Federal Surveys Demonstrate E-Cigarettes Have Been Successful Quit-Smoking Aids For a Decade

 

New research based on U.S. government survey data shows, “The most popular methods used to stop smoking were nicotine products (53.9%; 1.5 million adults), especially e-cigarettes in combination with other methods (40.8%; 1.2 million) and e-cigarettes alone (26.0%; 0.7 million)” [confidence intervals removed by me]. Additionally, “Prescription drug products (8.1%; 0.2 million) and non-nicotine, non-prescription drug methods (6.3%; 0.2 million) were less popular.”

Tobacco researchers Floe Foxon (Pinney Associates) and Ray Niaura (New York University) made those observations in their new report, “Use of nicotine products, prescription drug products, and other methods to stop smoking by US adults in the 2022 National Health Interview Survey,” appearing in the journal Internal and Emergency Medicine (abstract here).

Foxon and Niaura analyzed “U.S. adults who self-reported having stopped smoking cigarettes for 6 months or longer in the last year and the methods they used, or who did not stop smoking but tried in the last year.”  The survey that supplied the raw data is the standard instrument used by the Centers for Disease Control and Prevention to count 29 million adult current and 56 million former U.S. smokers each year. 

The researchers note that their results are similar to those in an earlier analysis of adult smokers in the FDA’s Population Assessment of Tobacco and Health (PATH) Survey.  I conducted that study along with Nantaporn Plurphanswat and noted in a blog post, “e-cigarettes were one of the most commonly used quit aids by American smokers in 2013-2014, and that they were the only aid more likely to make one a former smoker (i.e., a successful quitter) than quitting cold-turkey.”

Now we have definitive population-level evidence, provided by the federal government, that e-cigarettes have been the most popular and among the most successful quit-smoking aids for almost a decade.  It is long past time for government officials to acknowledge these facts.

 

Federal Officials Endorse Impossibly High Standard for E-Cigarettes

NPR host Diane Rehm on August 5 discussed “Smoking in America Today” with Dr. Tim McAfee, Director of Office of Smoking and Health at the Centers for Disease Control and Prevention; Mitch Zeller, Director of Center for Tobacco Products at the FDA; Dr. Thomas Glynn, Director of Cancer Science and Trends at the American Cancer Society; Michael Felberbaum, journalist covering tobacco for the Associated Press; and Craig Weiss, President and CEO of e-cigarette maker NJOY (program available here).

The federal officials and Dr. Glynn held essentially identical views on e-cigarettes, providing a strong signal that FDA regulation is likely to be burdensome or even punitive.

Early in the program, Rehm asked about relative risk: “Is there any evidence whatsoever from the public health community regarding electronic cigarettes and whether they are in fact safer than tobacco products?”

The CDC’s McAfee gave an extended answer, starting with: “Well, there’s several different ways that we’re thinking about this, we think it’s an incredibly important question.”  Important, but unanswered, as Dr. McAfee shifted to the familiar cigarette mantra: “… we need to focus on the harm that’s caused by cigarette smoking, and ways to get smokers to quit and to prevent nonsmokers from starting.”  As for e-cigarettes, “.. the challenge is that we don’t yet know how e-cigarettes are going to completely fit into that.  The availability of a cigarette alternative that does deliver nicotine without also delivering harmful by-products of combustion… could this play a beneficial role in reducing tobacco-related death and disease?  This would be especially true if a large number of smokers successfully switched completely to e-cigarettes, either permanently or as a transition phase to nicotine abstinence.”

Dr. McAfee expressed concern that alternative tobacco products might foster dual use, prevent smoking cessation and serve as a gateway to smoking for new users and former smokers. “… The other alternative is that the availability of e-cigarettes could result in harm by increasing the initiation of cigarette use among youth and young adults or by delaying quitting among smokers who, rather than switching, engage in dual use, which currently looks like that’s the majority situation.  People are using them in situations where it’s hard to smoke cigarettes.  And we see ex-smokers think ‘Hey, maybe I can go back to e-cigarettes,’ and that re-kindles their nicotine addiction.  And they actually start smoking cigarettes themselves.”    

Regulator Zeller returned to these themes later in the program.  He alluded to, but never quite acknowledged, the vast difference in risk between traditional and electronic cigarettes: “The thing that’s most interesting about e-cigarette is that we look at individual-level risk, what is the risk, say, to a current smoker who would be otherwise unable or unwilling to quit, if that person completely substituted all of their conventional cigarettes for an e-cigarette, that’s individual-level risk.”

