The American Medical Association Only Promotes and Protects Doctors, Not Public Health

 

Dr. Gerald E. Harmon, president of the American Medical Association (AMA), authored a commentary November 19 claiming that the “FDA made the wrong choice in allowing Vuse marketing.”

Dr. Harmon said that the FDA’s decision “is wrong on many levels,” but I will show that his commentary better fits that description.

Harmon says that the FDA’s “gravest error is to frame its action as ‘appropriate for the protection of the public health.’”  Gravest error?  Harmon tells his readers in the next paragraph that the FDA had no choice: Congress dictated that precise standard in legislation giving FDA regulatory authority over tobacco in 2009 (here).

Next, Harmon claims that “the role that e-cigarettes may play in smoking cessation strategies is unclear.”  That may be true – for someone who has never looked at federal surveys (here, here and here), never read the scientific literature (here, here and here) and/or never met a former smoker (also called an “anecdote”) (here).    

Incredibly, Harmon cites a recent study from the University of California San Diego involving “smokers who turned to e-cigarettes as a cessation device.”  No.  They.  Didn’t.  As I recently explained in a critique on that study (here and here). 

Then he gets to the core of his commentary: “The AMA has specifically recognized the use of e-cigarettes and vaping as an urgent public health epidemic and has called for a total ban on all e-cigarette and vaping products that do not meet FDA approval standards as cessation tools.” (emphasis added)  In other words, the AMA wants prohibition if the FDA doesn’t regulate e-cigarettes as harshly as it regulates cancer chemotherapy.

Harmon comes up with a claim that will make ever smokers laugh out loud: “Data has shown that using FDA-approved cessation medicine can double a persons [sic] chance of quitting smoking successfully.” 

Double what?  Every year only 5% of smokers quit, so doubling that number makes 10%.  Does Harmon care about the other 90% of smokers who couldn’t quit the AMA way?  I don’t think so.

A lot of Harmon’s rant about Vuse was devoted to “fruit- and candy-flavored” products.  This is strange.  The only Vuse products the FDA authorized are tobacco-flavored.

Why does the AMA, one of the most influential organizations in American medicine, take such a prohibitionist position when 480,000 American smokers are dying prematurely every year?  Well, its influence derives not from its commitment to public health, but from its power as a trade organization.  And trade organizations’ first and foremost goals are to advance the interests of its members.  According to blogger Matthew Yglesias, the AMA actively makes the number of doctors in the U.S. scarce, by blocking increased scope of practice for nurses, making it hard for foreign-trained doctors to practice in the United States, and historically pushing to train too few doctors here at home.  This results in big salaries for doctors and dismal, expensive access to medical care for Americans compared to many other developed countries (see chart below). 

The AMA protects and promotes doctors, it doesn’t care about American smokers.

 

 

Smokers: Step Away From the Fire With These Safer Cigarette Substitutes

Most cigarette smokers “say” they want to quit, but that is terribly misleading.  Most smokers answer yes to the quitting question because they know it’s the desired response.  In reality, the vast majority of smokers don’t quit in any given year.  All of them would welcome a healthier lifestyle, but they are unable or unwilling to abandon the immediate benefits of tobacco and nicotine, especially smoking.

If you smoke, here’s your guide to vastly safer substitutes that provide nicotine and tobacco satisfaction.

E-Cigarettes and Vape Products

The best harm reduction options for smokers unable or unwilling to give up nicotine and tobacco are e-cigarettes and vape products.  There are thousands of choices, reflecting the fact that they are the most popular – and most successful – quit-smoking aids. 

Vape Shops

Smokers can take the first step away from the fire by visiting local vape shops, which are often staffed by former smokers who are knowledgeable about your best options and dedicated to your success.  These shops sell popular products and also cater to vapers who want advanced hardware and special e-liquid flavors.  To locate nearby shops, check out Vaping 360’s online locator.  The Vapetrotter Directory is another valuable source.

