Thursday, May 16, 2019

The 2018 American Teen Vaping Epidemic, Recalculated

Former FDA Commissioner Scott Gottlieb and other government officials have repeatedly asserted that the U.S. is in the midst of a teen vaping epidemic (example here).  Their claim is based on last year’s National Youth Tobacco Survey, the full contents of which was finally released six weeks ago by the Centers for Disease Control and Prevention.  With that data in hand, I have confirmed some of the assertions made by anti-vapers but easily put the lie to others (here).

Federal officials claim there were over three million high school vapers in 2018.  Let’s take a look at the actual numbers.  Each table below lists the number of high school students who used e-cigarettes 0, 1-5, 6-19 or 20-30 days in the past month, according to whether they were underage or of legal age (18+ years).   

Table 1 shows that 3.13 million high schoolers vaped, with 877,500 using the products 20-30 days in the past month.

Table 1. Number of High School Students in 2018 Who Vaped in the Past Month, According to Age

Days VapedLess than 18 years18+ yearsAll



Next, let’s remove any high school students who ever tried CIGARETTE SMOKING.  As shown in Table 2, that leaves 1.36 million, with 198,000 using the products 20-30 days in the past month.

Table 2. Number of High School Students in 2018 Who Vaped in the Past Month But Never Tried Cigarette Smoking, According to Age

Days VapedLess than 18 years18+ yearsAll



Removing students who ever tried CIGARS, the total drops to 978,000, with 132,500 using the products 20-30 days in the past month (Table 3).

Table 3. Number of High School Students in 2018 Who Vaped in the Past Month But Never Tried Cigarette or Cigar Smoking, According to Age

Days VapedLess than 18 years18+ yearsAll



Finally, subtracting students who ever tried SMOKELESS TOBACCO, Table 4 reveals that the vaping epidemic consists of 897,000 individuals, with 116,000 using the products 20-30 days in the past month.  Of those, 95,316 were underage.

Table 3. Number of High School Students in 2018 Who Vaped in the Past Month But Never Tried Cigarette or Cigar Smoking or Smokeless Tobacco, According to Age

Days VapedLess than 18 years18+ yearsAll



For comparison, I conducted the same analysis on the 2017 NYTS, which yielded 26,660 underage teens who vaped 20-30 days in the past month but never used other products.  That was less than 0.2% of all high school students. 

It is true that frequent vaping among underage high school teens increased substantially from 26,660 in 2017 to 95,316 in 2018.  These numbers translate into an increase from less than 0.2 to 0.6% of all high school students.

In summary, the oft-cited teen vaping epidemic involves not three million youths, but rather 95,000 underage teens who vaped frequently but never used other tobacco products – or 0.6% of the nation’s 14.8 million high school students.     

Monday, May 13, 2019

About Sensationalist Science and Rhetoric on E-Cigarettes

Last week the Louisville Courier-Journal published my plea to stop confusing the public with sensationalist rhetoric on e-cigarettes.  Read it here or on the Courier-Journal website.

The problem of misinformation is widespread. The public constantly receives alarmist misrepresentations about vaccinations, the food they eat, the household products they use, and now e-cigarettes and vaping. But hysterical rhetoric has consequences, because people act on what they are told. And health officials at all levels of government are misinforming Americans that e-cigarettes are as dangerous as cigarettes and pose an existential threat to their children. Unfortunately, this misinformation can be deadly.

Production of tobacco misinformation follows a formula, originating in “user fees” (read: taxes) Congress established in 2009, giving the FDA regulatory authority over tobacco (here).  Every year tobacco manufacturers consumers pony up over $700 million dollars in user fees to the FDA, which then transfers a big chunk of that money to the National Institutes of Health, which distributes it to thousands of researchers at the nation’s universities to study tobacco products.  This system, which has been operating for several years, isn’t set up to discover the truth about tobacco.  Instead, it generates only what the NIH, and others in the federal government, wants: bad news about all tobacco products.  Including tobacco-free, smoke-free, and vastly safer e-cigarettes.   

This bad news is then amplified by university media departments and our brave new world of social media, which makes it hard to see what’s true, and what’s exaggeration, distortion or pure fiction. Americans are exposed to a tsunami of fictitious “dangers” from vaping and of an e-cigarette “epidemic” that will put a generation of youth in danger. Of course, no policy measure is too strong when our kids are at risk.

But the result of this misinformation cycle is significant. A study last month in JAMA Network Open found that the percentage of American adults who perceive e-cigarettes as equally harmful as cigarettes more than tripled from 11.5 percent in 2012 to more than 36 percent in 2017; those who perceive e-cigarettes as more harmful also tripled from 1.3 percent to over 4 percent.

