Friday, January 31, 2020

The Surgeon General’s Bogus Report on Smoking Cessation

The U.S. Surgeon General’s new 700-page report on smoking cessation includes a foreword by former CDC director Robert Redfield that succinctly describes the government’s tobacco prohibition objective: “we remain committed to…end the tobacco use epidemic and provide all Americans with the opportunity to live tobacco-free.”

The report’s “major conclusion” with respect to e-cigarettes is that “there is presently inadequate evidence to conclude that e-cigarettes, in general, increase smoking cessation.” 

This is the standard position of prohibitionists.  They state with absolute certainty that vapor injures cells, animals and people; and it causes addiction, teen epidemics and a host of other nasty problems.  But with respect to positive impact like smoking cessation, well, there’s just not enough evidence.  Federal authorities minimize as mere “anecdotes” the millions of cases of former smokers who have quit via vaping.

Far more difficult to ignore are the many well-conducted clinical trials published in prestigious medical journals.  For example, Hajek et al. published the results of a British trial in the New England Journal of Medicine, reporting that e-cigarette users are more likely to quit smoking than smokers using nicotine medicines (Relative risk = 1.83; 95% confidence interval [CI], 1.30 to 2.58).  Commenting on this research, the Surgeon General emphasized largely vaporous caveats.  The UK, he said, is different than the U.S.  More research needs to be done, he argued, and most importantly, “80% of participants in the e-cigarette group were using e-cigarettes at 52 weeks follow-up [versus] the [nicotine medicine] group.”  In other words, the Surgeon General was more impressed with the 4 subjects (out of 44) who achieved complete abstinence than the 63 (of 79) who were vaping, but NOT SMOKING, at one year.

The Surgeon General also shortchanged epidemiologic evidence published by me in 2017.  I found population-level proof in an FDA survey that e-cigarettes are not only popular, they are the only aid more likely to make one a former smoker (i.e., a successful quitter) than quitting cold-turkey.

While, to his credit, the Surgeon General cited my study twice in his report, he never mentioned my main finding.

The Surgeon General’s bogus claim of “inadequate evidence … that e-cigarettes … increase smoking cessation” and his failure to stem smokers’ deaths by encouraging switching to vaping are a disservice to the cause of public health.

Thursday, January 23, 2020

Where Did Underage Vapers Get E-Cigarettes in 2019, and Why Did They Use Them?

The 2019 National Youth Tobacco Survey (link here) offers a wealth of critical data. In last week’s blog entry I noted that underage vaping increased over the prior year, as the number of frequent “virgin” vapers (those who never used other tobacco products and used e-cigarettes 20-30 days in the past month) rose from 95,000 to 172,000.  This negative news was accompanied by a dramatic decline in the use of cigarettes (2.6% to 0.8%) from 2018 to 2019, indicating that the eradication of teen smoking is within reach.

Recently, Congress enacted Tobacco 21 legislation, which the FDA implemented in December.  The agency also announced a partial ban on e-cigarette flavors. 

The 2019 NYTS survey collected information from high school vapers that is relevant to these policies.  It asked, (1) “where did you get or buy the e-cigarettes that you have used” (during the past 30 days); and (2) “what are the reasons you have used e-cigarettes?”  The results for underage current vapers are shown in the accompanying tables.  The percentages don’t add to 100, because participants could select more than one response for each question.  So the numbers indicate the relative importance of the various sources (i.e. friends versus a grocery store).

Table 1. Where Did Underage Vapers Get or Buy Their E-Cigarettes?
Other person14%
Family member10%
Gas station/Conv store17%
Vape shop13%
Other place6%
Drug store2.9%
Grocery store2.4%

Clearly, most underage teens get their vape products from friends (62%), family members (14%) and/or “others” (10%).  I endorsed Tobacco 21 a year ago principally because it will diminish the black market supply by eliminating legal (age 18+) tobacco purchasers in the nation’s high schools.

Retailers supply significantly less vape products to underage teens.  Gas stations and convenience stores are the most popular in this category, with vape shops a strong second.  The internet was cited as a source by only 6% of underage vapers, while other brick-and-mortar stores were chosen less frequently.

Table 2. Reasons Underage Vapers Used E-Cigarettes
Curious about them50%
Use them to do tricks24%
Available in flavors23%
Friend/family member used them21%
Use them unnoticed at home/school18%
Other reason18%
Less harmful than other tobacco17%
Peer pressured into use8.9%
Try to quit other tobacco7.4%
Easier to get than other tobacco6.3%
Cost less than other tobacco5.5%
People on TV/online/movies use them4.1%

Unsurprisingly, underage teen vapers were mainly motivated by curiosity (50%).  That may be a response to the FDA’s poorly crafted vaping epidemic ad campaign, which was translated recently by Clive Bates: “Hey, time to get with the program. All kids, especially cooler kids are doing it...Everyone else is at it, except you...” 

Flavors (23%), with which the FDA is obsessed, placed in the second tier of reasons, along with tricks (24%). Friends and family, it turns out, are not just important suppliers, but significant influencers (21%), especially when combined with peer pressure (8.9%).  Friends and family are, in fact, dominant factors for all risky behaviors, but unlike retailers, they cannot be controlled by government regulation.

Clive Bates interpreted another portion of the FDA campaign as “… you can keep it hidden from mom,” and sure enough, the NYTS shows their use of vape products goes unnoticed (18%).  Additionally, despite a barrage of misinformation about exaggerated and fake e-cigarette illnesses, some underage vapers act on scientific reality, saying they use e-cigarettes because they are less harmful than other tobacco products (17%).