As of March 1, the National Council of State Legislatures reports that only 29 states require sex education, and only 22 of those states require that sexuality education curriculums present “medically, factually or technically accurate” content. 

It is concerning enough that 21 states have no requirement for sexuality education or HIV prevention education. But even in those that have such requirements, “medically, factually or technically accurate” content is not always well-defined and, in some states, allows for a range of interpretations.

Often, these programs do not discuss prevention of HIV and avoid discussion of contraceptives and condoms.

Amid different definitions of “accurate” and varied state and local laws, sexuality education programs in the US exist on a spectrum that ranges between two paradigms: abstinence-only until marriage and comprehensive sexuality education. 

In their purest form, abstinence-only until marriage programs are exactly what the name implies. Often, these programs also do not discuss prevention of HIV or other sexually transmitted infections (STIs) and avoid discussion of contraceptives and condoms. Another hallmark is that abstinence is often presented as the only morally acceptable option. 

These programs are also sometimes called sexual risk avoidance education or abstinence-centered education, versions that often include some information about STIs and contraception while still emphasizing abstinence until marriage. Similarly toward the abstinence end of the spectrum is what some refer to as “abstinence-plus” education, which emphasizes abstinence but includes some information about contraception.

States whose curriculums could be considered abstinence-centered include, for example, North Carolina, Illinois and Texas. All three states cover contraception and condom usage to prevent HIV; however, their curriculums must also stress abstinence, the importance of abstinence until marriage and the negative outcomes of teen sex.

The other paradigm, comprehensive sexuality education, features information about pregnancy prevention (including abstinence), unintended pregnancy, contraceptive methods, STI prevention, reproductive development, sexual/gender identity and expression, healthy sexual and nonsexual relationships, sexual and dating violence prevention, consent and communication. 

These programs outperform abstinence-only programs on measures of behavior modification and of biological outcomes. 

Needless to say, it is comprehensive sexuality education that represents a harm reduction approach to sexual health and behavior. Much like syringe exchange programs acknowledge that some people will choose to inject substances regardless of education and prevention efforts, comprehensive sexuality education acknowledges that some young people will engage in sexual activity regardless of adults’ wishes, and equips them with ways to reduce their risks if they do.

These programs outperform abstinence-only programs on measures of behavior modification—like delay of first sex, use of condoms, number of partners—and of biological outcomes, such as STIs or unwanted pregnancies. 

But pushback against comprehensive sexuality education tends to center more on morality arguments than facts. Opponents often insist that comprehensive sexuality education encourages sexual risk-taking. Of course, we also know from other areas of harm reduction practice that providing information and tools to prevent harm does not result in more risk-taking behavior. 

Surveys consistently find that comprehensive sexuality education is broadly acceptable to American parents. A survey of parents in North Carolina, where the current standard was abstinence-only education, showed that 89 percent supported comprehensive sexuality education in public schools. Similarly, when California parents were surveyed, 96 percent opposed abstinence-only education. These results were consistent across ethnic and religious groups, indicating that different cultural standards do not prevent consensus about the need for young people to receive information about preventing unwanted outcomes from sexual activity. 

Of course, public sentiment and public policy do not always align. Still, the limited adoption of comprehensive sexuality education is particularly odd from a policy standpoint, since major medical organizations have advanced and support such programs. The American College of Obstetricians and Gynecologists, American Public Health Association, the American Medical Association and the American Academy of Pediatrics encourage school systems to adopt these curriculums—a consensus that one would expect to be persuasive.

Although comprehensive sexuality education is harm reduction, other strategies from the harm reduction playbook could further improve upon this already effective program. For one, sexual education should try to meet young people where they are at, by reaching them not only through traditional classroom instruction. 

Making condoms available for free, at after-school school functions or in completely different settings, could be one example. This does not have to be as ostentatious as setting out a bowl of condoms at prom, but taking the extra step of making barrier methods of contraception readily available destigmatizes their use and is a form of education in itself.