In short, Americans are listening to the alarmism about the “dangers” of e-cigarettes and the teen vaping “epidemic.”  They deserve better from our lawmakers and public health officials. The FDA knows that nicotine is the reason people smoke but it is not the reason that smokers die. Yet officials have not actively communicated this message to the public.

Even worse, the FDA has exaggerated the teen vaping problem by manipulating data and incorrectly blaming retailers, in order to justify onerous regulations that will give consumers fewer healthier choices.

Meanwhile, the real risks are forgotten. Smoking continues to prematurely kill 500,000 Americans every year, and smoking-related healthcare costs are nearly $300 billion. According to the CDC, more than 16 million people live with a smoking-attributable disease.

In recent decades, anti-tobacco crusaders have tried everything to kill cigarettes, including litigation, legislation, taxation and regulation. But their crusade lost its direction when it started to target all tobacco products – even those that don’t contain tobacco.  Officials in international health organizations and national governments know that “tobacco” is not synonymous with “smoking,” yet they purposefully conflate them.  In desperation, they have tried to kill e-cigarettes and vaping, an innovative, satisfying and vastly safer cigarette substitute. Ironically and tragically, their actions are sustaining and extending the cigarette market. 

E-cigarettes contain nicotine – which is addictive – but they lack the toxins in smoke that cause lung cancer, heart disease and other maladies. This substantial difference is what led prestigious British medical organizations like the Royal College of Physicians and Public Health England to deem e-cigarettes at least 95 percent safer than combustible cigarettes.  In fact, the British government’s Department of Health helps smokers switch from combustibles to vapor.

The good news is that even though misinformation is rampant, American smokers are still using e-cigarettes more frequently – and more successfully – than FDA-approved medicines to help them quit, according to a population-level study using the FDA’s national survey.  In February, British researchers reported in The New England Journal of Medicine that e-cigarettes are nearly twice as effective in helping smokers quit as FDA-approved nicotine medicines like patches and gum.

Free and open conversation about truthful information is essential to a healthy democracy. But it’s also critical to establishing sound public health policy. It’s time for Americans to have all the facts about e-cigarettes, so they can make educated choices in order to enjoy longer and healthier lives.

Friday, May 10, 2019

CDC Quit-Smoking Ads Lack Real-World Solutions

People regularly ask me why I’ve spent the last 25 years researching and advocating for tobacco harm reduction and related products.  While it’s difficult to provide a succinct answer, a powerful ad campaign from the Centers for Disease Control and Prevention illustrates why I am dedicated to helping smokers. The campaign is called “Tips from Former Smokers”.

For the first 15 years of my career, I was on clinical staff at the Comprehensive Cancer Center of the University of Alabama at Birmingham.  As an oral pathologist I made microscopic diagnoses of hundreds of cancers.  But as a clinician and member of a multidisciplinary team treating countless patients with mouth, throat and lung cancer, leukemia and other serious smoking-related diseases, I was compelled to search for practical quitting options for smokers just like Terrie, the patient in the CDC public service ad above.  Click here to watch the entire ad.

Those smokers reminded me always of my maternal grandfather.  He had smoked for most of his 65 years, despite the onset of heart disease that led to his early retirement from operating a dragline excavator in the coal strip mines of Western Pennsylvania.  I remember my great-grandfather, an underground coal miner who chewed tobacco until he passed away at age 99, pleading with him: “Worthy, every cigarette is another nail in your coffin.” 

My grandfather never quit, and in 1965 he suffered a stroke that left him hospitalized for months before he died.  Every night, my parents drove us 25 miles to visit him. One memory from that sad period is still with me: my grandfather, on oxygen and barely able to move or talk, begging his nurse for a cigarette.

For many tobacco opponents, patients like these are only an abstraction, numbers to be wielded in a fight for absolute prohibition.  Most extremists have never worked with smokers suffering from a devastating disease.  If they had, they would care enough to ensure that smokers are offered every option to quit before it’s too late.

That’s the frustrating thing about the CDC advertising.  It doesn’t endorse the most frequently used, and most frequently successful quitting aids: e-cigarettes.  Instead, the CDC pitches telephone quit-lines and gives smokers trite advice: “keep your mouth busy…do something else…go for a walk or a jog…take slow deep breaths.”  These tips are worthless for most of those who are desperate for their next cigarette. 

What about children?  After my lectures, I am often asked by parents, “What if my child learns about you and your ideas, then starts using smokeless tobacco or e-cigarettes?”

My answer: “What if, despite all of your good intentions and nurturing, your child becomes a smoker?  And what if, after 10 or 15 years, they are unable or unwilling to quit?  As a parent, wouldn’t you want your child to know about safer tobacco products?”

We have to keep tobacco out of the hands of children, but safer cigarette alternatives must not be regulated out of reach of their parents and grandparents, whose smoking habit leaves them desperate to avoid fatal illness.