smoking rather than total tobacco product use. This is an exceptionally important variable because if e-cigarettes are increasing nicotine use among youth, that is a bad thing.
And that is what Lauren Dutra and I found through 2014 (figure above). The rapid increase in e -cigarette use after 2014 in Levy’s Figure 1 reinforces this concern.
New data for 2018 released by the CDC in the November 16, 2018 MMWR (2) reinforces how serious this problem is. They documented continuing increases in e-cigarette use through 2018 (figure in MMWR) and, more important, increases in any tobacco use.
That is the real reality.
REFERENCES
(1) Dutra L, Glantz S. E-cigarettes and National Adolescent Cigarette Use: 2004-2014. Pediatrics. 2017 Feb;139(2). pii: e20162450. doi: 10.1542/peds.2016-2450.
(2) Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the Field: Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students — United States, 2011–2018. MMWR Morb Mortal Wkly Rep 2018;67:1276–1277. DOI: http://dx.doi.org/10.15585/mmwr.mm6745a5
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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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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 a factor influencing adolescent smoking.
Dr. Glantz also criticizes our study by pointing out several years during the vaping period when smoking prevalence did not decline. While it is true that smoking did not decline in some years during the vaping period, exceptions do not prove the rule. Indeed, the point of statistical analysis is to distinguish salient trends. Our aim was to provide straightforward analyses of the trends in cigarette smoking replicated across six different surveys. We estimated equations which allowed for long-term trends and changes in trend, and corrected for autocorrelation in the error terms where tests indicated a problem. Across six separate surveys, we obtained remarkably consistent results showing that the downward trend in smoking rates were greatly accelerated since vaping became more widespread.
In his criticism of our study Dr. Glantz focused particular attention on our results from the NYTS. We began our analysis of these data in 2011 because data became publicly available on an annual basis beginning in that year. Further, these data show that, while high school smoking rates fell from 15.8% to 12.7% between 2011 and 2013, representing a 20% drop in that three-year period, smoking rates declined to 9.8% in 2014 representing a 25% decline in just one year. Smoking prevalence further declined to 7.6% in 2017, representing a 40% drop since 2013. Nonetheless, the NYTS data provides the weakest indication of the change in trend during the vaping period due to the limited ability to detect pre-vaping trends.
Since our study was completed, more recent data have been published on youth and young adult smoking and vaping. In particular, the just released Monitoring the Future data indicate that last 30 day prevalence of smoking by 12th graders fell from 9.7% in 2017 to 7.6% in 2018, a 22% drop in just one year. In addition, NHIS data indicate that smoking prevalence for 18-24 year olds (both genders) fell from 13.1% in 2016 to 10.4% in 2017, a 21% drop in one year. These new data are consistent with the trends we describe in our paper.
Finally, we disagree in three ways with Dr. Glantz’s criticism that our paper only narrowly focused on cigarette use while ignoring total tobacco product use, including e-cigarettes. First, our decision to focus on the associations between e-cigarettes and cigarettes was based on concerns that e-cigarette use leads to increased smoking (3). Second, we think it is inappropriate to combine e-cigarettes and cigarettes in the same category of health risk, since virtually all scholarly evidence reviews have concluded that e-cigarettes are likely substantially less harmful than cigarettes and other combustible tobacco products, including the NASEM (3), PHE (4), and RCP (5) reports. Third, despite FDA’s legal classification of e-cigarettes as tobacco products, a strong argument can be made that e-cigarettes are not tobacco products at all, but rather a specific type of nicotine delivery product, just as nicotine patches, gum, and lozenges are also nicotine delivery products. No one would classify nicotine patches, gum, and lozenges as tobacco products. Indeed, classifying e-cigarettes as tobacco is the reason that Dr. Glantz can make his final claim that total tobacco use has risen with the introduction of e-cigarettes. While this conclusion is true under the classification scheme that Dr. Glantz uses, it is irrelevant to the arguments we made. Our arguments hinge on whether the increase in vaping is offset by a greater decrease in smoking (and other tobacco use) than would be expected in a world without e-cigarettes. We have never suggested better than one for one substitution, and would agree that vaping has substantially increased.
The data presented by Dr. Glantz on e-cigarette use are based on any last 30 day use. An important advance in our study over prior analyses, including the earlier study by Dr. Glantz and colleagues (2), was that we also considered measures of more established use, such as having smoked 100 cigarettes, daily smoking and smoking half a pack a day. These are more valid measures of regular smoking and are thus more directly related to public health impacts. Our study found that the conclusions about trends in vaping and smoking were robust across different measures of smoking. Indeed, we considered the ratio of daily to last 30 day smoking as an indicator of transitions from experimental to more regular cigarette smoking. We again found more rapidly declining rates during the period after vaping became more widespread.
It will be important to carefully monitor trends in the use of cigarettes, e-cigarettes and other nicotine delivery products to inform the kinds of policies that are likely to yield beneficial health outcomes for the population.
References
(1) Levy DT, Warner KE, Cummings KM, et al., Examining the relationship of vaping to smoking initiation among US youth and young adults: a reality check. Tob Control. 2018 Nov 20. pii: tobaccocontrol-2018-054446. doi: 10.1136/tobaccocontrol-2018-054446. [Epub ahead of print]
(2) Dutra L, Glantz S. E-cigarettes and national adolescent cigarette use: 2004-2014. Pediatrics. 2017 Feb;139(2). pii: e20162450. doi: 10.1542/peds.2016-2450.
(3) National Academy of Sciences Engineering and Medicine. Public health consequences of e-cigarettes. Washington, DC: The National Academies Press, 2018.
(4) Public Health England. E-cigarettes and vaping: policy, regulation and guidance. London: PHE;2018.
(5) Royal College of Physicians. Nicotine without smoke: Tobacco harm reduction. London: RCP;2016.
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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.
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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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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.”
• PMI has a new, larger study 6-month human study comparing IQOS with conventional cigarettes that concluded that IQOS is less risky than conventional cigarettes.3
With regard to the first point, one is left with the question of why PMI submitted and represented data in the original MRTP application, when it now admits that the study was not designed to provide key evidence. They did not question the specific conclusions that I drew in my paper.
The new 6-month study differs from the study presented in the original MRTP application in several important ways.
First, it is much larger (984 people in the new study compared to 79 in the US study and 112 in the Japanese study cited in the MRTP application). Making the study larger increases statistical power and makes it more likely to declare a difference statistically significant. This is a good thing.
Second, and of greater concern, the new study only considers 6 of the 24 non-cancer biomarkers in the earlier study, leaving the question of why PMI did not measure the other 18. (The 2 other biomarkers in the new study are biomarkers of exposure [CO and NNAL], which were not included in the earlier study and are not at issue in my paper.) Most of the things that they leave out are determined from blood tests, but they had to draw blood to measure the biomarkers they do report. The others are more detailed measures of lung function than the one reported in the new study and easily measured measures of blood pressure.
PMI should be expanding, not dropping, clinical endpoints because of evidence that IQOS is different from cigarettes.4,5 Indeed, the data they presented in the MRTP application suggested that IQOS may be causing liver damage not observed in cigarettes.6
Given the millions of dollars PMI’s application represents, cost does not justify dropping these routine clinical measures. Their detailed presentation on the new study3 does not address this question.
Third, PMI uses an arcane, little-used statistical method, the Hailperin-Rüger method, that was developed to confirm earlier studies.7 (Neither I nor two biostatistics colleagues have seen this used in any recent clinical trials. A PubMed search with the keyword “Hailperin-Rüger” conducted on December 19, 2018, resulted in just one study.8 The basic argument of the Hailperin-Rüger method is that it is overly cautious to require that all observed changes be statistically significant in order to confirm that a therapy works, and that if some lesser number of the variables change significantly, that should be good enough for a global test. The number of significant changes is specified in advance and the probability of a chance finding is adjusted.
PMI decided that if 5 of the 8 biomarkers (6 clinical risk and 2 exposure) changed in the direction of less risk, that would be enough to conclude that IQOS was less risky than conventional cigarettes. They do not provide a clear explanation of why they used 5, other than it was “more than half.”
PMI justified using Hailperin-Rüger because “the probability of finding five significant tests (p<0.05) by chance alone is extremely low (0.006%).” This is a misleading statement because this low probability would only be the case a chance finding if none of the five variables actually changed. The probabilities are much higher when there are real changes.
So, in the new study, PMI went from considering changes in 24 clinical risk biomarkers in the original study to 8 in the new study to only requiring 5 to be statistically significant.
That is a pretty major drop in the level of evidence PMI now suggests is sufficient to demonstrate that IQOS is less risky than cigarettes.
In the new study 5 of the changes were statistically significant, so PMI concluded that, overall, IQOS was better. Had they picked 6 in their plan, the overall results would not have been significant, even under the Hailperin-Rüger method’s relaxed standards.
There are other problems with using the Hailperin-Rüger method. First, it is designed to confirm results of earlier studies. The earlier study did not convincingly show that IQOS was better than conventional cigarettes. Second, the usual way that Hailperin-Rüger is used is when you have several measures of the same thing. (For example, the one paper8 located in PubMed that used Hailperin-Rüger assessed 10 different measures of neurological function and pre-specified that if 5 of the 10 were statistically significant, the global test would be considered statistically significant.) The idea is that requiring all of them to change significantly is being too stringent a requirement to identify a change in lung function. In this case, PMI mixed apples and oranges by applying the text to a set of 6 clinical variables and 2 exposure that were measuring different underlying physiological processes.
PMI also used a one-tail test that assumes that one only need worry above improvements in the biomarkers without any concern for the possibility that they might worsen the biomarkers. (As noted above, PMI presented – but did not emphasize – other evidence in their MRTP application showing that IQOS caused problems not observed in cigarettes.6) I tell my students that, with rare exceptions, one should always do two-tail tests. Two-tail tests require larger differences to reach statistical significance, so by using a one-tail test, PMI made it easier to conclude changes were statistically significant. In this case the overall conclusion would have been the same with a two-tail test, so this bias did not make any practical difference, but they should have not used a one-tail test.
PMI’s use of a one-tailed test was especially hypocritical since back in the early 1990’s the tobacco companies sued the US EPA for using a one-tail test in their risk assessment that concluded that secondhand smoke caused lung cancer.9 EPA used a one-tail test because they said it was inconceivable that secondhand smoke exposure would protect against lung cancer (the other tail). The irony there was that EPA would have reached the same conclusion using a two-tailed test.