Another way that comprehensive sexuality education programs can expand their reach is to include parents. State laws vary regarding parental consent laws for receiving prescription contraception and the morning after pill and participating in school-based sexuality education programs, but one vital harm reduction tool almost universally requires parental consent: human papilloma virus (HPV) vaccination. The CDC recommends that all young people receive this two-vaccine series between the ages of 11 and 12, because the vaccine is more effective if received prior to becoming sexually active. 

In 2019, New Jersey experienced a measles outbreak, which inspired legislation that would allow young people to receive vaccinations, including for HPV, without parental consent. Unfortunately, the legislation failed, just as similar legislation in New York has failed multiple times since 2009. When Canadian parents were asked why they opposed HPV vaccination, 20 percent feared that it would discourage their children from using condoms. 

Providing safer ways to engage in risky behaviors does not encourage greater risk-taking⁠.

Again, as harm reductionists know, providing safer ways to engage in risky behaviors does not encourage greater risk-taking⁠—and this was confirmed for HPV vaccination by a study that found no difference between new STI infections in young women vaccinated for HPV compared to their unvaccinated peers. Given the prevalence of misinformation about sexual risk-taking among parents, and the power they have over their children’s sexual health outcomes, it makes sense to include parents in parts of the sexuality education curriculum.

Parents, schools and lawmakers also must realize that a one-size-fits-all approach to sexuality education may not be the most effective way to help young people have healthier sexual and non-sexual relationships. Advocates for Youth recommend a three-tiered approach to sexual education that begins with comprehensive sexuality education as the foundation for all students, with provision of sexual health services and targeted interventions for students at higher risk of negative sexual health outcomes. 

Just as not every person who uses drugs needs methadone, not every young person needs a targeted after-school program about sexual health; however, both forms of harm reduction should be available to those who do need and want them. 

Comprehensive sexuality education in no way merits the controversy that persistently prevents progress in improving young people’s sexual health outcomes. Existing evidence specific to sexuality education, as from other areas of harm reduction, shows that information and access are tools of protection—not nefarious instruments of immorality. 

For many negative sexual health outcomes, the consequences are lifelong. If a young person misses an opportunity to decrease (or eliminate) the risk of contracting an STI or preventing an unplanned pregnancy because they do not have the information they need to protect themselves and make their own healthiest choices, we have failed them. 

Comprehensive sexuality education early and often is harm reduction, giving young people the best chance of a healthy future.

Photo of a box of condoms by BrokenSphere via Wikimedia Commons/Creative Commons 3.0

The author’s employer, the R Street Institute, has provided restricted grants to The Influence Foundation, which operates Filter, to support the production of four reports on harm reduction topics.

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Unfortunately, not only does this campaign deliberately avoid acknowledging the benefits of new smoking quit tools, it is embarrassingly out of touch with the people whom traditional quit methods have failed.

As is clear from both research and anecdotal experience, smoking is a tough habit to break. The smoking cessation methods that the Food and Drug Administration deems “safe and effective” include nicotine replacement therapy products like gums, patches and lozenges; prescription medications like Chantix; and counseling programs. Yet academic literature shows that only 5 to 20 percent of smokers who use these methods succeed at quitting long-term. Safe, perhaps. Effective? Not so much.

Fortunately, in recent years, smokers gained a more effective option. E-cigarettes, which researchers have determined are at least 95 percent less harmful than their combustible cousins, are helping smokers quit or substantially cut back on combustible cigarettes at record rates. In fact, e-cigarettes performed nearly twice as well as nicotine replacement therapy products during a randomized trial comparing the two options as smoking cessation treatments. E-cigarettes may not be completely harmless, but combustible cigarettes are deadly, and making the switch is vastly better for smokers’ health.

Indeed, the secret that tobacco control organizations don’t want people to know is that when compared to other addictive substances, nicotine itself is a rather benign chemical. Yet much like other substances, the means of consumption can make nicotine more or less harmful. For tobacco, the health hazard is largely attributable to the combustion process of many tobacco products. E-cigarettes eliminate the combustion process, thereby rendering them much less harmful.

The campaign shows that tobacco control has not evolved beyond the abstinence-only tactics that other areas of public health discarded long ago.