For lots of factual information about e-cigarettes and vape products, visit the website operated by Consumer Advocates for Smoke Free Alternatives Association.  And for moral support, visit CASAA’s testimonials webpage containing thousands of success stories.

 

JUUL

JUUL has taken the vaping market by storm; it’s making cigarette manufacturers nervous, and for good reason.  JUUL pods contain a satisfying nicotine salt that won’t have you climbing the walls or kicking the dog because you don’t have the nicotine hit you need.  Additionally, the pods are inconspicuous, and easy to use and recharge. 

JUUL products are widely available, although the company is only selling tobacco and menthol flavors in convenience and other brick and mortar stores. Its popular flavors -- mango, cucumber, fruit, and crème – are available online.

Vuse

Vuse is another family of vaping products that are available in several hardware choices and a wide variety of flavors, including menthol, mint, mixed berry, melon, fruit-and-cream, chai, nectar, tropical fruit and classic tobacco. 

Vuse is available online and in stores nationwide.

Heat-Not-Burn Products

IQOS

The FDA recently approved the sale of IQOS heat-not-burn products in the U.S.  They are already available in over 30 other countries, and they have produced an unprecedented decline in cigarette consumption in Japan.  An FDA advisory committee in 2018 concluded that the products significantly reduce smokers’ exposure to toxic chemicals found in cigarette smoke.  I believe IQOS products have the potential to compete with vapor products, as they deliver the tobacco flavor and satisfaction many smokers find lacking in e-cigarettes. 

The first U.S. test market for IQOS will be Atlanta, where it will be available at a dedicated Lenox Square store. 

Nicotine Pouches

            ZYN

ZYN is a discrete new pouch product from Sweden that contains no tobacco, just nicotine and flavor – spearmint, wintergreen, cool mint, coffee, cinnamon or peppermint.  Also note that there are two strengths, ZYN 3 and ZYN 6 (milligrams). 

Originally launched in Western states, ZYN is now available nationwide anywhere cigarettes are sold.  It’s also available from Northerner.com. 

On!

On! is another nicotine pouch made in Sweden, available in mint, wintergreen, cinnamon, berry, citrus and coffee flavors and in three strengths, 2, 4 and 8 milligrams.

These pouches have been in limited distribution here in the U.S., and they are also available at Northerner.com.  However, Altria has just bought a large share of the company, so look for these pouches soon in your local convenience store.

Smokeless Tobacco

Camel Snus

Camel Snus packets come in several flavors: mint, frost (spearmint) and winterchill (wintergreen).  If you prefer more tobacco flavor, try Robust or Mellow.  There are also two sizes, a slim version containing 0.6 gram of tobacco, and a larger pouch with 1.0 gram.  I suggest that smokers start with the small size of their favorite flavor.

Camel snus is available nationwide anywhere cigarettes are sold, and online at Northerner.com. 

Skoal Snus

Skoal Snus packets come in mint and smooth mint. 

You can find them nationwide in the smokeless tobacco section of convenience stores, and they are available at Northerner.com.

Skoal Bandits

In 1995, when conducting the first-ever smoking cessation clinical trial using smokeless tobacco (abstract here), my research group recommended that smokers switch to Skoal Bandits, the only widely available pouched smokeless tobacco product at that time.  They are still available nationwide in wintergreen and mint flavors.

Oliver Twist

Oliver Twist is the planet’s most discrete smokeless tobacco product.  It consists of mini-rolls of tobacco (smaller than a pencil eraser), which are made in Denmark by rolling whole tobacco leaves into a rope, which is then cut into small pieces.  Flavors include original (tobacco), wintergreen, sunberry and tropical.

Oliver Twist can be difficult to find.  Look for stores that sell premium cigars and pipe tobacco, or order it at Northerner.com.      

Helpful Tips:

First and foremost, place smokeless products inside your UPPER LIP.  That is the key to minimize tobacco juice and the need to spit.  At first it might feel like a cannonball, but it won't be noticeable.