All this raises the question of whether PMI manipulated the experimental design and analysis to get the desired conclusion, as they have done in the past.10
The law requires the MRTP applicant PMI to demonstrate, among other things, that IQOS, as it is actually used by consumers, will “significantly reduce harm and the risk of tobacco-related disease to individual tobacco users.” Neither the original 3 month study nor the newer 6 month study meet this standard.
The bottom line: FDA and other regulatory agencies should not rely on PMI’s new study to support a conclusion that IQOS is less risky than conventional cigarettes.
As slightly reformatted version of this post has been submitted to the IQOS MRTP docket at FDA with tracking number 1k2-978f-eqmr. A PDF of the comment is available here.
References
1. Glantz S. PMI’s Own in vivo Clinical Data on Biomarkers of Potential Harm in Americans Show that IQOS is Not Detectably Different from Conventional Cigarettes. Tob Control. 2018;27(Suppl 1):s9-s12. doi: 10.1136/tobaccocontrol-2018-054413. Epub 052018 Aug 054421.
2. Baker G, Harris C, Hankins M, et al. The Difference between IQOS and Continued Smoking. 2018; https://www.pmiscience.com/resources/docs/default-source/news-documents/.... Accessed 19 Dec 2018.
3. PMI Research & Development. Study Results Overview: ZRHR-ERS-09 US (Evaluation of Biological and Functional Changes in Healthy Smokers After Switching to THS 2.2 for 26 Weeks. In PMI IQOS MRTP June 8, 2018 Amendment: Additional Information and Data from a Recently Completed Clinical Study (.zip – 1.3 GB) (added November 29, 2018). 2018; https://digitalmedia.hhs.gov/tobacco/static/mrtpa/PMP/June%208%2C%202018.... Accessed 18 Dec 2018.
4. Glantz S. Heated tobacco products: The example of IQOS. Tobacco Control. 2018;27(Suppl 1):s1-s6; DOI: 10.1136/tobaccocontrol-2018-054601.
5. St. Helen G, Jacob P, Nardone N, Benowitz N. IQOS: Examination of Philip Morris International’s claim of reduced exposure. Tob Control. 2018;27(Suppl 1):s30-s36. doi: 10.1136/tobaccocontrol-2018-054321. Epub 052018 Aug 054329.
6. Chun L, Moazed F, Matthay M, Calfee C, Gotts J. Possible Hepatotoxicity of IQOS. Tob Control. 2018;27(Suppl 1):s39-s40. doi: 10.1136/tobaccocontrol-2018-054320. Epub 052018 Aug 054321.
7. Koch GG, Gansky SA. Statistical Considerations for Multiplicity in Confirmatory Protocols. Drug Information Journal. 1996;30(2):523-534.
8. Schellenberg R, Todorova A, Wedekind W, Schober F, Dimpfel W. Pathophysiology and psychopharmacology of dementia--a new study design. 2. Cyclandelate treatment--a placebo-controlled double-blind clinical trial. Neuropsychobiology. 1997;35(3):132-142.
9. Schachtman NA. EPA Post Hoc Statistical Tests – One Tail vs Two. 2012; http://schachtmanlaw.com/epa-post-hoc-statistical-tests-one-tail-vs-two/. Accessed 19 Dec 2018.
10. Wertz MS, Kyriss T, Paranjape S, Glantz SA. The toxic effects of cigarette additives. Philip Morris' project mix reconsidered: an analysis of documents released through litigation. PLoS medicine. 2011;8(12):e1001145.
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...
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 have tried to quit in the previous year. By including these non-attempters, who by definition cannot have quit, Berry et al (1) may have introduced an important bias toward finding a higher daily e-cigarette effect on abstinence. We expect that daily e-cigarette use at Wave 2 will be much higher among those who made a recent quit attempt than in those who did not.
In their supplement tables (TableS3), they include an analysis of those who made a quit attempt prior to Wave 1(rather than between Waves 1 and 2). Using this analysis, there is a drastic reduction in the effect size amplitude and in the absolute number of involved smokers. We would expect similar, or even larger, reduction in effect estimates were they to have restricted their analysis to those who made a quit attempt in the year prior to Wave 2 and included reason for using e-cigarettes.
In order to know the effect of e-cigarettes on cessation, those who used an e-cigarette to help them to quit should be contrasted with comparable non-users: those who used other aids to quit as well as to those who quit unaided. There are numerous important potential confounders for these comparisons as it is well known that those who are least likely to be successful in the quit attempt are the most likely to use an aid. (5) For unbiased analyses, the exposure of interest needs to be isolated and covariate balance achieved between exposed and unexposed. There is a role for methodological approaches that help achieve covariate balance, such as propensity score matching, in deciding whether e –cigarettes improve population smoking cessation.
References:
1. Berry KM, Reynolds LM, Collins JM, Siegel MB, Fetterman JL, Hamburg NM, Bhatnagar A, Benjamin EJ, Stokes A. E-cigarette initiation and associated changes in smoking cessation and reduction: the Population Assessment of Tobacco and Health Study, 2013-2015.Tob Control. 2018 Mar 24. pii: tobaccocontrol-2017-054108. doi: 10.1136/tobaccocontrol-2017-054108.
2. Coleman BN, Rostron B, Johnson SE, Ambrose BK, Pearson J, Stanton CA, et al. Electronic cigarette use among US adults in the Population Assessment of Tobacco and Health (PATH) Study, 2013–2014. Tobacco Control. 2017. doi: 10.1136/tobaccocontrol-2016-053462.
3. National Academies of Sciences Engineering, and Medicine,. Public Health Consequences of E-Cigarettes. Washington, DC: Health and Medicine Division, National Academies of Sciences, Engineering, and Medicine, 2018
4. Zhu S-H, Lee M, Zhuang Y, Gamst A, Wolfson T. Interventions to increase smoking cessation at the population level: How much progress has been made in the last two decades? Tob Control. 2012;212:110–118
5. Leas EC, Pierce JP, Benmarhnia T, White MM, Noble ML, Trinidad DR, Strong DR. Effectiveness of Pharmaceutical Smoking Cessation Aids in a Nationally Representative Cohort of American Smokers. J Natl Cancer Inst. 2017 Dec 21. doi: 10.1093/jnci/djx240
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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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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, with another 121 having resumed smoking as well as using EC (i.e. became dual users). Importantly, 502 of 896 (56%) exclusive e-cigarette users were those who had never been established smokers prior to using e-cigarettes. Alarmingly, of these 502 adults, 120 (23.9%) progressed from using only e-cigarettes to either dual use (54 or 10.8%) or smoking only (66 or 13.2%).
Taken together, 886 dual users in Wave 1 relapsed to become exclusive cigarette smokers in Wave 2, and 230 exclusive vapers in Wave 1 took up cigarette smoking in Wave 2 (dual use or exclusively cigarettes). Undoubtedly, these should be considered as negative outcomes.
The table below shows that for every person vaping at Wave 1 who benefited across 12 months by quitting smoking, there are 2.1 who either relapsed to or took-up smoking. Most disturbingly, in this adult cohort nearly one in four of those who had never been established smokers took up smoking after first using EC. Concern about putative gateway effects of ECs to smoking have been dominated by concerns about youth. These data showing transitions from EC to smoking in nearly a quarter of exclusive adult EC users with no histories of established smoking should widen this debate to consider adult gateway effects too.
By far the largest proportion of those with negative outcomes are those dual users who relapsed to smoking (886 or 43.5% of dual users). As the authors note in their discussion, many of these were infrequent EC users, possibly involved in transitory experimentation at Wave 1. If we add the 902 who were still dual using at Wave 2, then 1788 of 2036 dual users (87.8%) in this sample might be said to have been held in smoking (dual using or exclusive smoking) 12 months later compared to 12.1% dual users who may have benefitted by using ECs.
We would expect commercial interests in both the tobacco and EC industries would be more than delighted with these findings. However, from a public health harm reduction perspective these results argue against EC being an effective harm reduction strategy, and point to their far stronger potential to both recruit smokers and hold many smokers in smoking.
Reference
1. Coleman B et al Transitions in electronic cigarette use among adults in the Population Assessment of Tobacco and Health (PATH) Study, Waves 1 and 2 (2013-2105). Tobacco Control 2018; doi:10.1136/tobaccocontrol-2017-054174
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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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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 increases.
If our concern is (as it should be) to better understand the means of quitting that produce the largest net volume of ex-smokers across whole populations, studying the methods these former smokers used when they succeeded is critical. Yet the “inverse impact law of smoking cessation [3] shows that unassisted cessation, which undisputedly delivers more ex-smokers than any other method, is hugely neglected in smoking cessation research [4].
It is almost as if researchers want to turn away from learning more about the most successful route that has always delivered the largest number of successful quits. [5]
Rather than seeing the increase in unassisted quitting as something to be highlighted as a positive, motivating celebration of agency that could be megaphoned in campaigns to smokers imbued with pessimistic messages about how hard quitting is going to be, the authors conclude that their findings ”highlight the need for approaches to ensure that smokers get support”.
In 40 years of tobacco control, I cannot ever recall attending a meeting or conference on cessation where those whose living depended on them selling smoking cessation aids or providing professional cessation services did not reach similar conclusions. Yet 40 years on, the same cracked record is being played: we need to convince more smokers that they should not try foolishly to quit alone and that they need our help!
Analysis at the level of the success of quit “attempts” often shows that head-to-head, unassisted cessation attempts are less successful than those using assistance. But many so-called cessation attempts are empty gestures akin to those who attempt to get fit by buying an exercise bike, use it once or twice and then consign it to the corner. West and Sohal’s work on catastrophe theory noted that many who were not planning to quit at time 1, had succeeded at time 2. They suggested that “smokers have varying levels of motivational “tension” to stop and then “triggers” in the environment result in a switch in motivational state. If that switch involves immediate renunciation of cigarettes, this can signal a more complete transformation than if it involves a plan to quit at some future point.” [6]
The importance of continually stimulating the motivational tension to stop smoking and providing both informational and policy triggers for quitting cannot be over-emphasised.
It is long overdue that we gave far more attention to the net contribution of unassisted cessation at the population level. [7 ] Many smokers have little interest in being helped to quit. In this, they are very aware of many friends and acquaintances who quit alone when they were sufficiently motivated to do so. Over 40 years of professional hand-wringing, research and campaigning about how to undermine unaided quitting and sell more drugs and clinic appointments have thankfully done little to erode this.