However, he made clear that FDA regulation isn’t about individual smokers: “… Policy is going to be made here at the population level, and there’s population-level harm.  Who is actually using these products?  And how are they being used?  Tim [McAfee] talked about this earlier.  Are current smokers going to be less inclined to quit, and more likely to engage in what we call dual use of both the combustible version and the electronic version?  Are kids going to start using e-cigarettes?  These are the kinds of questions that we have that ultimately comes down to behavior, and right now we have far more questions than answers.”

I discussed in 2010 scientific evidence documenting that a population-level evidentiary standard was “unattainable” (here).  I also said that the standard was unprecedented.  The FDA has regulatory authority over other consumer items – food, cosmetics, drugs, medical devices and vaccines.  FDA regulations assure that drugs, medical devices and vaccines provide the intended medical benefit.  Far more importantly, they assure that all of these products are safe to consume.  The FDA does not traditionally compromise individual safety with a population standard.

Today, the FDA also regulates tobacco products.  One of these (the cigarette) is highly toxic, killing over 400,000 Americans every year.  When the FDA asserts regulatory authority over e-cigarettes, it would be criminal to use an arbitrary population standard to deny American smokers access to these products. 

Federal Warnings Undermine Smokeless Tobacco Harm Reduction Messages

I recently discussed research showing that warnings on smokeless tobacco (ST or SLT) products discourage smokers from switching, while messages describing risk differentials between ST products and cigarettes encourage switching (here).

A new study provides further evidence that federally-mandated warnings in ST advertisements undermine the likelihood of comparative risk information motivating switching.  The study was published in the Journal of Consumer Affairs (abstract here) by Michael L. Capella, Charles R. Taylor and Jeremy Kees, professors in the School of Business at Villanova University.

Capella and colleagues modified Camel Snus advertisements to display a current federal health warning (“This product can cause mouth cancer”) with or without a harm reduction statement (HRS), such as “Using This Product is 90% Safer Than Cigarettes” or “Using This Product is 90% Less Hazardous Than Cigarettes.”  They measured the effect these messages had on perceptions of ST risks and the intention to use ST among smokers and non-smokers. 

The authors report, “In the presence of a conflicting message from the government, it is apparent that consumers are not easily swayed by the presence of an HRS…the presence of harm reduction information in an ad did not reduce smokers’ perceptions of the relative harm of SLT (vs. cigarettes) when a warning was present.  The most likely explanation for this is that the simultaneous presence of a government-mandated warning on the dangers of SLT offset the impact of the HRS…When smokers were presented with an HRS in an ad in the absence of any warning information, they reported higher beliefs that SLT is safer than cigarettes.”

This research demonstrates that federally-mandated warnings on ST products would essentially negate harm reduction messages.  The data also suggests that these warnings reinforce smokers’ mistaken beliefs that ST is as dangerous as cigarettes, effectively discouraging smokers from switching.  This is consistent with the federal government’s abstinence-only public health messaging, which basically abandons nicotine-addicted inveterate smokers.

For non-smokers, the results were promising: “While perceptions of SLT risk were generally lowered and attitudes toward SLT ads were significantly more positive as a result of exposure to harm reduction messages among nonsmokers, there was not a significant difference in intention to use SLT. Moreover, nonsmokers showed very low raw levels of intention to use SLT in any condition.  Thus, the argument that the inclusion of an HRS could help serve as a ‘gateway’ for nonsmokers is not supported by this study.”

Why did Capella and colleagues include non-smokers in their research?  They explain, “Under the law, promoting new SLT products associated with lower health risks as ‘harm reducing’ can be approved only if makers can demonstrate health benefits to society as a whole. The SLT products would need to be sure to not induce nonsmokers or would-be quitters to try SLT rather than abstaining.” (emphasis added).  In other words, a manufacturer must prove that an HRS will not induce a non-smoker, or a smoker who would otherwise quit smoking, to switch to ST. 

Capella and colleagues pefectly frame the question that the FDA must consider: “Specifically, switching to SLT reduces the risk of fatal heart and lung diseases because the tobacco is not incinerated. Hence, the primary question is no longer about whether SLT is considered by the scientific community to be of significantly less risk than cigarette smoking, but whether the population as a whole could benefit from information which communicates the relative risk of using SLT vs. smoking cigarettes.”

Scientific research would require the FDA to answer “Yes.”