Yet the ALA’s anti-smoker rhetoric inaccurately implies that the harm caused by combustion to nicotine by ignoring that tobacco products exist on a continuum of risk. They state that “Switching to e-cigarettes does not mean quitting. Quitting means ending your addiction to nicotine….” This is especially odd considering that the prevailing opinion of health organizations is that long-term use of nicotine replacement therapy—which supplies users with nicotine to ease withdrawal symptoms—is a safe means of quitting smoking.

In fact, nicotine replacement therapy works in a strikingly similar way to e-cigarettes: The person is still consuming nicotine—whether orally, in the cases of gum and lozenges; through the skin, in the case of patches; or by inhalation, in the case of e-cigarettes— only there is no combustion, no smoke and no tar.

So while the ALA may find it alarming that “[E-cigarettes] were designed to appeal to people who wanted to use something beside[s] a cigarette,” this is actually what makes e-cigarettes successful quit tools.

Remember, it’s hard to quit smoking, and even harder to quit nicotine. E-cigarettes appeal to smokers precisely because they mimic combustible cigarettes in terms of inhalation, hand-to-mouth action, social aspects and pleasure. All of this helps explain why smokers who switch to vaping have a higher chance of successfully kicking their smoking habit than those who use other quit methods.

The ALA notes, “No tobacco product is safe, and that includes e-cigarettes,” meaning that “Quit, Don’t Switch” may eliminate all harm related to nicotine consumption, if successful. But the campaign also shows that tobacco control has not evolved beyond the abstinence-only tactics that other areas of public health discarded long ago.

A harm reduction approach, on the other hand, acknowledges that abstinence-only approaches don’t work for everyone. For people unable to abstain, abstinence-only policies do nothing to reduce risk of harm and may even increase the danger of engaging in high-risk activities by eliminating access to safer options or criminalizing behaviors.

In the tobacco realm, harm reduction advocates embrace all smoking quit methods—including total abstinence, traditional nicotine replacement therapies and e-cigarettes—as having the potential to improve individual and public health. In short, they don’t let achieving the ideal become the enemy of improvement.

By refusing to accept the notion that harm reduction can be part of tobacco control, the ALA and its allies are admitting they have little interest in actually helping smokers improve their health. And by casting harm reduction as a devious marketing tactic rather than a proven prevention strategy, tobacco control organizations are stoking the flames of moral panic and steering the conversation about e-cigarettes toward prohibition—to the detriment of smokers and public health. 

“Quit, Don’t Switch” is the latest example of insensitivity by ALA and other tobacco control groups. Since combustible tobacco products are the largest cause of preventable death and disease worldwide, it is shameful to push aside any innovation that allows smokers to consume nicotine in a less harmful way. For the sake of the world’s 1.1 billion smokers, one can only hope that every health organization focuses on the known harm combustible cigarettes cause and the need to extinguish combustible product use through all available means.

* The R Street Institute, the author’s employer, previously provided a restricted grant to The Influence Foundation, which operates Filter, to support production of two reports on harm reduction topics.

Photo by Lindsay Fox via Wikimedia/Creative Commons.

The post American Lung Association’s “Quit, Don’t Switch” Campaign a Big Mistake appeared first on Filter.

To maintain the trust of an anxious public, the public health system must remain objective. Unfortunately, the messaging regarding the current outbreak of lung injuries associated with the use of vapor products provides a discouraging case study in how public health can be conscripted as a political tool.

The trouble began at the outset. On August 17, the Centers for Disease Control issued its initial statement on the outbreak, announcing, “While some cases […] appear to be linked to e-cigarette product use, more information is needed to determine what is causing the illnesses.” By mentioning a link to e-cigarettes before stating that the cause of the illnesses was unknown, the CDC’s statement primed the public and the media to associate the outbreak with nicotine vapes. This then became the context in which all future messages were interpreted, even after the evidence implicated only illicit cannabis products. 

The CDC’s biggest failure in this outbreak to date has been that, beginning with its first statement, it referred to “e-cigarettes” generally.