References
1. Filippidis FT, Mons U, Jiminez-Ruiz C, Vardavas CI. Changes in smoking cessation assistance in the European Union between 2012 and 2017: pharmacotherapy versus counselling versus e-cigarettes. Tobacco Control http://dx.doi.org/10.1136/tobaccocontrol-2017-054117
2. Cohen JE, McDonald PW, Selby P. Softening up on the hardening hypothesis. Tobacco Control ttp://dx.doi.org/10.1136/tobaccocontrol-2011-050381
3. Chapman S. The Inverse Impact Law of Smoking Cessation. Lancet 2009; 373(9665):701-3.
4. Chapman S, Mackenzie R. The global research neglect of unassisted smoking cessation: causes and consequences. PLoS Medicine 2010; 7(2): e1000216. doi:10.1371/journal.pmed.1000216.
5. Smith A, Chapman S. Quitting unassisted: the 50 year neglect of a major health phenomenon. JAMA 2014;311(2):137-138. doi:10.1001/jama.2013.282618.
3. West R, Sohal T. “Catastrophic” pathways to smoking cessation: findings from national survey. BMJ. 2006 Feb 25; 332(7539): 458–460.
doi: 10.1136/bmj.38723.573866.AE
4. Smith A, Carter SM, Chapman S, Dunlop S, Freeman B. Why do smokers try to quit without medication or counseling? A qualitative study with ex-smokers. BMJ Open 5:e007301 doi:10.1136/bmjopen-2014-007301
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...
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 policies in Europe.”(1) is optimistic, at best. The European Union is the chimney of rich countries: smoking prevalence in Italy, France and Germany is almost twice that in Australia and 1.5 fold that in the US. Almost no tobacco control in the European Union but Finland! The Scale is a smokescreen for tricky politicians cherry picking the weakest measures without even providing tools for implementation or monitoring.
Last, I am not aware that a critical assessment of the Eurobarometer method is available, and the limitations of such surveys cannot be overlooked. This deserves scrutiny as other data from the European Union on such a topic are a cause for concern: eg. the European School Project on Alcohol and other Drugs estimates smoking prevalence only on a declarative basis, roughly 10% of the data are missing despite only recruiting those attending school and only 80 % of the students said that they thought that their classmates had answered the questions honestly.(4)
1 Feliu A, Filippidis FT, Joossens L et al. Impact of tobacco control policies on smoking prevalence and quit ratios in 27 European Union countries from 2006 to 2014. Online Feb 22.
2 Kuipers MA, Monshouwer K, van Laar M, Kunst AE. Tobacco control and socioeconomic inequalities in adolescent smoking in Europe. Am J Prev Med 2015;49:e64-e72.
3 Braillon A, Mereau AS, Dubois G. [Tobacco control in France: effects of public policy on mortality]. Presse Med 2012;41:679-81.
4 Hibell B, Molinaro S, Siciliano V, Kraus L. The 2013 ESPAD validity study. European Monitoring Centre for Drugs and Drug Addiction. Publications Office of the European Union. Luxembourg. 2015.
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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.
NOT PEER REVIEWED
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.
The Truth Initiative is proud of its advocacy for young people, but as far as presentation and interpretation of data are concerned, such activist commitment amounts to a competing interest. For that reason, everyone, including Truth, is served by full disclosure of the survey data in an appropriate and accessible form and answers to key data questions that would help understand the JUUL phenomenon.
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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...
NOT PEER REVIEWED
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 absence of formaldehyde cyanohydrin by injecting the reference standard (Sigma, CAS# 107-16-4, ref. 50640). The formaldehyde cyanohydrin is eluting at 11.53 min and does not correspond to the peak eluting just before e-caprolactone that the authors tentatively identified as formaldehyde cyanohydrin (17.97 min under their conditions). This peak, based on existing literature [1] and high resolution mass spectra, is highly likely to be meso-lactide, the third isomers of lactide. The experimental details are available on PMIScience.com (https://www.pmiscience.com/library/publication/analysis-of-polylactic-ac...)
It is well known among analytical chemists that unit mass matching with a single data base is insufficient to prove the identity of a compound. Therefore, we typically use commercially available reference standards to verify our findings. This is important to us, as we are focused on developing reduced risk alternatives to combustible cigarettes. In this context, it is key that our science is always verified to the highest possible standards.
[1] Arrieta MP, Parres-Garcia F, Lopez-Martinez J et al. Pirólisis de residuo de bioplásticos : Productos obtenidos del ácido poliláctico (PLA). Dyna Ingenieria e Industria, 2012 ; 87(4):395-399. doi:10.6036/4673
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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...
NOT PEER REVIEWED
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 absence of formaldehyde cyanohydrin by injecting the reference standard (Sigma, CAS# 107-16-4, ref. 50640). The formaldehyde cyanohydrin is eluting at 11.53 min and does not correspond to the peak eluting just before e-caprolactone that the authors tentatively identified as formaldehyde cyanohydrin (17.97 min under their conditions). This peak has been confirmed, using the purchased reference standard (NatureWorks, CAS # 13076-19-2), to be meso-lactide, the third isomers of lactide. The experimental details are available on PMIScience.com (https://www.pmiscience.com/library/publication/analysis-of-polylactic-ac...).
It is well known among analytical chemists that unit mass matching with a single data base is insufficient to prove the identity of a compound. Therefore, we typically use commercially available reference standards to verify our findings. This is important to us, as we are focused on developing reduced risk alternatives to combustible cigarettes. In this context, it is key that our science is always verified to the highest possible standards.
NOT PEER REVIEWED
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...
NOT PEER REVIEWED
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 this particular factor in itself might deter adolescents from buying tobacco products. We feel that limiting sale of tobacco products to alcohol-licensed premises will surely prevent initiation of cigarette by adolescents.
References:
1. Barua MP, Mishra V, Kumar S. Reducing adolescent smoking in India. Lancet Glob Health. 2017 Mar;5(3): e266. doi: 10.1016/S2214-109X(17)30036-0. PubMed PMID: 28193389
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....
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.
Cited Reference
Chaloupka, FJ, Sweanor D, Warner KE. Differential taxes for differential risks—toward reduced harm from nicotine-yielding products. N Engl J Med 2015 Aug 13;373(7): 594-7.
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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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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 public health gains by directly reducing smoking. It would be foolish for the public health community to reject or not support such a tax increase because it did not also increase taxes on non-combustible tobacco products. But the paper suggests otherwise.
A tobacco tax increase on cigarettes and all other combustibles would secure even larger public health gains if it also used different sized tax increases on different combustible products in order to raise the prices of all smoked tobacco products to the same level as cigarettes (typically the most highly taxed tobacco products), thereby making it more likely that cigarette smokers would respond to the tax increases by cutting back their smoking or quitting altogether, rather than by switching to less-taxed and less-expensive smoked tobacco products, such as little cigars or RYO. But the paper does not consider this option, and its support for comparable tax increases for all tobacco products argues against it.
A tax increase for combusted tobacco products could secure even larger public health gains if it also increased non-combustible tobacco product taxes and prices. But only if the increases to the combusted and non-combusted tobacco product taxes did not make the non-combustibles significantly more expensive relative to cigarettes and other smoked tobacco products, either relatively or in real terms, that they dampened moves from smoking to e-cigarettes or other non-combustibles or prompted some non-combustible users to increase their smoking. But that, also, is not discussed in the paper.
Instead, the main text of the paper talks about taxes to produce equal price increases for each type of tobacco product and concludes by offering the overly broad and potentially misleading recommendation that countries with tobacco-diverse markets “should raise taxes on non-cigarette tobacco products to prevent premature death.”
Perhaps all the additional policy analysis suggested here is too much to expect from a study with the rather simple stated objective of just systematically reviewing the price elasticity of demand of non-cigarette tobacco products. But the paper goes well beyond providing that information and also encourages tax increases for non-cigarette tobacco products, either on their own or along with comparable increases for cigarettes. Given that the paper has decided to make policy recommendations, it should do so more thoughtfully, with more explanation and more detailed guidance.
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. ...
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. https://tobacco.ucsf.edu/pmi’s-own-data-biomarkers-potential-harm-americans-show-iqos-not-detectably-different-conventional-cigs
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.
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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...
NOT PEER REVIEWED
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 make a modified-risk claim must also show that the proposed claim will benefit the health of the population as a whole (taking into consideration impacts of the product and its marketing with the modified-risk claim on implementation, cessation, relapse, etc.).
This study’s findings could have been presented even more powerfully if the article had also discussed their relevance to FDA’s consideration of how reduced-risk or reduced-exposure claims would impact the public health based on the claims likely influence on youth and adult consumer behaviors.
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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...
NOT PEER REVIEWED
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 30 days of exposure (1.3% [1 participant] in IQOS arm, 4.8% [2 participants] in CC arm, 7.5% [3 participants] in SA arm).
Taken together, the changes reported by the authors concern a small number of participants across all arms and most likely represent normal fluctuations of these parameters.
Finally, the grade 2 ALT increase in IQOS arm that was mentioned in the letter corresponds to a participant with an isolated increase at Day 30, which is explained by the use of concomitant medication. This information was also part of the publicly available information but was not taken into account by the authors.
In conclusion, the data submitted to the FDA as well as the data gathered in the context of our post-market safety surveillance system, based on pharmaceutical industry best practices, show unquestionably that there is no increased risk of developing hepatotoxicity after switching to IQOS.
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...
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 the outcome if administered by an organization such as my own where the respondents would likely be more at ease. And while if started from scratch with recruitment it might also attract other-thinking smokers that could skew it the other way (but also then questioning this study's sample at the same time), it need not be necessary in regard to the study limitation present here today.
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].
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].
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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...
NOT PEER REVIEWED
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, 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. Current policy, which had its beginnings some 20 years or more later, is painted as being an outgrowth of the low tar programme and as being similarly tainted with industry influence. It reflects no credit on the editorial processes and decision making of Tobacco Control that authors were permitted to get away with such unsupported conclusions in their published paper.
The idea that reduction in tar yield of cigarettes could be an effective way of reducing the health risks of smoking goes back to the 1960s at least. It was supported by many distinguished epidemiologists, including Doll, Peto, and Wynder. See for example this 1979 statement by Ernst Wynder: ““One of the things that has always appealed to me about science is that if I find something that makes biological sense, then I feel reassured. Thirty years ago, when we had a 40mg tar cigarette, if you smoked 30 cigarettes a day you were exposed to about 1200 mg tar a day. Today’s cigarettes have 20 mg tar, so you are exposed to 600 mg daily. If there’s one thing everybody can agree on, it is that all tobacco-related cancers are dose related.” (1)
What was lacking in this formulation was an understanding that the risk from products is not simply determined by their composition, but resides in the interaction between the user and the product – as Michael Russell pointed out, if tar yield was everything, the most dangerous product would be the large Cuban cigar (1).
