The Cleveland Clinic Deceives Smokers

 

The Cleveland Clinic (CC) just published an egregiously misleading article titled, “Vaping and Smoking: Both are Dangerous, Nicotine in any form is hazardous to your health.” 

The 2007 British Royal College of Physicians report, “Harm Reduction in Nicotine Addiction: Helping People Who Can't Quit,” was unequivocal: “…that smokers smoke predominantly for nicotine, that nicotine itself is not especially hazardous, and that if nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved…” (emphasis added)

Despite the established science, the CC asks: “But how do e-cigarettes and cigarettes really stack up when it comes to your health?”  They don’t provide a straight answer, but in its 2016 report the Royal College did: “the hazard to health arising from long-term vapour inhalation from the e-cigarettes available today is unlikely to exceed 5% of the harm from smoking tobacco.”  (emphasis added).  No research findings in the past 10 years have changed that.

Further ignoring the literature, the CC makes these other evidence-free false equivalence claims:

“[CC] pulmonologist Peter Mazzone, MD, MPH, Director of Cleveland Clinic’s Lung Cancer Screening Program…explains why vaping and smoking are both dangerous.”

“Both cause unnecessary damage to your health and increase your risk of serious illness.” 

“You’ll find just as many dangerous substances in a cigarette as you do in a vape, and the health risks mirror each other.”

“Sure, both vaping and smoking are bad for you.” 

“But we do know, for sure, that both behaviors are risky.”

“The health issues associated with vaping and smoking run the gamut, from premature aging and gum disease to neurodevelopmental delays and seizures. 

“Both vaping and smoking are sources of thirdhand smoke.  You read that right. Thirdhand smoke is the name researchers give the toxic particles left behind on clothes, furniture, walls and more after you exhale tobacco smoke or aerosolized e-cigarette fluid. The stuff resists cleaning and can linger for years, harming people you’ll never even meet.” (emphasis in original) 

 

The phrase “thirdhand smoke” was invented in 2009 by Massachusetts pediatrician Jonathan Winickoff and his colleagues as a “notion” (their word), which I debunked with simple math and common sense (here).

In the quoted text above, I retained the original Cleveland Clinic link to thirdhand smoke (THS) because the Clinic claims it is a “link to our research so you can see our sources.”  However, the link just points to another article written on the same date by Dr. Mazzone, the main source for this drivel.  He suggests, “To get your home as close to THS-free as possible, you’d have to: Replace the carpets; Repaint the walls; Replace clothing; Have your car professionally cleaned and replace the air filters; Clean out or replace ventilation systems in the affected building.”[

The Cleveland Clinic offers this shocking advice for smokers: “You may have also heard that vaping is a good way to kick a smoking habit, but experts discourage it. The risks, Dr. Mazzone explains, are simply too high.”

This flies in the face of two pivotal clinical trials, reported in the New England Journal of Medicine, documenting that vapor works for smoking cessation (here and here).  The risks of vapor are simply so low that it is unethical not to recommend them. 

 

 

Anti-Tobacco/Nicotine Activists Blame Smoke-Free Tobacco for the Dual Use They Promoted

 

Arielle Selya has published an excellent Substack commentary on the latest attack on tobacco harm reduction: Dual Use of Cigarettes and E-cigarettes.  Dr. Selya’s confirmation that the evidence for e-cigarettes as a quit-aid for smoking is unimpeachable should be read in conjunction with my documentation of the fact that the “teen vaping epidemic” has always been wildly exaggerated.

Dr. Selya explores dual use in detail, focusing on one-year follow-up results of an e-cigarette quit-smoking clinical trial by Britain’s Francesca Pesola and colleagues (here).  Compared with exclusive smokers, dual users were much more likely to quit at both the four-week and one-year timepoints in the trial.  This is solid evidence that dual use is not the deadly behavior that activists claim.  Ironically, the behavior itself is largely caused by activists.  Let me explain.

Some who use one tobacco product are inclined to try and/or use other combustible or smoke-free products.  Their preferences are influenced by a variety of factors, including family and social contexts, budget and concern about adverse health effects.

