Are We Seeing Early Signs of Common Ground in US Tobacco Control?

January 28, 2022

On January 27, a group of tobacco control experts published a letter in the American Journal of Public Health (AJPH), urging the public health community to move away from categorizing scientists as either “opponents” or “supporters” of e-cigarettes.

The co-authors—including Micah Berman, an associate professor of public health and law at Ohio State; Pamela Ling, a professor of Medicine at the University of California San Francisco; and Joanna Cohen, the Bloomberg professor of disease prevention at Johns Hopkins University—write that the terminology “highlights division rather than the many areas in which there is agreement.” Meaning, they go on, that most scientists would agree both that e-cigarettes have a place for adult smokers looking to switch and that youth should not experiment with nicotine.

The authors of the letter were responding to an AJPH article from last August, when some of the most esteemed and influential tobacco control experts endorsed the harm reduction benefits of vaping and lamented that news coverage skews overwhelmingly toward risks to youth. They agree, they write, “that much more needs to be done in the United States and in countries around the world to reduce the burden of combustible products quickly and decisively and to help smokers quit.”

Still, the letter is a relatively balanced response, and can be read as a rare olive branch.

“However,” they continue, “highlighting e-cigarettes and harm reduction as the only solution disregards the critical utility of proven, established, science-supported interventions. We strongly encourage the scientific community to consider how e-cigarettes (in all of their heterogeneity of design and use patterns) perform in the real world when making conclusions about their effects and move away from the opponents/supporters false dichotomy.”

As tobacco harm reduction proponents have already pointed out, no serious advocate has attempted to argue that vaping is “the only solution”—just that, as a consumer product, it is an option with unique capabilities, like replicating the hand-to-mouth action of smoking and helping smokers who never even wanted to quit transition to a safer alternative.

Still, the letter is a relatively balanced response, and can be read as a rare olive branch in an ongoing exchange where common ground remains shaky at best.

While there are shades of gray in any perceived dichotomy, tobacco control has been dominated for the past few years by two vocal factions: Abstinence-based public health organizations, like the Michael Bloomberg–funded Campaign for Tobacco Free Kids (CTFK), that center youth use to call for bans and restrictions; and the former smokers, manufacturers and harm reductionists who make evidence-based arguments that draconian legislation on safer nicotine alternatives, like flavor bans, only contributes to smoking death. (Tobacco use, of course, is the number one cause of preventable death on the planet.)

The nuance here could represent an early sign of what the future might look like.

The letter writers also insist that e-cigarettes need to “perform at the individual and population levels in practice” to reduce “tobacco-related disparities”—which depends “in large part on how the products are regulated and marketed”—and that e-cigarettes “comprise a heterogeneous class of products,” so their short-term and long-term effects will vary given a certain vape’s design, e-liquid composition, and how a respective company advertises them.

The nuance here could represent an early sign of what the future might look like, where vaping’s biggest antagonists and skeptics will have to accept that we will never be a nicotine-free society, even if restrictions, exceptions and wrangling remain rife. The hard reality, with innovation and uptake accelerating, is that e-cigarettes are not going anywhere.

That’s true despite the regulatory mess in the US: The Food and Drug Administration (FDA) has been waffling on many of the premarket tobacco product applications (PMTAs) that vapor companies had to file last September to remain on the market. Companies had to prove, in short, that each individual product would be “appropriate for the protection of public health”—a standard that’s come to be understood as a given product’s likelihood to help adult smokers transition while not introducing nicotine to a new generation of users. So far, the agency has authorized just a single vaping product, while blowing past a court-imposed deadline, denying thousands of applications from smaller companies, and punting on the largest players. Some denied manufacturers, like Triton, have filed lawsuits against the FDA, alleging that it acted “arbitrarily” and “capriciously” by requiring extensive studies that it had not made clear would be necessary.

It has long been expected, by the industry and consumer advocates, that the federal government would prioritize the biggest producers, those with the capital and resources to plow through the agency’s bureaucracy. It’s easier, the logic goes, to regulate an essential oligopoly than a bevy of small- and medium-sized manufacturers.

“I see this as evidence that authorized products subject to marketing restrictions should be able to earn support from the entire spectrum of tobacco control advocates.”

“I see this as evidence that authorized products subject to marketing restrictions are ones that truly should be able to earn support from the entire spectrum of tobacco control advocates,” one vape industry insider, who requested anonymity so as not to affect the PMTA process, told Filter. “What you may start to see is something like what we are observing in New Zealand—an embrace of vapor (PMTA’s authorized vapor specifically) on the part of previous skeptics, together with advocacy for increasingly harsh measures against combustible cigarettes.”

As part of its comprehensive tobacco control agenda, the FDA has also signaled it will move toward prohibiting menthol cigarettes and lowering the nicotine levels in combustibles close to zero with the aim of eliminating dependency—coercive and punitive strategies that some drug war critics have argued would simply fuel the illicit market in the United States while increasing criminalization. But these processes could take years.

This is not the end of the battle, nor is it even the beginning of the end. Tobacco control is set to enter uncharted territory, where many experts in the field will have to address questions they have not yet had to face, sometimes ill-equipped to do so.

How robust can an illicit market grow? To what lengths will consumers go to vape their favorite flavors, which may no longer be legally available? What if, decades down the line, vaping nicotine’s long-term effects are demonstrated to be even less concerning than scientists’ cautious estimates—effectively no different, say, to drinking a cup of coffee?

The authors titled their letter “Balancing Risks and Benefits of E-Cigarettes in the Real World.” But with nicotine, the future “real world” is difficult for any of us to imagine.



Photograph by Peter Franz via Flickr/Creative Commons 2.0

Alex Norcia

Alex was formerly Filter’s news editor. He previously worked as a reporter and copy editor at VICE, and has been published in the New York Times Magazine, the Columbia Journalism Review, the Los Angeles Times and the New Republic, among other outlets. He was also previously a freelance editorial consultant for the Foundation for a Smoke-Free World; The Influence Foundation, which operates Filter, has received grants from the Foundation for a Smoke-Free World. He is currently based in Los Angeles.

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