Russell was an outspoken critic of the ISCSH’s record. In a 1980 comment on the committee’s second report (2) he noted “Most of all it [the report] is remarkable for the stunning naivety of its implicit model of smoking behaviour”. He pointed out that: “Lower risk cigarettes are equated with cigarettes with lower tar and nicotine yields. If people smoked cigarettes in the same way that smoking machines do, this would indeed be the case. But there is much evidence that they do not….The tendency for smokers to regulate their smoke intake has been ignored by the Hunter Committee”.
Russell was not a member of the ISCSH (indeed, the membership of the committee was heavily tilted towards epidemiology and toxicology, and included no behavioural science expertise). It is in Russell’s insights and policy prescriptions that we can see the real intellectual underpinnings of UK policy on harm reduction in recent years.
Russell had a number of key insights, the most fundamental of which is that people smoke for nicotine (3). This coupled with the observation that the harms of smoking come not from the drug people are seeking, but from contaminants of the delivery system used to obtain it, led to his dictum “People smoke for the nicotine, but die from the tar”. As early as the mid-1970s he began to advocate an approach to tobacco harm reduction that was based on an appreciation of nicotine’s role (4, 5). He was the first to expose the fallacy of low tar cigarettes (6) and the first to explore the potential of non-combustible nicotine products for harm reduction (7-9). His 1991 paper in the British Journal of Addiction (10) and editorial in The Lancet (11) set out a vision for a transformed nicotine market: “If a strategy were adopted to sanction and encourage the use of purified nicotine products as substitutes for smoking, and at the same time impose stringent regulations on permissible constituents of cigarette smoke …….. the virtual elimination of smoking could become a more realistic health promotion target” (11). This represents a paradigm shift from the failed approach adopted in the 1970s. How it, or something springing from it, became a part of UK tobacco control policy in recent years, is a story for others to tell. But it did not happen through tobacco industry influence.
References
1. Gori GB, Bock FG. Banbury Report 3: A Safe Cigarette? Cold Spring Harbor Laboratory; 1980.
2. Jarvis MJ, Russell MAH. Comment on the Hunter Committee's second report. British Medical Journal. 1980;5; 280(6219):994-5.
3. Russell MA. Cigarette smoking: natural history of a dependence disorder. Br-J-Med-Psychol. 1971;44(1):1-16.
4. Russell MA. Realistic goals for smoking and health. A case for safer smoking. Lancet. 1974;16; 1(851):254-8.
5. Russell MA. Low-tar medium-nicotine cigarettes: a new approach to safer smoking. Br-Med-J. 1976;12; 1(6023):1430-3.
6. Russell MAH, Jarvis M, Iyer R, Feyerabend C. Relation of nicotine yield of cigarettes to blood nicotine concentrations in smokers. British Medical Journal. 1980;280(6219):972-6.
7. Russell MAH, Jarvis MJ, Feyerabend C. A new age for snuff? Lancet. 1980;1; 1(8166):474-5.
8. Russell MAH, Jarvis MJ, Devitt G, Feyerabend C. Nicotine intake by snuff users. Br Med J. 1981;26; 283(6295):814-7.
9. Russell MAH, Jarvis MJ, West RJ, Feyerabend C. Buccal absorption of nicotine from smokeless tobacco sachets. Lancet. 1985;2(8468):1370.
10. Russell MAH. The future of nicotine replacement. Br-J-Addict. 1991;86(5):653-8.
11. Russell MAH. Nicotine use after the year 2000. The Lancet. 1991;337:1191-2.
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...
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 tobacco companies succeeded in hijacking the tobacco public policy and media agenda, and diverted the government of the day from evidence-based approaches recommended by health authorities to reduce smoking. Elias and Ling have good reason to suggest that there are similarities between then and now.
In passing, Jarvis’s summary that the novel products of the day failed “because consumers rejected them” omits much. One important reason for the failure of tobacco substitutes was that industry rhetoric and hype to the contrary, there was ultimately justifiable concern, with concomitant media coverage, that “all the generally available brands contained 75 per cent tobacco, and were no more than additions to the low and low-to-middle tar range” (1). Indeed, it would have been quite possible for smokers switching to part-substitute brands to find themselves moving to higher tar products.
But before this message hit, there had been a mountain of industry-generated publicity promoting the notion that “safer” and (as inevitably reported) “safe” new brands were on the way. This approach was supported with public relations ploys such as an Imperial Tobacco press conference about part-substitute cigarettes the day after the launch of the 1977 Royal College of Physicians’ “Smoking Or Health” report. Not surprisingly, the tobacco trade press was quick to congratulate the company concerned on its success in diluting the impact of the College report.
1. Daube M. The politics of smoking: thoughts on the Labour record. Community Medicine. 1979; 1, 306-314
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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...
NOT PEER REVIEWED
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 as the ISCSH. While Russell criticized the ISCSH for its discount of compensation, (which he believed medium- high- nicotine cigarettes could help remedy) the same foundations appear in his recommendations: reduced toxicity is reduced risk, (1) collaboration with the tobacco industry doesn’t influence outcomes, (2) nicotine addiction is inevitable, (3) and products must be popular to curtail use. (4)
We caution that enthusiasm for the tantalizing fantasy of reduced risk products and tobacco industry resources may lead us to readopt the premises promoted by the tobacco industry for decades.
In their response, Drs. Britton and O’Connor implore public health to promote evidence-based tobacco harm reduction. We could not agree more.
1. The Lancet. Nicotine Use After the Year 2000. Lancet. 1991; 337: 1191-2.
2. Russell M. Conversation with Michael AH Russell. Addiction (Abingdon, England). 2004; 99: 9-19.
3. Jarvis M and Russell M. Comment on the Hunter Committee's second report. British medical journal. 1980; 280: 994.
4. Russell M. The future of nicotine replacement. British Journal of Addiction. 1991; 86: 653-8.
NOT PEER REVIEWED
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...
NOT PEER REVIEWED
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 view of the wider national context and the factors that contribute towards it (as described above) – no single source or figure is taken as definitive and all figures undergo this wider review. Furthermore, this wider context is discussed at length in the attendant analysis in each country report where the trends behind the figures are laid out.
Given Euromonitor’s exhaustive geographic coverage of this dataset – at 100 markets researched in-field for illicit trade, there is no other source like it – as well as our annual revisiting of this dataset, it is inevitable that some changes between editions will be necessary. Euromonitor is transparent about its reasons for change and welcomes any discussion on what can be a opaque area - we are always happy to engage with all concerned stakeholders and review their own sources, on a country-by-country basis, should they exist.
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
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...
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 the black smoke coming out of the cigarette into the white wispy vapour which is eventually expired. The surrogate lung fluid, on the other hand, changes from a clear solution to one which is tinged with yellow. We found that a significant amount of aluminium (ca 50(micro)g/L), presumably originating from the tobacco, was retained by the surrogate lung fluid and we speculated that this aluminium could contribute towards tobacco-related illnesses.
The arrival of e-cigarettes encouraged us to repeat our previous experiments. In the first instance we measured the aluminium content of many commercially-available e-liquids. Their aluminium content ranged from 26(micro)g/L for pure propylene glycol (the usual vehicle for e-liquids) to 147(micro)g/L (<0.2ppm) for a Virginian e-liquid with high nicotine content. Nevertheless even the higher figure is considerably lower than the aluminium content of tobacco (ca 2.0ppm) and so we were not expecting e-cigarettes to be a significant source of aluminium to lung fluids. However, we were to be surprised! When a 0.5mL volume of e-liquid was ‘smoked’ to completion through 50mL of a surrogate lung fluid the aluminium content of the lung fluid varied between 2000 and 9000(micro)g/L which equated to between 100 and 500(micro)g of aluminium per 0.5mL of e-liquid. Further experiments where the branded e-liquid was replaced with propylene glycol (which contains only 26(micro)g/L aluminium) produced results up to 13000(micro)g/L aluminium in the surrogate lung fluid, equivalent to approximately 700(micro)g of aluminium per 0.5mL of propylene glycol vehicle.
Smoking e-cigarettes is potentially much more hazardous with respect to potential toxicity due to aluminium than smoking tobacco. The source of the aluminium is the e-cigarette itself and not the e-liquid though the latter may contribute towards the dissolution of aluminium from various components of the e-cigarette.
We do not know if some of the health-related effects of smoking tobacco are attributable to aluminium in tobacco. However, if they are then such will not be addressed by smoking e-cigarettes.
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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...
NOT PEER REVIEWED
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 models like MCDA (Multi Criteria Decision Analysis); in comparison of the e-cigarettes that are “new” products, with less users and long-term information. Therefore, the possible consequences would be less precise and suggest a lower risk. Besides this, the authors found that the use of e-cigarettes expose the users to 9 from the 12 significant hazards identified in the conventional cigarettes, which are more related to neoplastic and respiratory effects. In addition, the virulence increase of the methicillin-resistant Staphylococcus aureus (MRSA) strains exposed to the vapor of e-cigarettes has also been described in rat models of pneumonia (4). Do we want to promote their use, although we don´t truly know the potential hidden risks of these devices?
As noted above, future research about e-cigarettes as an alternative to cigarettes has to consider the known risks about this topic. Therefore, it would provide a valuable conclusion about this global health problem instead of a dangerous illusion.
References:
1. Levy D, Borland R, Lindblom E, Goniewicz M, Meza R, Holford T, et al. Potential deaths averted in USA by replacing cigarettes with e-cigarettes. Tob Control. 2017 Oct 2. pii: tobaccocontrol-2017-053759.
2. Müezzinler A, Mons U, Gellert C, Schöttker B, Jansen E, Kee F, et al. Smoking and All-cause Mortality in Older Adults: Results From the CHANCES Consortium. Am J Prev Med. 2015 Nov;49(5):e53-e63.
3. Chen J, Bullen C, Dirks K. A Comparative Health Risk Assessment of Electronic Cigarettes and Conventional Cigarettes. Int J Environ Res Public Health. 2017 Apr 5;14(4).11.
4. Hwang J, Lyes M, Sladewski K, Enany S, McEachern E, Mathew D, et al. Electronic cigarette inhalation alters innate immunity and airway cytokines while increasing the virulence of colonizing bacteria. J Mol Med (Berl). 2016 Jun;94(6):667-79.