The CDC did not make it adequately clear that its use of the term “e-cigarettes” encompasses not only legal vaping products containing only nicotine, but illegal ones containing cannabis derivatives. With increases in youth vaping as a backdrop, the statement sparked a firestorm of inaccurate messaging that continues to this day. 

As the investigation progressed and the number of cases increased, the CDC released few additional details other than case counts and deaths. Then on September 6, after the media reported that researchers had found a suspicious chemical agent—Vitamin E acetate—in cannabis product samples, the CDC announced that “no one substance, including Vitamin E acetate, has been identified in all of the samples tested,” continuing the trend of downplaying the outbreak’s connection to unregulated cannabis products. 

It was not until September 27 that the CDC announced that “THC products may play a role in outbreak of lung injury.” Nevertheless, its preventative recommendations maintained that nicotine vapor products could also be implicated. 

Meanwhile, toxicology tests began identifying potentially harmful chemical compounds in cannabis vapor products. The proportion of afflicted patients reporting use of cannabis surpassed 75 percent, while those who used only nicotine hovered around 10 percent. By this time, it should have become clear to the CDC that legal nicotine vapor products were not at the root of this illness. And indeed, as of October 28, the CDC has concluded, “The latest national and state findings suggest products containing THC, particularly those obtained off the street or from other informal sources (e.g. friends, family members, illicit dealers), are linked to most of the cases and play a major role in the outbreak.” 

Yet the agency’s recommendation continues to hold that “the only way to assure that you are not at risk […] is to consider refraining from use of all e-cigarette and vaping products.” The CDC’s unwavering message that “no one compound or ingredient has emerged as the cause of these illnesses to date” is true, but they seem to be using it as an excuse to stall for as long as possible before exonerating nicotine products.

The CDC’s biggest failure in this outbreak to date has been that, beginning with its first statement, it referred to “e-cigarettes” generally. Its continued reliance on the term represents a missed opportunity to distinguish the elevated risk—or lack thereof—between illegal, unregulated products containing cannabis derivatives and legal, regulated products containing nicotine. What’s more, its continued reluctance to state definitively that regulated, legal e-cigarettes are not the cause of the illnesses only compounds the communication failures that began with that initial statement.

The truth is that real-world outbreaks are messy. Self-reported data, dose-response relationships, inconsistent data collection methods, and other factors obscure the connections between cases and exposures. Yet this does not mean that public health agencies should withhold information or obscure messages until every potential variable is accounted for.

Consider the Salmonella outbreak that the CDC is currently investigating. The agency has definitively linked this outbreak to ground beef, based on the fact that 75 percent of those diagnosed reported eating ground beef (as opposed to 40 percent among the general public). Despite a quarter of the afflicted patients reporting that they did not eat ground beef, the CDC did not delay announcing the culpable product. And unlike its messaging about vaping products, in this case, the CDC “is not advising that consumers stop eating thoroughly cooked ground beef, or that retailers stop selling ground beef.”

The CDC’s failure … makes it difficult to believe its actions are not politically motivated.

In the case of novel disease outbreaks like these lung injuries, even if the source is identified, it may take many months or years to sort out the specifics of the disease process and causes. This was evident in the investigation of the first cases of HIV, Legionnaires’ disease and Ebola virus disease, and will likely be the reality for these types of lung injuries. In fact, between 2002 and 2011, the CDC identified both the source and the pathogen in only 38 percent of foodborne outbreaks reported. Nevertheless, it is possible for the CDC to help prevent new cases of the disease in the interim by providing timely and actionable safety recommendations to the public.

The CDC’s failure to differentiate between e-cigarettes that deliver nicotine and those that deliver cannabis compounds, coupled with the insistence that legal nicotine products are involved, despite the lack of compelling publicly available evidence, makes it difficult to believe its actions are not politically motivated.

As lawmakers continue to propose and adopt increasing numbers of bans on vaping products, the fact that neither the CDC nor the Food and Drug Administration has mentioned that the evidence from this outbreak does not support bans of registered, legal nicotine vapor products becomes increasingly disappointing.

