Tobacco Harm Reduction Is A Life-Saving Policy, No Matter Who Promotes It

 

Dr. Joanna Cohen recently authored a misleading and factually incorrect commentary on tobacco harm reduction in The Hill.  Here is my rebuttal, in bold.

Cohen: “So why should we trust cigarette companies to help reduce tobacco use?”

No one trusts cigarette companies.  That’s why Congress gave the Food and Drug Administration regulatory authority over tobacco in 2009.  Cohen misrepresents the principle public health goal, which isn’t to reduce tobacco use, but to prevent the 480,000 premature American deaths that result each year from smoking. That number hasn’t appreciably changed for the 15 years the FDA has had regulatory authority.

Cohen: “For the last several years, the tobacco industry has been co-opting the term ‘harm reduction’ from public health, using it to frame electronic devices and e-cigarettes as the be-all, end-all of smoking cessation tools.”

False.  Harm reduction wasn’t co-opted, because Cohen and most public health officials never applied it to tobacco.  They insisted that smokers quit only through total nicotine and tobacco abstinence.  Conversely, cigarette manufacturers did ultimately acknowledge that their products were deadly, and that there were vastly safer smoke-free ways to consume nicotine.  In the mid-2000s, they started acquiring smokeless tobacco companies, which produced those safer products, and more recently, pushed by disruptive technology and new competitors, they adopted vapor and heat-not-burn tobacco products, which are also significantly safer than cigarettes.

Cohen and company are the only ones calling e-cigarettes “the be-all, end-all of smoking cessation tools.”  They seemingly forget that only 5% of all smokers achieve nicotine/tobacco abstinence in any given year. 

Cohen: “Such [harm reduction] methods include restricting tobacco advertising and promotion, increasing the price of tobacco products, and establishing 100 percent smoke-free public spaces. These all support people who are ready to quit without requiring abstinence.”

How do those steps support people who are ready to quit without requiring nicotine abstinence?  Cohen merely recycles failed measures that limit smokers’ options of ‘quit or die.’       

Cohen: “It is critically important, however, to note that, to date, no company in the U.S. has sought out FDA authorization to market these products as approved cessation devices.”

No, it’s not.  Authorization as a cessation device would not be handled by the FDA tobacco center, but by the drugs or medical device centers.  The FDA approved nicotine medications decades ago, even though, to meet FDA requirements for approval, they’re expensive and ineffectively low-dose, require warnings far greater than those on cigarettes, and don’t provide the nicotine spike that smokers get when they light up.  With a regulatory framework like this, no wonder nicotine medications are successful for only about 7% of smokers who try them. For what other medications does the FDA accept a 93% failure rate?  Let alone medications to treat a condition that will unnecessarily kill 480,000 Americans this year.  It is outrageous that the agency and most of the public health community promotes this failed strategy when safer, popular harm reduction tools are readily at hand.

Cohen: “…enabling tobacco to remain the leading preventable cause of death around the world.” 

Cohen knows that tobacco is not a synonym for smoke, but she repeats the egregious conflation, proving again she chooses to ignore that nicotine is the reason people smoke, but not the reason that smokers die.

Cohen: “tobacco industry allies baselessly position e-cigarettes and heated tobacco products as the only viable harm reduction method for people who want to stop smoking. They discount existing FDA-approved cessation methods entirely.”

This statement is full of falsehoods.  Tobacco harm reduction proponents are not industry allies; they are allies of those 480,000 smokers who will die prematurely this year.  The FDA-approved cessation methods Cohen et al. diss have only a woeful 7% percent success rate, as noted above.  Many other alternatives to cigarettes are already available, and many others are under development.

Cohen: “…we know that nicotine can still be extremely addictive.”

Yes, nicotine can be addictive, which is why her goal of nicotine-and-tobacco abstinence is so misguided.  Harm reduction proponents recognize that many smokers cannot achieve Cohen’s abstinence nirvana, so they promote practical solutions that save lives.