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.
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I am writing in response to the article "Smoke-free law compliance and predictive factors in Ethiopia: observational assessment of public places and workplaces" published in Tobacco Control. As a psychiatrist from Taiwan, I would like to commend the authors for shedding light on the low compliance rates of smoke-free laws in public places and workplaces in Ethiopia.
The study's findings highlight the urgent need to strengthen smoke-free laws and promote compliance to reduce tobacco use and its related health consequences. As a country that has implemented comprehensive smoke-free laws for over a decade, Taiwan has faced similar challenges in enforcing the ban in indoor environments. However, our government has taken various measures to address non-compliance, including increasing penalties and expanding the scope of smoke-free areas.
In addition to government efforts, collaboration between businesses, civil society organizations, and public health advocates is crucial in promoting compliance and a smoke-free culture. The Ethiopian government and civil society can learn from our experiences in Taiwan and other countries that have successfully implemented smoke-free laws.
The study's findings provide a valuable framework for policymakers and public health advocates to address the challenges of enforcement and promote a smoke-free culture. I urge the Ethiopian government and civil society to work together to im...
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Show MoreThe study by Gallus et al. [1] sought to establish whether electronic cigarettes (ECs) and heated
tobacco products (HTPs) reduce or increase the probability of smoking in a cohort of Italian
participants and concluded that both EC and HTP use predict smoking initiation and relapse
among respondents. We would like to raise some concerns about the interpretation of the study
findings. The study suffers from a potentially crucial bias of the outcome being present at baseline, as
compared non-users with people who were already using products at baseline. Specifically,
smokers who were using ECs or HTPs at baseline may already represent failed attempts to quit at
baseline. Additionally, ex-smokers using these products may have already been in a trajectory to
relapse to smoking at, or even long before, baseline, and may in fact have initiated such product
use in order to avoid relapse. Still, this group may represent ex-smokers who were at higher risk
for relapsing at baseline compared to ex-smokers who did not use these products. Similarly,
never smokers who use novel nicotine products may represent individuals prone to the
engagement of an inhalational habit. Therefore, they would be more likely to initiate smoking.
The situation is very similar to assessing if people who drink beer at baseline are more likely to
drink whiskey at follow up compared to non-drinkers of bee...
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Show MoreWe welcome discussion of our research even when it comes from those whose view on accepting tobacco industry funding is very different from ours. Tomaselli and Caponnetto, from the Center of Excellence for the acceleration of HArm Reduction (CoEHAR),[1] a group funded by the Foundation for a Smoke-Free World (FSFW), an organisation established by Philip Morris International (PMI) with funding of US$1 billion that promotes electronic cigarettes (e-cigarette) and heated tobacco products (HTP),[2] take issue with our finding [3] that these products increase smoking initiation and relapse and reduce quitting. [4]
First, we are puzzled by their main criticism. Of course we agree that smokers who have failed to quit, ex-smokers prone to relapse, and never smokers prone to engage in addictive behaviours could be overrepresented among the baseline e-cigarette or HTP users in our study.[4] But this does not undermine our main conclusions. Even if we were to assume that either none or all novel product users in our cohort were more prone to addiction, our results would still be incompatible with the argument, which underpins the work of FSFW, that these products can reduce smoking conventional cigarettes when used as consumer products.
Second, we hope that they agree with us that we should consider the totality of evidence on a topic as it is rare for a single study to provide a definitive answer, and especially given the record of the tobacco ind...
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In his rapid response to our paper, Dr Pesko expresses concern with the paper’s conclusions. Our study, conducted at the US population level, demonstrated that the prolonged decline in cigarette smoking among young adults was largely unaffected by the introduction of e-cigarettes. Dr Pesko reminds us that this conclusion is contrary to findings from several quasi-experimental designs, which he feels should have primacy over our population-level analysis of time trends. We acknowledge that there are potential threats to the validity and generalizability of the findings of our study, and indeed of every study. Hence, a conclusion of causality requires that an association be robust and replicable across settings and methods. Given the significant public policy implications of any finding that e-cigarette vaping has a role in reducing cigarette smoking prevalence, we feel that presentation of transparent and easily understood population trends have an important role to play in policy discussions. In particular, to support the argument that high e-cigarette taxes cause increased smoking among youth, it would be important to have an exemplar of one or more jurisdictions that imposed a high e-cigarette tax and subsequently experienced an increase in cigarette smoking.
A substantial portion of Dr Pesko’s critique of our paper is directed towards our commentary on a paper that he co-authored, Abouk et al. (1). This commentary was incorporated at t...
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The current article has a number of problems, including factual errors, unsupported statements, failure to conduct relevant statistical testing, and failure to include relevant studies.
The authors state: “Abouk et al studied 14 jurisdictions with at least some tax on e-cigarettes,43 but only two of these were large states with taxes large enough to possibly influence behaviour.44 They concluded that taxing e-cigarettes would push young people to cigarettes; however, in the two states with sizeable e-cigarette taxes, we did not find this to be the case.”
First, the referenced study uses data through mid-2019, at which different jurisdictions have the following standardized tax rates (according to Abouk et al.’s Table 1): District of Columbia ($2.52), Minnesota ($2.49), California ($1.65), Cook County, IL ($1.50), and Pennsylvania ($1.05). The current study treats only Minnesota and Pennsylvania as being large states with large taxes, but the authors’ failure to include these other states that are used in Abouk et al. (2023) makes their comparison incomplete.
Second, the authors state: “During this period, the prevalence of cigarette smoking in Pennsylvania declined by 6.3% pp and, in Minnesota, it declined by 8.6% pp (online supplemental eTable 4). Thus, the cigarette smoking prevalence decline in both states with meaningful e-cigarette taxes was greater than the 5.6% decline for the USA as a whole (2014–15=13.0%, 95% CI 12...
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Despite 20 years of sustained engagement and reductions in smoking prevalence rates globally, smoke free policy implementation remains inconsistently applied in low- and middle-income countries where there are high smoking prevalence rates and where >80% of the 1.3 billion smokers reside.1-2 Merrit’s study3 is a stark reminder that despite the forward steps of the Framework Convention on Tobacco Control,2,4-5 variations in achieving smoke free policies in specialist settings persist. Acknowledged challenges in implementing smoke free hospital policies include a lack of data, inadequate reporting, and reduced prioritisation of tobacco control at governmental level.1,3 The lack of an intersectional lens and co development with communities continues with policy development. 6
Inconsistencies in application of smoke free policies are balanced by reporting of positive implementations demonstrating improvements in some hospital systems evidenced by reductions in smoking rates and improved access to smoking cessation services underpinned by longitudinal data. 7-9
Previously, Chan 10 indicated that ‘tobacco use … threatens development in every country on every level and across many sectors — economic growth, health, education, poverty and the environment — with women and children bearing the brunt of the consequences’, - this continues today intensifying the impact of the social, structural and commercial determinants of health and n...
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He et al cite (ref 43 in their paper) our meta-analysis of the association between e-cigarette use and smoking cessation [1} to support the statement, "[e-cigarettes] have demonstrated potential in recent years in helping smoking cessation." Quite the contrary, the abstract of this paper concludes, "As consumer products, in observational studies, e-cigarettes were not associated with increased smoking cessation in the adult population."
A subsequent meta-analysis [2] concluded the same thing.
Both these meta-analyses include the other paper (ref 44 in their paper) He et al cite to support their statement that e-cigarettes assist smoking cessation [3].
The authors need to accurately represent the literature and stop promoting the myth that e-cigarettes as consumer products increase cigarette smoking cessation. They also need to correct their paper to avoid perpetuating the literature.
REFERENCES
1. Wang RJ, Bhadriraju S, Glantz SA. E-cigarette use and adult cigarette smoking cessation: a meta-analysis. Am J Public Health 2021;111:230–46. doi:10.2105/AJPH.2020.305999
2. Hedman L, Galanti MR, Ryk L, et al. Electronic cigarette use and smoking cessation in cohort studies and randomized trials: a systematic review and meta-analysis.
Tob Prev Cessat 2021;7:62.
3. Zhuang Y-L, Cummins SE, Sun JY, et al . Long-term E-cigarette use and smoking cessation: a longitudinal study w...
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Regarding the first two questions, the analyses were based on the public use data from both the PATH Study and the MCS, with links to their archives, and the PATH study sample was drawn from the original cohort, the replenishment cohort, and the shadow cohorts (see 1st and 2nd paragraphs of Methods Section). Regarding the remaining questions, please note that our stated goal was to make the MCS and PATH analytical samples as comparable as possible when testing our hypotheses using both cohorts (3rd paragraph of Methods section). As we note in the limitations section (5th paragraph of Discussion section), the MCS had relatively limited items on e-cigarette use and tobacco smoking compared to PATH. The MCS did not assess other combustible tobacco product consumption in early adolescence, nor did MCS measure the sequencing of early adolescent tobacco and e-cigarette use (noted in the limitation section). Also, MCS youth answered survey questions about ever using e-cigarettes from 2015 to 2016 (3rd paragraph of Methods section), which gave us limited variability to test for a wave x e-cigarette interaction in both datasets.
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I respectfully request answers to the following questions:
1. Was public use or restricted PATH data used. This is important, since Table 2 contains a cell, n=7, that is not generally approved by NAHDAP.
2. Was the PATH cohort drawn from Waves 1 and 4, with follow-ups to age 17 years as needed from the other waves?
3. There were significant differences in youth smoking-vaping between Wave 1 (2013-14) and Wave 4 (2016-18) that might have affected the results. Was each wave analyzed separately as well as together?
4. The analysis included a variable relating to “parent(s) smoking of cigarettes, cigars, or pipes.” Did the analysis include other combustible tobacco product consumption by the subjects themselves?
5. Did the authors account for age at first smoking or vaping (public use, < 12 years and 12-14 years) or which product(s) had been used first?
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Show MorePichon-Riviere et al concluded that the four tobacco control interventions analyzed could successfully avert deaths and disability and significantly ease the tobacco-attributable economic burden, but are not enough, as smoking remains a leading cause of health and economic burden in Latin America (1). According to the Global Burden of Disease Project (2), regardless of the relative decrease in tobacco prevalence in the last decades, age-standardized rates of deaths and DALYs for smoking-attributable diseases remain high in Latin America, a region hard hit by the epidemic (3). Unfortunately, in most of the countries in Latin America, there are other problems related to the main strategy to reduce tobacco consumption (i.e., taxation falls short of WHO recommendations) for example cigarettes remain affordable mainly due to the commercialization of illegal tobacco products and smuggled cigarettes, an important distractor for public health authorities, as the real number of users is hidden, access for younger people is easier and health risks are surely higher (4).