There are many options, so don’t be discouraged if one product doesn’t fit your lifestyle or taste.

Whatever product you use, get your nicotine buzz, but don’t overdo it. When you inhale cigarette smoke, you get an immediate nicotine kick, and during your smoking career you learned to optimize your buzz. The effect from e-cigarettes or smokeless tobacco may be different, but you’ll learn how to get a similar effect.

Stick to the switch. Although some smokers make the transition quickly, smoke-free tobacco products don’t automatically “cure” your desire for another cigarette. These products will make it easier to quit and they’ll make those cravings less intense, but they don’t entirely replace the smoking ritual. If you’ve smoked for years, breaking the habit can still be a challenge.

If your ultimate goal is complete nicotine and tobacco abstinence, stepping away from the fire is a critical first step.  Remember that it’s the smoke that kills, so becoming and staying smoke-free, not necessarily nicotine- or tobacco-free, is your first priority.  It’s the key to a longer and healthier life.

The E-Cigarette Revolution

Richard Craver, a writer for the Winston-Salem Journal, recently described the growing popularity of e-cigarettes (here).  Bonnie Herzog, a Wells Fargo security analyst who has followed the tobacco industry for many years, described e-cigarettes as “here to stay,” suggesting that sales would reach $1 billion within a few years.  In an August research note to investors (here), Herzog predicted that e-cigarette sales could surpass combustible cigarettes within ten years.

These predictions are based on impressive increases in e-cigarette sales since 2008.  The chart illustrates UBS data presented by NJOY CEO Craig Weiss during a conference call with Goldman Sachs on December 14.  U.S. e-cigarette sales totaled $20 million in 2008; they have doubled each subsequent year, to $500 million in 2012.  As Weiss noted, the explosive growth occurred even as the category was inundated with low-quality products that provided a suboptimal experience to smokers.  That problem is being resolved by substantial investment in quality improvement.  NJOY, which has a 40% share of convenience store e-cigarette sales, introduced King (here), describing it as “the first electronic cigarette with the look, feel and flavor of the real thing.”

 

Product improvements can be expected because cigarette manufacturers are also investing in the category.  In April, Lorillard purchased Blu (here), and Craver reports that the company has invested $40 million in a marketing campaign.  In July, Craver reported that RJ Reynolds launched e-cigarette Vuse in limited test markets in Virginia and North Carolina (here). 

British American Tobacco announced on December 19 that it had purchased CN Creative (here).  This company makes the Intellicig e-cigarette brand (here) and Ecopure nicotine solution (here), which it says is produced with pharmaceutical- and food-grade products and undergoes stringent testing.  BAT also owns Nicoventures (here), a company devoted to providing “…a new choice to smokers looking for a safer alternative to cigarettes.  Nicoventures will focus exclusively on the development and commercialization of innovative regulatory approved nicotine products that provide a consumer-acceptable alternative to cigarettes without the serious risk to health of smoking.  We want to explore the development of innovative nicotine products that, subject to regulatory approval, will provide smokers with an alternative to cigarettes and a product they actually want to use.”

Wells Fargo’s Herzog also notes that the steep decline in cigarette consumption will affect state payments from the 1998 Master Settlement Agreement.  While cigarette manufacturers promised to pay the 46 MSA states about $206 billion over more than 20 years, their payments will be reduced if cigarette sales decline.  This could lead state governments to impose excise taxes on e-cigarettes to cover those losses. 

So far, e-cigarettes have avoided excise taxes because they are not classified as tobacco products.  However, in 2011, federal courts ruled that e-cigarettes are tobacco products (here), so the “excise tax honeymoon” that e-cigarettes and their users have enjoyed won’t last forever.    

The tobacco harm reduction revolution is unstoppable, and e-cigarettes are poised to play a major role.  State legislators can facilitate smokers’ switch to healthier e-cigarettes by keeping excise taxes low, or nonexistent.