Taking a Sensible and Humane Approach to Tobacco Use and Vaping Based on the Continuum of Risk
On October 28, 2021, I presented on a panel at the annual Tobacco and Nicotine Products Regulation and Policy Conference sponsored by the Food and Drug Law Institute (FDLI). As the recent national vice president for tobacco control for the American Cancer Society and a veteran of 33 years in efforts to combat the smoking epidemic, I’ve been encouraged to make available on Medium my remarks on how we can and must take a more sensible and humane approach to addressing tobacco use and vaping based on a continuum-of-risk approach. I have reproduced them here. With FDLI’s generous permission, I’m also pleased to provide this YouTube link to the actual 13-minute presentation.
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I’m pleased to be a part of this panel covering some cutting-edge issues around the eclectic marketplace for tobacco and nicotine products. I’ll use my time to address a few current issues that strike me as worthy of attention in this forum.
Let me begin on a personal note. Vaping has affected me personally, as I know it has some of you. Back when what was named “EVALI” sickened more than 2,000 people and took the lives of more than 60 of them, there were constant news reports and statements by some in the public health community that alarmingly, but erroneously, conflated concerns with youth nicotine vaping and the lethal events caused by illicit use of devices containing THC and vitamin E acetate.
Some of that conflation persists to this day. In any case, the news coverage engendered widespread fear, and my young adult niece and her fiancé were among the many people who had switched to vaping but returned to cigarette smoking because, she said, they were afraid that Juul might kill them.
Very recently, I became aware that an 18-year-old family member who lives with ADHD and a mood disorder, which places him at higher risk for drug use, has started using e-cigarettes. He let me know that there are disposable, flavored vapes that he can easily purchase at a local gas station without showing an ID. This was difficult for me to hear. It worried me, and it made me angry.
People are aware of my advocacy for a well-regulated adult marketplace for less harmful, alternative nicotine-containing products. That has in no way wavered. But believe me, I feel strongly about the important, and challenging, duality of this issue: the need to effectively serve the needs of protecting our kids while making every effort possible to support tens of millions of addicted adult smokers.
I continue to maintain, with a large and rapidly growing community of highly credible, top-level scientists in the U.S. and abroad, that we must come together across the ideological divide to pursue our common cause of combatting illness and saving lives by preventing all forms of tobacco use by young people, to the furthest extent we can in the real world, while also making the most robust efforts possible to help adult smokers quit combustible tobacco use, which is responsible for every single one of the annual 480,000 tobacco-related deaths reported by the U.S. Surgeon General and the U.S. Centers for Disease Control and Prevention.
Regarding education and information: People who smoke should not have to die because they do not know they have less harmful sources of nicotine. People have the right to be informed of the fact that there is a continuum of risk for all tobacco and nicotine products and be able to make critical personal health decisions based on this knowledge.
As the U.S. Food and Drug administration has said, “A key piece of the FDA’s approach is demonstrating a greater awareness that nicotine — while highly addictive — is delivered through products that represent a continuum of risk and is most harmful when delivered through smoke particles in combustible cigarettes.”
There are also significant and persistent misperceptions among the public and healthcare professionals themselves regarding the varying role and health impact of nicotine itself.
Nicotine addicts, in varying degrees, depending on the type of delivery system — there is obviously a major difference in this regard between Marlboro cigarettes and Nicorette gum, for example — but in none of these products does nicotine cause the debilitating illnesses and casualties suffered chiefly by combustible tobacco users.
And nicotine can actually help a great deal when used in the right product by the right adult user. But to become the right user, a term I use loosely for these purposes without intending a technical definition, one benefits immensely by first becoming well-informed.
But, so far, our health authorities and the public health community have done a poor job of communicating the facts and realities of nicotine use accurately, clearly and consistently to, well, almost everybody.
If we continue to live in a country in which as many as 80 percent of physicians erroneously believe that nicotine causes the deadliest tobacco-related illnesses, then we cannot succeed. We must right this ship.
Who should do so? We have heard from the FDA’s Tobacco Center director, Mitch Zeller, that this educational venture targeting adults smokers is not a top priority of FDA, which has primarily messaged regarding nicotine with an eye toward deterring kids from using nicotine, which is generally depicted as Public Health Enemy #1.
I understand that focus. Again, it’s personal to me. I don’t want my young relatives or anyone else’s to start using this drug in any form.
But, at the same time, some major stakeholders need to step up and start educating adults in ways appropriate and useful to them. I’ve worked for three decades in a community of organizations who have large megaphones and, collectively, millions of constituents, including clinicians, and which are very well positioned to perform this critical service.
As of now, there exists no robust, national campaign focused on adult-oriented messages around nicotine and the continuum of risk among different products. And of course we know, from many years of experience predating the emergence of e-cigarettes, that as a result of this gap, many adults ironically have been deterred from using NRT to quit smoking because of their fear of nicotine.