Today, nicotine and tobacco prohibitionists have made vapes nearly as expensive as cigarettes, and they regularly promote flawed research to associate vaping with a range of diseases.  This environment discourages smokers from switching, and creates an ambivalence that often leads to dual use.

I was keenly interested in dual use throughout my entire tobacco research career.  Twenty-three years ago I published with Swedish colleagues a prospective follow-up study of tobacco users in northern Sweden.  Using World Health Organization data following Swedish men for five to 13 years, we found that “Snus was the most stable form of tobacco use amongst men (75%); only 2% of users switched to cigarettes and 20% quit tobacco altogether.  Smoking was less stable (54%); 27% of smokers were tobacco-free and 12% used snus at follow-up. Combined use (smoking and snus) was the least stable (39%), as 43% switched to snus and 6% switched to cigarettes.”

I published additional observations in a 2011 letter to Nicotine & Tobacco Research, which answered the “concern” of the chair of the FDA Tobacco Products Scientific Advisory Committee.  I wrote, “The findings from Rodu et al. (2003) confirm and extend those from Frost-Pineda et al. (2010), and both studies address Dr. Samet’s concern about cessation. Although dual users are less likely than exclusive smokers to be completely tobacco abstinent at follow-up, they are much less likely to be smoking.” 

In conclusion, dual use is promoted by anti-tobacco/nicotine activists who falsely portray smoke-free products as being as dangerous as cigarettes.  Given the actual facts, smokers and dual users will complete the switch to and significantly benefit from less harmful smoke-free products. 

 

A Deeper Dive into High School Vaping from the 2025 National Youth Tobacco Survey

 

I previously took a deep dive into high school vaping data reported in the 2023 National Youth Survey (here).  That analysis demonstrated that, contrary to the government narrative, vaping was not an epidemic or crisis threatening to enslave a generation of teens to nicotine.  The same can be said today, with even more certainty, based on the FDA’s recently released 2025 data.

In 2025, there were 1.1 million current users (i.e., past 30 days) of e-cigarettes or other vaping products.  This number is far lower than that at vaping’s peak in 2019 (here), yet anti-tobacco crusaders persist in claiming there is a public health crisis. 

The chart on the left breaks down the survey’s 1.13 million vapers to calculate the actual number of exclusive, or “virgin” vapers.  I use a sequential subtraction method to isolate factors integral to vaping.  The chart reflects CDC weighting to estimate the numbers in detail, but in the following text, acknowledging real world facts, I’ll use abbreviated estimates.

There were 16 million high schoolers in 2025; about 7.1% of those were current vapers, meaning they had used the product at least once in the past 30 days.  About 213,000 current vapers were also current smokers, which leaves 921,000. 

Of these remaining vapers, 337,000 “ever” smoked a cigarette, even one puff, leaving 584,000.

After subtracting another 86,000 who “ever” smoked a cigar, we have 498,000 current vapers.

Finally, there is a key factor that nicotine-obsessed crusaders completely ignore, despite its coverage in the NYTS: “ever” vaping marijuana, tetrahydrocannabinol (THC) or cannabidiol (CBD).  There were 292,000 current vapers who had also vaped those marijuana-related products.

Now we have a reasonable estimate for virgin vapers, or those high schoolers who did not have any other exposure to similar tobacco or marijuana products.  The grand total is 206,184, representing only 1.3% of all high school students.

For further context, consider the frequency of vaping among virgin vapers: 67% had vaped only 1-9 days in the past month, 12% had vaped 10-19 days, and 21% had vaped 20-30 days.  While the latter group is at risk for being addicted to nicotine and vaping, these 42,700 frequent vapers represent just 3.8% of all high school vapers.  More importantly, they represent only 0.3% of all U.S. high school students.

Vaping among high school students is a legitimate concern, but vaping is neither an epidemic nor a teen health crisis.  It’s time that public health officials acknowledge that vaping, smoking cigarettes and cigars, and using THC/CBD are closely interconnected risk behaviors.  Vaping is by far the least of those. 

Public health leaders should stop leaning on an imaginary teen vaping epidemic to deny less harmful products to adult tobacco smokers, 480,000 of whom will die this and every year.