Given the CDC’s disapproval of any non-pharmaceutical product that contains nicotine, it may be unrealistic to expect it to defend e-cigarettes. However, for the sake of the current adult smokers and former smokers who benefit from the availability of e-cigarettes, the agency should not encourage the conscription of an outbreak for political purposes—especially when the facts do not support the policies so many are pushing in response to the messaging.

By allowing baseless fears to circulate, the CDC is using the outbreak as a political chess piece in a game that will sacrifice the health of millions.

CDC logo via Wikimedia Commons. 

The Influence Foundation, which operates Filter, has received a restricted grant from the author’s employer, the R Street Institute, to support production of two reports about harm reduction subjects.

The post Vapes and Lung Disease: The CDC’s Lesson in How Not to Handle an Illness Outbreak appeared first on Filter.

Electronic nicotine delivery devices and liquids, which provide a less harmful way for smokers to consume nicotine, have been in regulatory limbo since 2016, when they came under Food and Drug Administration authority. At that time, the FDA required manufacturers of all nicotine products introduced to the market or modified after 2007 to submit applications to evaluate their suitability for sale. Failure to do so would put them at risk of removal from the market.

Products introduced or modified between 2007 and 2016 were provided a grace period that was extended to August 2022. Enacting this rule involved establishing an entirely new regulatory pathway that was supposed to be efficient and transparent (it has been anything but).

Then on July 12, as Filter recently reported, a district judge mandated that all manufacturers submit their approval applications to the FDA by May 2020—more than two years earlier than the original deadline—or risk having their products pulled from the market. This decision dooms the process to failure—and it puts both smokers and former smokers at risk.

Completing the application process on time may not seem like an unrealistic challenge to many, especially since all manufactures will now have to comply with the same deadline. But the undertaking to compile all the information required for these applications involves immense costs, both financially and in terms of human resources. Current FDA estimates run at $3 million and up to 5,000 hours per application, with each individual product (i.e. flavor, nicotine content, device, etc.) requiring its own application. For example, a manufacturer with one device and two flavors of e-liquid, each with two different nicotine concentrations would need to submit five separate applications for those products.

It is very likely that most small businesses’ products will not receive FDA approval and will therefore become inaccessible to consumers.

The most prolific vaping brands, many of which are affiliated with large tobacco companies, have multimillion-dollar budgets and teams of scientists and attorneys to help them scramble to meet the new deadline. Smaller manufacturers and vape shops that mix their own e-liquids do not have these resources and are at a significant disadvantage.

The FDA has already received 373 applications for products affected by this rule change. Of those, all but four have been deemed “non-compliant,” requiring the companies to resubmit. What’s more, the FDA disclosed that none of the remaining four applications are for electronic nicotine delivery products, but did not report further specifics. With that record, it is very likely that most small businesses’ products will not receive approval and will therefore become inaccessible to consumers, even if these businesses dump all their resources into preparing an application.

Most troublingly, Philip Morris International’s IQOS, a heat-not-burn product, is the only electronic nicotine delivery system that has successfully completed the process. Although PMI* has not disclosed the cost of preparing its applications (why would it?), it is safe to assume the company spent more than the annual revenue for an average local vape shop.

Indeed, from the small number of premarket authorization successes, it seems likely that the only companies able to produce adequate data will be those affiliated with Big Tobacco—and even that is uncertain. This puts the estimated 10 million American adults who use electronic nicotine delivery systems in a bind that could leave them few options other than returning to much more harmful combustible cigarettes—a perspective that the FDA’s tobacco products director shares.

We are at a critical point in the tobacco control effort in the United States. We finally have less harmful products available to smokers. These innovations have the potential to replace combustible cigarettes and improve public health. Putting them at risk of failure while leaving combustible cigarettes prominently placed on shelves is the real hazard to public health.

Photo via Wikimedia Commons

*Disclosures: The Influence Foundation, the nonprofit organization that operates Filter, has received unrestricted grants from PMI. The Influence Foundation has also received a restricted grant from The R Street Institute to support production of two articles, about harm reduction and women and harm reduction and youth. The editorial team of Filter retains full authority over editorial decisions, per our Editorial Independence Policy.