In addition, as in not all countries among our region there are available pharmacological alternatives to help current smokers, cessation strategies may be adapted for novel products, and treatment recommendations for tobacco use disorder should be made within the context of a harm reduction framework wherein alternative product use may be the desired outcome (5). Also, nicotine e‐cigare...
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I read with interest the article "Global tobacco advertising, promotion, and sponsorship regulation: what’s old, what’s new, and where to next?[1]" published in Tobacco Control. As a psychiatrist specializing in addiction treatment at Taoyuan Psychiatric Center in Taiwan, I wish to share our institution's experience in implementing a successful smoke-free hospital program, which may serve as a model for other psychiatric centers.
Since 2014, Taoyuan Psychiatric Center has made significant progress in promoting a smoke-free environment through a comprehensive tobacco control program. Our program's objectives include creating a smoke-free hospital, increasing smoking cessation services for outpatients and inpatients, and improving patient smoking status documentation. Furthermore, we prioritize smoking cessation counseling for adolescents, pregnant women, and their families.
In psychiatric settings, smoking cessation is crucial as tobacco use can influence the blood concentration of psychotropic medications, potentially destabilizing psychiatric symptoms. Assisting patients in quitting smoking not only lowers the risk of tobacco-related diseases but also contributes to stabilizing their psychiatric conditions.
Our program encompasses various initiatives, including staff training, community tobacco harm prevention promotion, provision of second-generation smoking cessation treatments for outpatients and inpatien...
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We acknowledge receipt of a private e-mail message from JLI regarding our paper (Yassine et al., 2022). Given the industry‘s long history of industry obfuscation, interference, and deception regarding research on tobacco products, we decided that the most transparent approach to the private e-mail that we received from an employee of a tobacco product manufacturer would be for us to report our results independently and respond to any public discussion of our work if and when it arose. Now that public discussion has arisen, we are pleased to respond to it.
We very recently analyzed the menthol and nicotine content of samples of liquid from six menthol flavor pods purchased in 2020. Three of these were liquids extracted from the pods in June 2021 for our paper and had been stored since in sealed amber glass containers at 5°C in the dark. The other three pods had been stored in their original sealed packages and were taken from the same batches as the pods analyzed in June 2021. These unopened packages were stored in the dark at room temperature over the intervening 18 months. The data from this small sample demonstrate a 24% reduction in menthol content over that period (12.01±0.46 vs 9.15±0.22 mg/ml), which helps to explain the results we reported (Yassine et al., 2022). We also found a 5% reduction in nicotine content (62.47±0.63 vs 59.52±0.49 mg/ml), as well as discoloration of the liquid in the pods that were stored at room temperatur...
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Authors previewed this study on March 16, 2022, at the Annual Meeting of the Society for Research on Nicotine and Tobacco[1]. Prompted by this presentation, on April 5, 2022, I emailed Drs. Talih, Eissenberg, and Shihadeh with product-specific information and questions that raised substantial doubt in the authors’ claims about JUUL products, specifically the purported modification of Menthol JUULpods.
Due to word limits here, we have posted a full copy of my email to the authors on PubPeer[2]. This email predated by almost a month the authors’ submission to the journal. Below please find an excerpt from this correspondence:
“In your presentation, you conclude that Juul Labs has in some way altered or otherwise modified its e-liquid formulations, but these claims are incorrect. Juul Labs has not altered or modified these e-liquid formulations since they were introduced into the market before August 2016 (i.e., FDA’s deeming date). We have supporting documentation, including batch records and certificates of analysis to confirm this.
“Setting aside any issues with methodologies or environmental conditions in the study, there are a number of possible explanations for the variations you found. For example, one potential explanation for the differences in tested products is the loss of menthol over time. It is well-documented in scientific literature[3] that menthol may migrate from areas of high concentration to low concentration,...
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I would like to make three comments by way of a brief post-publication review.
1. The impacts of vaping tax on smoking have been completely overlooked
For a study of e-cigarette taxation to have any public health relevance, it must consider the impact of e-cigarette prices on *cigarette* demand. Cigarettes and e-cigarettes are economic substitutes. The demand for one responds to changes in the price of the other, an idea well understood in economics and quantified through the concept of cross-elasticity. The paper appears to pay no regard to the impact of vaping taxes on cigarette demand, Yet such effects might easily overwhelm any benefits from reduced e-cigarette use - in fact, impact on demand for other tobacco products and the development of informal markets are by far the most important impacts of a vaping tax. By way of example, a 2020 paper by Pesko et al. [1] concluded:
"Our results suggest that a proposed national e-cigarette tax of $1.65 per milliliter of vaping liquid would raise the proportion of adults who smoke cigarettes daily by approximately 1 percentage point, translating to 2.5 million extra adult daily smokers compared to the counterfactual of not having the tax."
2. The case for reducing adult vaping by taxation has not been made
The authors have based their paper on an unexamined assumption that it is a justifiable goal of policy to lower rates of adult e-cigarette use. Why should...
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I have a number of concerns with the paper as currently written.
1) The authors write: “Besides, none of the previous studies except Pesko et al (15) that examined the associations between vaping product excise tax adoption and ENDS use has accounted for the clustering of respondents within the same localities…” This is not accurate, as citation 19 also clusters standard errors at the locality level in all specifications.
2) The authors write: "A working paper reported reduced ENDS sales, but not ENDS use prevalence or behaviours, after implementation of a vaping product excise tax policy. (19)” This is not accurate, as the cited study uses the magnitude of e-cigarette tax values, rather than an indicator variable for tax implementation. States have adopted e-cigarette taxes of different magnitudes and a number of them (such as California) have changed the magnitudes of these taxes after adoption. All of this variation is used in citation 19, contrary to the current study’s description. It's also unclear from the sentence whether citation 19 studied use and found imprecise estimates, or did not study use. It's the latter and this should be clarified. It's also unclear why the authors did not use magnitude of e-cigarette taxes themselves in the current paper, as has been commonly done in the referenced literature.
3) Authors write they use a “nationally representative sample of US young adults.” I do not beli...
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We appreciate the comments from Bates and the opportunity for us to respond and clarify.
First, Bates' argument heavily relies on the assumption that e-cigarettes and combustible cigarettes are substitutes, which is theoretically possible as some consider vaping as a harm reduction alternative to combustible cigarettes. Empirically, however, there have been mixed findings about whether e-cigarettes and combustible cigarettes are substitutes (or complements). Bates cited Pesko et al. (2020) that concludes e-cigarettes and combustible cigarettes are substitutes, whereas other studies have shown that they are complements. For example, Cotti et al. (2018) found that higher cigarette excise taxes, in fact, decrease sales of both e-cigarettes and combustible cigarettes, suggesting that they are complements. Such mixed results abate Bates' argument that taxing ENDS could lead to more use of combustible cigarettes.
Second, Bates might have ignored that our study focused on young adults aged 18-24 years rather than general adults when examining the effect of vaping product tax on e-cigarette use. Although Pesko et al. (2020) suggests that e-cigarettes and combustible cigarettes are substitutes, the findings are based on the general adult population (average age: 55 years) which may not be generalizable to the young adult population. In fact, one study conducted by Abouk and Adams (2017) indicates that e-cigarettes and combustible ci...
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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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We appreciate the interest of the world’s largest transnational tobacco company, PMI,1 in our recent systematic review and would like to follow up on the points raised in Dr Baker’s rapid response.
Our review did not seek to assess the harms or benefits of HTPs. As public health researchers we are most interested in the quality of studies according to whether they give reliable evidence of the health outcomes and public health impact of HTPs. We sought to critically appraise the quality of clinical trials on HTPs and lay out for Tobacco Control readers all aspects of their design which may have implications for interpretation, especially in regard to the potential impacts of HTPs.
We decided to explore overall risk of bias when excluding the blinding of participants and personnel domain because we wanted to differentiate between studies. This is a really important domain. We excluded it because so few studies were judged to be at low risk of bias in this domain. Performance bias (which blinding if done well can guard against) remains an important source of bias that can influence study results, and one which was present in all of PMI's studies submitted to the U.S. Food and Drug Administration (FDA).1 As we explain in our risk of bias assessments, the consequences of this bias could have been minimised had the control intervention been active. Likewise, PMI’s withdrawal of its carbon-heated tobacco product from the market, which o...
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The objective of the systematic review by Braznell et al. was “𝘵𝘰 𝘤𝘳𝘪𝘵𝘪𝘤𝘢𝘭𝘭𝘺 𝘢𝘴𝘴𝘦𝘴𝘴 𝘵𝘩𝘦 𝘮𝘦𝘵𝘩𝘰𝘥𝘰𝘭𝘰𝘨𝘪𝘤𝘢𝘭 𝘤𝘩𝘢𝘳𝘢𝘤𝘵𝘦𝘳𝘪𝘴𝘵𝘪𝘤𝘴 𝘢𝘯𝘥 𝘲𝘶𝘢𝘭𝘪𝘵𝘺 𝘰𝘧 𝘪𝘯𝘵𝘦𝘳𝘷𝘦𝘯𝘵𝘪𝘰𝘯𝘢𝘭 𝘤𝘭𝘪𝘯𝘪𝘤𝘢𝘭 𝘵𝘳𝘪𝘢𝘭𝘴 𝘪𝘯𝘷𝘦𝘴𝘵𝘪𝘨𝘢𝘵𝘪𝘯𝘨 𝘵𝘩𝘦 𝘦𝘧𝘧𝘦𝘤𝘵𝘴 𝘰𝘧 𝘩𝘦𝘢𝘵𝘦𝘥 𝘵𝘰𝘣𝘢𝘤𝘤𝘰 𝘱𝘳𝘰𝘥𝘶𝘤𝘵𝘴 (𝘏𝘛𝘗𝘴).” ¹ The review was intended to examine the quality of HTP clinical trials “𝘣𝘦𝘧𝘰𝘳𝘦 𝘤𝘰𝘯𝘴𝘶𝘮𝘦𝘳𝘴 𝘢𝘯𝘥 𝘳𝘦𝘨𝘶𝘭𝘢𝘵𝘰𝘳𝘴 𝘮𝘢𝘬𝘦 𝘪𝘮𝘱𝘰𝘳𝘵𝘢𝘯𝘵 𝘥𝘦𝘤𝘪𝘴𝘪𝘰𝘯𝘴 𝘣𝘢𝘴𝘦𝘥 𝘰𝘯 𝘵𝘩𝘦 𝘳𝘦𝘴𝘶𝘭𝘵𝘴 𝘰𝘧 𝘵𝘩𝘦𝘴𝘦 𝘴𝘵𝘶𝘥𝘪𝘦𝘴.” We have three important observations in relation to Philip Morris International’s (PMI) clinical program, which impact the interpretation of the authors’ broad-reaching conclusions.