Some of the public health groups, who have been my professional family and remain close to my heart after more than three decades, consistently frame the debate as one between public health and the tobacco industry. Case in point: Recently, more than 100 independent global experts in nicotine science and policy, which I was honored to join, sent an open letter to the delegations of all of the nations that are parties to the WHO’s Framework Convention on Tobacco Control urging them to encourage WHO to support and promote tobacco harm reduction pursuant to the FCTC. The letter criticized the agency for misleading the public regarding the relative risks of different tobacco products, despite the fact that tobacco harm reduction is part of the official policy set forth in the formal language of the treaty itself.
This large group of highly regarded experts highlighted the fact that WHO has aggressively rejected a public health strategy that could help avoid millions of projected smoking-related deaths. The agency’s antagonistic approach, the letter noted, has had an especially damaging influence in vulnerable low- and middle-income countries, where 80% of the world’s one billion smokers live.
One of the immediate responses to the experts’ letter from some in public health was not to engage in thoughtful discussion of the well-documented issues presented, but rather to argue that the 100+ experts were serving the interests of the tobacco industry.
Unfortunately, this is too common. A persistent challenge is that the public health side frequently attributes harm reduction advocacy to the influence of the tobacco industry, or at the very least argues that it helps the industry and is therefore automatically illegitimate.
This reduces the discussion to a false and conveniently oversimplified battle between us and them, between good and evil. In this narrative, the many expert scientists and policy specialists who advocate for tobacco harm reduction become mere tools of the tobacco companies, or worse, knowing fronts for industry interests.
Of course, let me make crystal clear, suspicion of the industry is warranted. Anyone who knows my background in exposing industry misconduct and bringing industry whistleblowers forward to assist the FDA and the Justice Department, and testify in court and before Congress, knows where I stand on that question.
The industry shouldn’t be taken at its word. The proof will come in the form of action, and ensuring meaningful and effective action requires well-wrought regulation by the FDA and other health authorities around the world.
On a related note, the Federal Trade Commission recently released its 2020 reports on cigarettes, smokeless tobacco and, for the first time, nicotine lozenges and pouches not containing tobacco.” The FTC reported that cigarette marketing expenditures rose last year overall and that almost all of that increase came in the form of price discounts to retailers.
The increased discounting of conventional cigarettes, which obviously incentivizes their purchase, could be fairly interpreted as evidence that the cigarette companies are not serious about transitioning to lower-risk alternatives. Common sense tells you that if one genuinely wants to transition smokers away from cigarettes, it could be done quite efficiently by raising prices for cigarettes and widening the price differential between cigarettes and lower-risk alternatives.
Finally, I want to be sure to note the primacy of the need to render combustible tobacco products non-addictive. It’s important that FDA move ahead expeditiously with the development of that product standard and support related efforts by manufacturers seeking to provide this critical option to adult smokers.
It was the top behavioral scientist at Philip Morris who perhaps put it best in a secret presentation to industry colleagues, back in 1972, when he reported: “Without nicotine . . . there would be no smoking.” He elaborated by saying, “No one has ever become a cigarette smoker by smoking cigarettes without nicotine … Think of the cigarette pack as a storage container for a day’s supply of nicotine … Think of the cigarette as a dispenser for a dose unit of nicotine … Think of a puff of smoke as the vehicle of nicotine … Smoke is beyond question the most optimized vehicle of nicotine and the cigarette the most optimized dispenser of smoke.”
So, bearing that in mind, FDA should assertively reinvigorate its comprehensive plan of 2017, which is based in part on the important harm-reductionist premise that we not take away from nicotine users what we can’t replace. If and when nicotine is reduced to non-addictive levels in combustibles, people who smoke must have appealing, accessible and well-regulated nicotine options available to them in addition to NRT, such as e-cigarettes, lozenges, pouches, low-nitrosamine smokeless tobacco and other products yet to be developed.
So, in this complicated time, we continue to have our work cut out for us. For my part, I’ll join other like-minded colleagues in continuing to call for reconciliation in this internecine war within public health and tobacco control. We must find our way to common cause and bring more cohesion to our collective efforts to defeat the epidemic of combustible tobacco-caused illness and death, understanding that in all such public health ventures there will likely be difficult trade-offs that must be made in order to achieve the best outcomes.
I want my 18-year-old family member, whom I love dearly, to quit vaping as soon as possible. And I want the older folks I know who have been smoking for many years to switch completely to vaping if they can’t or won’t otherwise quit combustible tobacco use now, as I articulated in 2018 with other American Cancer Society leaders in ACS’s Public Health Statement on Eliminating Combustible Tobacco Use in the United States — and also to ultimately end entirely the sale of addictive, lethal combustible tobacco products.
That’s the real world we live in. Let’s deal with it. Together.