FDA Authorization of iQOS: The Good, The Bad and The Ugly

 

Clive Bates recently described his reactions to the FDA re-authorization of iQOS, Philip Morris International’s innovative heat-not-burn tobacco. The FDA action means that PMI can market the products in the U.S., and make claims the FDA deems "appropriate to promote the public health" under Section 911 of the Tobacco Control Act.  Clive’s description follows:

____________________________

I think the FDA's announcement is positive and good for public health to have a wider range of smoke-free, far safer products available as alternatives to cigarettes, with authorised risk communication suitable for adult consumers.

But there is a far bigger story here, in my view: the technology lag imposed on U.S. consumers by the FDA's authorisation regime.  

The iQOS 2.4 and 3.0 are essentially obsolete, and iQOS 3.0 is only available in a few isolated U.S. markets. They were launched internationally in 2016 and 2018, respectively.  These are based on PMI's original blade-based heating technology (first launched in 2014 in Japan), which has been superseded by an induction-based heating system in the iQOS ILUMA. The ILUMA products offer a material advance over blade-based systems from a consumer perspective: cleaner, less routine maintenance, more reliable, and improved aerosol consistency. The ILUMA was launched internationally in 2021, with a new version, the ILUMA i, launched in 2024 outside the United States.

The manufacturer, PMI, submitted a combined PMTA and MRTP for ILUMA in October 2023, and the FDA took until March 2024 merely to accept the application.  In April 2026, the first ILUMA remains under FDA review. So American consumers have access only to obsolete technology that is now about 10 years old. These obsolete products are not sold anywhere else in the world. In the UK, the available iQOS product is the ILUMA i (e.g., see here). 

There is a similarly dismal story with the Juul products.  The Juul 2 was available in the UK in September 2021, but it is still not available in the United States. Juul Labs Inc. submitted Pre-Market Tobacco Applications for the Juul 2 in July 2023.  The PMTA evaluation is required by law to be completed in 180 days under Section 910c(1)A. The original Juul, the only one that can be sold legally in the United States, was launched in 2015 and took just over 1,800 days to pass through FDA... 10x the statutory maximum. The Juul 2 application has now been with the FDA for more than 1,000 days. A new version of the Juul cannot be that far away and is probably necessary for the European market.

The FDA's evaluation system is so cumbersome that it cannot meet its own statutory timetable and limits Americans to obsolete technologies, mostly from a small pool of relatively large manufacturers that can cope with the extreme burdens of its process. This serves to protect the cigarette trade and is driving a giant illicit market - over 80% of the U.S. vape market consists of unauthorised products (Juul Labs estimate). 

If you are interested in what the FDA could do about this, please see our report: Regulating the Tobacco and Nicotine Market in the American Public Interest: A Reform Agenda for the FDA, September 2025, for the American Enterprise Institute, by Sally Satel, Brad Rodu, Don Kenkel and me.

Clive Bates

High School Smoking Almost Gone, Vaping Way Down Too

 

Recently the U.S. Food and Drug Administration released data from the 2024 and 2025 National Youth Tobacco Surveys (NYTS).  A few specialty media articles reported some general findings (here, here and here), but otherwise the release was a non-event.

I downloaded the NYTS data and conducted an analysis of high school vaping and smoking, seen in the chart at left.  This explains the lack of media coverage: the teen vaping crisis is over.

The chart clearly shows that exclusive smoking among high schoolers was almost extinct in 2025, at 0.5%.  In fact, it’s getting so rare that it’s hard to attach labels.  Dual smoking-vaping (1.3%) and exclusive vaping (5.7%) were also much lower in 2025 than just five years earlier (3.6% and 16% respectively).

Where is the celebration?  We are close to achieving a smoke-free generation of youth and young adults, which in a few decades will transition to a smoking-disease-free generation of older adults. 

For years I complained about CDC manipulation of the NYTS numbers as it withheld the data and spun the narratives (examples here, here, here, here and here).  I am grateful that the FDA released the NYTS data without spin or fanfare, a big departure from previous releases when the CDC Office of Smoking and Health was the source. 

April 15: Note to the post.  The original chart contained a small error in the 2025 column.  H/T to Charles Gardner for pointing this out.  Correction has been made.