(𝟭) 𝗥𝗲𝗴𝘂𝗹𝗮𝘁𝗼𝗿𝘆 𝗱𝗲𝗰𝗶𝘀𝗶𝗼𝗻𝘀 𝗵𝗮𝘃𝗲 𝗯𝗲𝗲𝗻 𝗺𝗮𝗱𝗲 𝗯𝗮𝘀𝗲𝗱 𝗼𝗻 𝗣𝗠𝗜’𝘀 𝗰𝗹𝗶𝗻𝗶𝗰𝗮𝗹 𝘀𝘁𝘂𝗱𝗶𝗲𝘀, 𝘄𝗵𝗶𝗰𝗵 𝘄𝗲𝗿𝗲 𝗷𝘂𝗱𝗴𝗲𝗱 𝘁𝗼 𝗯𝗲 𝗮𝘁 𝗹𝗼𝘄 𝗿𝗶𝘀𝗸 𝗼𝗳 𝗯𝗶𝗮𝘀
Whilst we will only comment on the clinical studies performed by PMI, we were pleased to see the confirmation that the study designs in our clinical assessment program were not significantly associated with a risk of bias. The authors judged that all Tobacco Heating System (marketed as IQOS) clinical studies submitted to the United States Food and Drug Administration (FDA) and other regulators were at low risk of bias when the authors excluded “blinding of participants and personnel” to the product, due to the impracticality of concealing visually distinctive products. The authors also noted that the scoring was slightly improved when compared to a similar exercise performed as part of the recent Cochrane review. ²
We agree that regulatory decisio...
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Clive Bates’ commentary on our paper repeats claims we previously addressed [1]. Here, we address seven points, the first is contextual and the remaining are raised in his letter.
1. We note the failure of the author to acknowledge Māori perspectives, in particular their support for endgame measures, concerns in relation to harm minimisation [2] as outlined in his “all in” strategy, and ethical publishing of research about Indigenous peoples. [3]
2. We reject the assertion that the basis of our modelling is “weak”. While there is uncertainty around the potential effect of denicotinisation, as this policy hasn’t been implemented, there are strong grounds to believe that it will have a profound impact on reducing smoking prevalence. This is based on both theory and logic (i.e., nicotine is the main addictive component of cigarettes and why most people smoke), and the findings of multiple randomized controlled trials (RCTs) showing that smoking very low nicotine cigarettes (VLNCs) increases cessation rates for diverse populations of people who smoke [4-7].
Our model’s estimated effect on smoking prevalence had wide uncertainty, namely a median of 85.9% reduction over 5 years with a 95% uncertainty interval of 67.1% to 96.3% that produced (appropriately) wide uncertainty in the health impacts. The derivation of this input parameter through expert knowledge elicitation (EKE) is described in the Appendix of our paper. Univariate se...
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I have published a summary critique of this modelling exercise on PubPeer. [1] This summarises concerns raised in post-publication reviews of this paper while it was in pre-print form by experts from New Zealand and Canada, and me. [2][3]
By way of a brief summary:
1. All the important modelled findings flow from a single assumption that denicotinisation will reduce smoking prevalence by 85% over five years. Yet the basis for this assumption is weak and disconnected from the reality of the market system being modelled.
2. The central assumption is based partly on a smoking cessation trial that bears no relation to the market and regulatory intervention that is the subject of the simulation. Even so, the trial findings do not support the modelling assumption.
3. The central assumption also draws on expert elicitation. Yet, there is no experience with this measure as it would be novel, and there is no relevant expertise in this sort of intervention. Where experts have been asked to assess the impacts, their views diverge widely, suggesting that their estimates are mainly arbitrary guesswork.
4. The authors have only modelled benefits and have not included anything that might be a detriment or create a trade-off. The modelling takes no account of the black market or workarounds. These are inevitable consequences of such 'endgame' prohibitions, albeit of uncertain size. Though it may be challenging to mo...
Show More¶ 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.
Show More¶ 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...
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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Show MoreIn 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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Show MoreAfter 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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Show MoreThese 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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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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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.
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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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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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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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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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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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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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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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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...
Show MoreWe thank Cummings and colleagues for their interest in and comments on our umbrella review published recently in Tobacco Control.[1] The authors criticize us for not including the latest studies. Yet, for an umbrella review, those studies need to be in a published review to be included, as we indicated in our methods and limitations. Generally, given the lengthy review and publication processes, any review will not be inclusive of all studies in a field that has as high a publication breadth and intensity as tobacco regulatory science. In addition, the authors mentioned that our meta-analysis was not available in PROSPERO pre-registration. This is because the review registration was completed in the very early stages of the review. We have updated this information in PROSPERO now to include the meta-analysis. The issue of overlap was addressed in our limitations, as we had to screen over 3,000 studies included in our selected reviews. However, given the importance of this issue for the meta-analysis, we performed a new meta-analysis that included the individual studies in each domain instead of using the odds ratio reported by the review to eliminate the effect of including the same study more than one time on our results. We confirm that the results of the new meta-analysis, which includes each study only once, are similar to the original meta-analysis (Supplement A: https://www.publichealth.me...
Show MoreThe paper by Asfar et al (1) had a noble objective, which was to inform ENDS health risk communications by updating the 2018 evidence review by the US. National Academies of Sciences, Engineering and Medicine (NASEM) (2). The need for improved risk communications about ENDS is reinforced by a recent study which found that only 17.4% of US smokers believe that nicotine vaping is safer than smoking (3). While ENDS use is not safe, the evidence from toxicant exposure studies does show that ENDS use is far safer than smoking cigarettes and may benefit public health by assisting those who smoke to quit smoking (4, 5).
Show MoreAn important limitation of the umbrella review method utilized by the authors is that it does not directly attempt to systematically characterize new research. This is a concern because the marketplace of ENDS products used by consumers has evolved since the 2018 NASEM report (4, 5). Furthermore, the authors have included some meta-analyses of selected reviews for some domains, but these meta-analyses were not in the Prospero pre-registration (6), nor explained in the paper. It’s thus unclear how or why certain reviews were selected for meta-analysis, and also whether the comparators are the same for these reviews. More importantly, these meta-analyses risk single studies contributing multiple times to the same pooled estimate. The authors noted this as a limitation commenting inaccurately that ‘it was impossible to identify articles that were included in...
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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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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...
Show More¶ 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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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.
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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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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...
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We object to the framing of Association of Vapers India (AVI), erroneously referred to as ‘Vape India’ in the paper, as a tobacco industry front group, without providing any basis for the claim except our membership of International Network of Nicotine Consumer Organisations (INNCO).
AVI was organised in August 2016, when consumers of low-risk alternatives came together to arrest the tide of state bans in India, which were being lobbied for by the Bloomberg Philanthropies network the authors belong to.[1] Though one of our directors is the current president of INNCO’s governing board, elected through a member vote in the 2020 General Assembly, he is serving in unpaid, honorary capacity.
AVI has not received funding from INNCO, nor from the Foundation for Smoke-free World (FSFW), and neither from the tobacco industry. Our work is financed through voluntary contributions, and like INNCO, the affairs are conducted by a governing board comprising unpaid consumer volunteers.
It is scurrilous to cast AVI as a tobacco industry group or anything other than a consumer-led movement that is seeking access to harm reduction avenues for India’s nearly 270 million tobacco users, among whom cancers are rising[2] even as most have meagre means to deal with the health consequences, which makes harm prevention a vital mitigation strategy. We are product agnostic and advocate access to lower-risk alternatives for both smokers and smokeless tobacco...
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We 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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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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Show MoreFreedom of speech is a fundamental right in a free society. There is no justification to either interfere with the right of stakeholders to participate in the public debate regarding tobacco harm reduction policy, or to malign those that exercise that right. Given that the outcome of these policy discussions will affect the lives of more than one billion people on the planet who smoke, everyone must be free to advance arguments for and against any policy, and each argument must be scrutinized and evaluated on its evidence base and merits. Unfortunately, the recent paper in Tobacco Control—Exploring the Twitter activity around the eighth meeting of the Conference of the Parties to the WHO Framework Convention on Tobacco Control—missed the opportunity to do this.
Instead of engaging in a discussion on the key issues and arguments put forth in the public discussion around the eighth meeting of the Conference of the Parties (COP8), the authors employ diversionary ad hominem tactics. They mischaracterize Philip Morris International’s (PMI’s) legitimate participation in the public debate on the role that products with the potential to reduce the risk of harm compared to smoking can play in global public health policy. Using phrases like ‘tobacco industry actors’ and ‘front groups’ the authors falsely imply that any person or organization who publicly supports tobacco harm reduction are paid to do so by the tobacco industry, and specifically PMI....
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Show MoreIt is disappointing to see the BMJ publishing a research paper which smears consumer advocates for tobacco harm reduction by attempting to link consumer activity on social media with the tobacco industry. One can only conclude that the goal was to devalue the opinions of former smokers who have found safer nicotine products to have been beneficial to their lives.
I write as chair of the UK New Nicotine Alliance and as it is highly likely that tweets from our supporters have been included in this research, so we welcome the right to reply to the article.
The attempt to paint consumers as part of some mythical tobacco industry plot is offensive to individuals and organisations promoting tobacco harm reduction. We and our supporters, along with many other vapers, are systematically excluded from the FCTC conferences and yet have a strong stake in the outcomes of the meeting. Social media is one of the few opportunities we have to get our views across. Consumers of safer nicotine products have been acutely aware of an increasing warfare against the products which have helped them to stop smoking.
In 2018, there were clear threats being expressed by the WHO FCTC in advance of COP8 towards products that vaping consumers value highly for helping them to quit smoking. Many vapers travelled to Geneva in 2018 at their own expense, but as ‘members of the public’ were excluded from the meeting.
The article by Robertson et al was funded b...
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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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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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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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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.