Cohen: “a whole new generation of consumers, including children and young people enticed by appealing flavors, who may spend the rest of their lives trying to curb a nicotine addiction.”

Everyone shares Cohen’s concern for children, and society should discourage them from adopting dangerous adult behaviors.  If Cohen was consistent, however, she would call for sanctions on companies selling alcohol, which poses a far greater threat to teen health, and she would focus on marijuana, used by 25 percent of all teens over the past 30 years.

Cohen worries that teens “may spend the rest of their lives trying to curb a nicotine addiction,” but nicotine is no more dangerous than caffeine, another addictive substance.  Cohen’s prescription – a ban on nicotine and tobacco – is doomed to fail, just as the complete ban on marijuana use failed for 30 years.

Cohen: “This playbook isn’t new. For decades, the tobacco industry refused to acknowledge that cigarettes are deadly…” 

Actually, the playbook changed dramatically, as cigarette manufacturers now acknowledge that combustible products kill.  But by denigrating safer tobacco products, Cohen et al.  prolong cigarettes’ dominance of the tobacco/nicotine market. 

In summary, do not mistake Cohen’s distorted idea of harm reduction as anything more than cigarette market prolongation.

 

Tobacco Controllers, Denying Harm Reduction Facts, Promote Orwellian Newspeak

 

Joanna Cohen is the Bloomberg Professor of Disease Prevention and the Director of the Institute for Global Tobacco Control at Johns Hopkins University’s Bloomberg School of Public Health.  Together with other editors of the prohibitionist journal Tobacco Control, she published a screed aiming to change the words people use to talk about tobacco, and particularly reduced risk products. 

Dr. Cohen, in a public email, further claimed that common, accurate terms such as “e-cigarette and heated tobacco products” serve “tobacco industry interests… We should not be doing the tobacco industry’s work for them.”

Dr. Cohen knows something about wording and misperception.  Here are the results and conclusions of a 2022 study for which she served as senior author:

“About 61.2% of smokers believe nicotine causes cancer or don’t know… High perceived threat of tobacco may be overgeneralized to nicotine…The current study supports the need for corrective messaging to address the misperception that nicotine causes cancer. Identifying that nicotine misperceptions are associated with higher harm perceptions about tobacco smoking suggests that there may be unintended consequences of high perceived harm of tobacco smoking that need to be addressed. As nicotine misperceptions are significantly more prevalent among those already at higher risk of tobacco smoking caused diseases, care should be taken to ensure equity in message dissemination.” (Cohen text, Brad Rodu corrections for accuracy)

The point of the above corrections is to underscore that Tobacco Control editors should not be advocating changes in terminology when they are guilty themselves of conflating the tobacco plant with lighting it on fire and inhaling smoke.  This is a topic I have blogged about before (here and here).

Dr. Cohen ought to direct her efforts toward the worst example of improper terminology – “e-cigarette or vaping product use-associated lung injury (EVALI).”  First coined by the CDC, this misleading formulation has been adopted by tobacco harm reduction opponents in order to obfuscate differences between vaping marijuana and vaping nicotine.  Rather than correcting their error, prohibitionists have doubled down, as seen in a recent EVALI endorsement by the American Thoracic Society (ATS).

Clive Bates explains in the following 10 paragraphs the damage caused by adoption of the EVALI fallacy:

“Truly appalling to the point of being cynical and sinister...The most notably absent feature of the [American Thoracic Society] workshop is any real recantation of the massive wave of misinformation about EVALI generated by the anti-vaping tobacco control community from 2019 to the present day, despite the fact that nicotine vaping was not (and could not have been) implicated in the 2019-20 outbreak of lung injuries in the United States (see analysis here).   Instead, there is something far worse: an attempt to redefine EVALI so that the misinformation was right all along.  