The post Federal Court Ruling Threatens Smaller Vape Companies’ Survival appeared first on Filter.

Consider a brief personal anecdote. Recently, a friend mentioned that she has a co-worker with health problems. This co-worker is also a smoker of more than 30 years. The co-worker credits switching to e-cigarettes with eliminating his chronic cough and improving his stamina.

The friend’s response: “That’s not exactly the poster child vaping needs.” She went on to say it would be more cost-effective for society if the co-worker kept smoking and expedited his death.

This exchange demonstrates how anti-smoker stigma remains even after a smoker quits or switches to a less harmful alternative. Smoking seems to be one of the few behaviors where making a healthier choice, no matter how small, is met with continued contempt instead of support.

While this story may seem to describe an unusually harsh viewpoint, it’s far from a rare one. In fact, it’s common enough that the Lung Cancer Alliance felt compelled to run a “No one deserves to die from lung cancer” campaign to decrease the stigma surrounding smoking and lung cancer diagnoses.

The stigma is even evident among medical practitioners—the people who should be least judgmental of those with health conditions. It is often apparent in the medical treatment smokers receive. One experimental study found that doctors were much less likely to offer a novel, marginally life-extending lung cancer treatment to a smoking patient than to a nonsmoking patient. Another study found that 83 percent of doctors in the United States consider Chronic Obstructive Pulmonary Disease (COPD) a self-inflicted condition.

Smokers sense the stigma, and it affects their behaviors. In one study, 8 percent of smokers reported not disclosing their smoking status to a medical professional, while others reported delaying care-seeking because of concerns about the stigma surrounding their behavior.

Perhaps the ultimate hypocrisy is that we condemn smokers for choosing to start smoking, yet we consistently make it more difficult for them to quit than it already is.

Ordinarily, stigmatizing a disease or observing medical practitioners making decisions based on social characteristics would raise the hackles of the public health community. With smoking, however, this hasn’t been the case. In fact, many anti-smoking campaigns actually turn to stigmatization as a behavioral control tactic.

While this strategy is correlated with the decreasing smoking rate, the effectiveness of stigmatizing smoking behavior to encourage cessation is still in question and is accompanied by many unintended consequences. One of which is morphing the anti-smoking message into an anti-smoker message.

This sentiment inevitably bleeds into any conversation about tobacco harm reduction. Anyone who considers themselves a public health practitioner will agree that not smoking—or completely quitting, if a person has already started—is the best health choice one can make. But consensus is quickly lost as soon as reduced-risk tobacco products enter the conversation.

The anti-smoker mentality lends itself to framing tobacco use as dichotomous: You either smoke cigarettes, or you are a nonsmoker. The reality is that tobacco use patterns exist on a continuum of risk, and stigma minimizes the reality that switching—fully or partially—to a reduced-risk product can significantly decrease the risk of negative health outcomes and improve the odds of later completely abstaining. As an added bonus, smoke-free tobacco products do not present the same secondhand exposure risks as cigarettes—and in the case of products like snus and other smokeless forms of tobacco, the secondhand exposure risk is zero.

Yet despite the established benefits of reduced-risk products, systemic stigmatization of smoking and smokers has resulted in reduced-risk products being viewed and regulated harshly—often even more harshly than combustible cigarettes. This makes switching to a reduced-risk product less appealing to current smokers. After all, if the cost, perceived risk and social stigma of using a reduced-risk product is equivalent to that of smoking a cigarette, why change one’s nicotine source?

Perhaps the ultimate hypocrisy of the smoking stigma is that we condemn smokers for choosing to start smoking, yet we consistently make it more difficult for them to quit than it already is. Successful behavior change requires empowerment, and stigma disempowers.

If we truly want to encourage smokers to quit, we have to meet smokers “where they’re at” and provide options that help them achieve their desired outcome.

Photo by Rafał Opalski on Unsplash

The post Widespread Anti-Smoker Stigma Is Harmful, as Well as Wrong appeared first on Filter.