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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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Show MoreRuth Malone's pursuit of common ground in the tobacco control and broader public health communities is most welcome. As I emphasize in a new commentary that has received wide circulation (https://drive.google.com/file/d/1C1nk1XEZ8WhnOXtCGTqHdeqomc9HOuko/view), we must collectively climb out of our bunkers, come to the table and genuinely work together. Everyone, on all sides of the concurrent debates over tobacco harm reduction and protecting youth must stop skirting the truth when it feels inconvenient and open our minds and ears to all of the science that is before us, while discouraging and abandoning studies and pronouncements that are demonstrably biased or inadequate. We must move beyond the adversarial nature of the debate and transparently acknowledge areas of ambiguity or concern.
Combating the smoking epidemic is a social justice issue, as too little attention is now being given in many places, including the U.S., to prioritizing the importance of promoting adult smoking cessation and, for those adults addicted to smoking who cannot or are unwilling to quit nicotine -- many of whom are socially marginalized, poor, less educated, experience serious mental health conditions, or are members of the military or veterans -- helping them switch to less-hazardous, noncombustible forms of nicotine.
Regardless of ideology and policy preferences, we...
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Show MoreI appreciated the editorial by Ruth Malone on finding "common ground" on the topic of product regulation and more broadly the role of tobacco control. I would certainly agree that the current climate in smoking harm reduction has become toxic and emotional, non-scientific, and counterproductive to achieving the public health goal of reducing premature deaths caused by using smoked tobacco (i.e., mainly cigarettes). I also agree that the cigarette companies are likely using this as a wedge to advance their own financial interests - what else would you expect? I don't think anyone interested in public health is suggesting that we dismiss the past bad actions of the cigarette manufacturers, nor accept the claims of manufacturers of alternative nicotine products. Rather, we need to heed the lessons of the past so as not to make the same mistakes going forward. The United States, the Tobacco Control Act created a framework that should incentivize manufacturers to move away from profiting from the sale of cigarettes that causes so much harm to consumers. Promoting dialogue summits would allow for participants to engage in a civil manner, educate one another about challenges and opportunities and agree to specific measurable goals and objectives. Bringing stakeholders together will not resolve all differences but it will allow serious and responsible stakeholders the opportunity to bring ideas forward and find areas of common ground...
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Professor Malone’s call for a better understanding of the context of the tobacco epidemic is timely. For tobacco as for sugar and alcohol, the extent of population harm is linked to the historic growth of an oligopoly which has used economies of scale, aggressive sales tactics and ingredient modification to transform commodities into highly-processed, convenient and affordable artefacts1-3. At a time when the pandemic has brought the role of governments in protecting the public into greater focus, the implementation of market restrictions which we know to be effective in reducing demand (higher tax, minimum price, minimum pack size)4 should receive a new impetus.
Professor Malone’s call to unite opponents and proponents of ‘newer and novel nicotine and tobacco products’ (NNNTPs) around opposition to the tobacco industry should be heeded. Imperial Brands’s recent decision to turn back to ‘neglected’ cigarettes after being ‘overly focused’ on alternative nicotine products shows that profits, not smokers’ lives, will always be the tobacco companies’ priority5. The enormous influence exercised by the tobacco industry over governments worldwide is perhaps the most pressing tobacco control issue today, with countries including the US continuing to score highly on the Global Index of Tobacco Industry Interference6.
As to whether NNNTPs represent a ‘breakthrough’, it is not so much the products themselves that are disruptive, but rather the...
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We thank Tobacco Control for the opportunity to respond to the comment above. Our study was obviously not looking into the harms of secondhand aerosol from e-cigarettes (SHA). Our paper departs from previous compelling research on the harms of SHA and assesses the prevalence and duration of such exposure among e-cigarette non-users, i.e., bystanders who are potentially exposed to the aerosols emitted by e-cigarette users.
Firstly, it is clear that we conducted the study on the basis of knowledge that bystanders were involuntarily exposed to potentially hazardous SHA in many places. We have clearly mentioned the growing evidence that supports our assertion about the potential harms of SHA in the Introduction and Discussion sections of the paper. SHA contains many toxicants, including nicotine, particulate matter and carcinogens (e.g., volatile organic compounds, polycyclic aromatic hydrocarbons, formaldehyde, acetaldehyde and tobacco specific nitrosamines-TSNAs). As mentioned, this evidence comes from previous scientific research (please, foresee the references 11 to 14 of our paper). Of special interest, fine particulate matter (PM2.5) concentration increased during e-cigarette use sessions with human volunteers in settings such as a room[1–3], during vapers’ conventions[4,5], and in vape shops and their neighbouring businesses[6]. Some TSNAs, such as N-nitrosonornicotine and nicotine-derived nitrosamine ketone, which are carcinogenic[7], hav...
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I wish to express my dismay with the clear and obvious intention to promote an agenda of fear. One might ask why you are not looking to see whether there actually are any harms from second hand aerosol as the study clearly acts upon a preface that this is the case. I would point you to the CDC's own testing of the air quality found here. Something smells a lot less like science and a lot more like virtue signalling funded by an agenda eager to skip the important part of knowing what you're dealing with before searching for potential victims.
https://tobaccoanalysis.blogspot.com/2017/05/vape-shop-air-sampling-by-c...
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Recent work from Ilies et al. (1) is very informative toward understanding the degree to which heated tobacco products might confer less health risk than combusted cigarettes. This publication extends well beyond the existing HTP emissions evidence base, much of which was not conducted by independent groups. The authors should be commended for leveraging strong methodology, and for their comprehensive evaluation of toxicants generated by these products.
While the methodology and results of this publication appear sound, there are a number of inaccurate claims that warrant criticism in the second paragraph of the Introduction section:
• The second paragraph discusses nicotine vaping products (e-cigarettes), however citation #2 (Centers for Disease Control and Prevention (CDC). Use of cigarettes and other tobacco products among students aged 13-15 years--worldwide, 1999-2005. MMWR Morb Mortal Wkly Rep 2006;55:553) utilize data from 1999 through 2005, which mostly spans a time frame prior to the invention of the first e-cigarette in 2004 (2), and certainly spans a timeframe prior to their widespread marketing in the United States. The citation follows the sentence “However, the death toll provoked by their [e-cigarettes] consumption has increased significantly, reaching 650,000 annually, and it is likely to rise over the coming year…” This citation is clearly inapplicable to the unfounded claim being made about deaths attributable to e-ci...
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The meta-analysis by Khouja et al. confirms the strong association in young people between e-cigarette use and subsequent smoking.[1] The critical issue is whether the relationship is causal. If there is a causal relationship, there are several factors which diminish its impact.
Firstly, most of the studies used ‘ever smoking’ as the outcome. Ever smoking is a poor marker for smoking-related harm as most smoking by vapers who later smoke is experimental and infrequent and few progress to established smoking (100+ lifetime cigarettes). Shahab et al. found that only 2.7% of youth who tried e-cigarettes first progressed to established smoking. Only established smoking is linked to significant smoking-related death and disease.[2]
Secondly, the absolute number of non-smokers who progress from vaping to smoking is small as smoking precedes vaping in the vast majority of cases (70-85%).[3] If there is a gateway from vaping to smoking, this only affects a minority of young vapers.
Thirdly, the authors use Bradford Hill’s dose-response and specificity criteria to assess whether the association between vaping and subsequent smoking is likely to be causal.
They acknowledge that the dose-response criterion is mostly based on nicotine dependence, indicating that that nicotine dependent vapers are more likely to progress to smoking. However, nicotine dependence in non-smoking vapers is rare, less than 4% in the 2018 National Youth T...
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This is a well written original research about the burning issue of tobacco manufacturer lobbying. These manufacturing industries have developed strategies to undercut minimum price laws. By increasing tobacco taxes an effective policy has been designed to decrease tobacco use. In Pakistan currently, 209 million people smoke and about 83 billion cigarettes are smoked per year. As Pakistan has not ratified any anti-smoking policies, there should be great effort made to raise excise duties and taxes on tobacco companies to reduce the demand for cigarettes. In 2017 the local price of cigarettes was about 75 rupees of which half was excise duties [1].
With this expansion of taxes, there will be responses of reducing tobacco consumption, but the cigarette manufacturing industries developed specific promotions and lobbies to encourage their consumers to purchase lower taxed or lower priced tobacco products. It is the responsibility of health authorities to regulate the prices and promotion of such hazardous products [2]. According to WHO, “MPOWER” was the slogan in 2015, according to which M= monitor tobacco usage, P= Protect people from tobacco smoke, O= offering help to quit tobacco use, W= warning about its hazards, E= enforce to ban its advertisement, R = Raise tobacco taxes [3].
For smoke free Pakistan and all over the world four key factors should be instruments: Education, legislation, quitting support and financial policies.
1....
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The atomizer used for testing has a maximum rating of 80 watts.
200 watts was applied. Needless to say, horrible results occurred.
This is not reputable science, it is a failed experiment, it should never have been published.
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It should be noted that the Aspire Cleito coils used in this study have a manufacturer stated operating power range of between 55 and 75 watts. This is noted both on the box and laser etched into the side of the coil housing proper. it should be noted that the first data points in the graph ( to demonstrate the presence of CO in both liquid samples are in excess of the stated power range of the element.
"Strawnana" at 80 watts
"Black Ice" at 100 watts
This leads me to question the normalizing curve for the black ice sample as there are no data points in the graph (Figure 2) within the manufacturer noted operating range for that coil.
Furthermore, while this statement " ...though the bulk liquid temperature is controlled by boiling limits of the e-liquid component" would be accurate were the coil to be completely submerged in liquid, the mechanics of coil design will confound that principle. The resistance coils in electronic cigarettes are not, by design, submerged in liquid, they are in contact with a liquid saturated wick. Any heat energy applied to the coil whether in magnitude or duration, that exceeds the supply of liquid saturating the wick will result in a temperature spike which could cause the temperature to spike causing thermal degradation of what liquid does remain, and the singeing of the cotton wick.
It can be expected that where combustion occurs, carbon compounds will...
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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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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.
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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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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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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.
Addressi...
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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/
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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.
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.
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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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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.
Show MoreConsequently, 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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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?
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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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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.
Show MorePATH 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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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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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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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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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.
T...
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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).
Show MoreHowever, we have demonstrated unambiguously the a...
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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).
Show MoreHowever, we have demonstrated unambiguously the a...
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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...
Show MoreNOT 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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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...
Show MoreNOT 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.
Show MoreThis 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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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.
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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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Show MoreMore 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...
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...
Show MoreNOT 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...
Show More2. 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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Show MoreElias & 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...
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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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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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...
Show MoreNOT 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
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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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...
Show MoreThere 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.
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