“‘EVALI: This term will be used to refer to all e-cigarette–related lung injury. This term will be used as an umbrella, as the EVALI epidemic has brought attention to e-cigarette–related health effects and is used broadly to document lung injury/disease attributable to e-cigarettes. It should be noted that the CDC does not limit EVALI diagnosis to those exposed to particular active ingredients, and use of all e-cigarettes were considered under the diagnostic criteria.’

“One wonders if this was a premise or finding of the 2021 ATS workshop or whether it has been added to the write-up retrospectively as an ex-poste justification for the flawed framing of the issue at the workshop. As we've seen on Stanton Glantz's blog and with Laura Crotty Alexander's statements, this definition is a kind of escape from accountability for the misleading attribution of EVALI (the 2019 US lung injury outbreak) to nicotine vaping.  There is nothing on the (now archived) CDC website that suggests CDC intended EVALI to refer to anything but the US lung injury outbreak and the agents and mechanisms that caused it.  

“This formulation allows a single case of an adverse respiratory reaction to nicotine e-cigarettes anywhere in the world to be classed as ‘EVALI’, and for academics/activists to say, ‘nicotine vaping causes EVALI.’ The effect of that, however, is to load the negative perceptions associated with the US outbreak of lung injuries (a large outbreak of 2,800 hospitalisations and 68 deaths) into risk perceptions about nicotine vaping, which did not cause these. It is deeply unethical and misleading to do this. Scientists should be trying to clear up misunderstandings and confusions (many of which they have created or amplified), not adding to them through unwarranted conflations. 

“They could try to justify this on the basis that ‘we are scientists, and we can use whatever terminology we like, as long as we are clear about it.’ However, it would still be unethical because the predictable consequence (whether unintentional or deliberate) will be a conflation of radically different risks and, therefore, the promotion of misunderstanding. Just like saying, ‘all tobacco products are harmful,’ but worse. Scientists behaving ethically would actively take care not to do this and to dismantle the confusions that they had previously worked so hard to promulgate.  There is perfectly good language available to describe effects other than the EVALI caused by THC-VEA for the extremely rare (and usually contested) cases where nicotine vaping may be implicated in adverse pulmonary reactions, for example, in people with allergies or pre-existing conditions.

“The inclusion of this is designed to increase the confusion and inappropriate conflation: 

‘Although most affected individuals reported use of cannabinoid e-cigarettes, approximately 20% reported using only nicotine e-cigarettes [citation removed]. It is unknown whether these patients were unintentionally exposed to VEA through cross-contamination of e-liquids or sharing of e-cigarettes or whether additional ingredients, such as medium-chain triglycerides (MCT), can lead to EVALI  [citation removed].’

“We need to be absolutely clear here. This 20% of cases were not and cannot have been caused by nicotine vaping. That is just inconsistent with the epidemiological evidence (the outbreak was confined in time and place and ended without any changes made to nicotine vaping products. the causal agent VEA cannot be added to nicotine e-liquids and would serve no purpose if it could be).  The reason people deny using THC is that illicit drug use presents problems with law enforcement, parole officers, employers, colleagues, schools and parents. How obvious do things need to be before they are understood by tobacco control academics?  It is also possible that some people were sold fake THC vapes with no active ingredients, just the cutting agent. So the statement above is pure merchant-of-doubt. 

“Personally, I suspect at least some of the authors are doing this deliberately. Firstly to cover their tracks over the massive misinformation sprayed over the public in 2019-20, but more insidiously because they want these products to be seen as harmful to deter use of them.  Further, they need nicotine vaping to be harmful, or they lose the rationale for control (the purpose of tobacco control - it's in the name) and, therefore, their reason to exist.  

“There are two ways to look at this: a disgraceful cynical, defensive fear play or so naive as to be negligent. Sorry, no nice way to put it.”

George Orwell, in his seminal book “1984”, coined the term “newspeak”, defined today by Merriam-Webster as propagandistic language marked by euphemism, circumlocution, and the inversion of customary meanings. George, meet Dr. Cohen and her fellow-travelers.