University of Michigan faculty members Ken Warner and Cliff Douglas have worked for decades to combat smoking. Warner, 75, an economist and former dean of Michigan’s public health school, wrote dozens of papers on tobacco control and edited a landmark Surgeon General’s report on smoking and health. Douglas, 64, a lawyer, led the campaign to ban smoking on commercial airline flights and connected tobacco-industry whistleblowers to Congress and the media.
The cause to which they have devoted themselves has saved millions of lives. As recently as 1980, more than one in three Americans smoked. Today, about one in eight currently smoke. That’s a monumental victory for public health.
Lately, though, Warner and Douglas have taken on a new and vexing challenge. They want to bring the tobacco control community together around the deeply divisive topic of e-cigarettes. In a paper in the journal Health Affairs, they put forth a policy agenda that is designed to prevent kids from vaping while making e-cigarettes available to adults who want to use them to quit smoking.
Their quest for common ground has generated both interest and criticism from tobacco harm reduction proponents and groups representing the e-cigarette industry. Douglas hopes to promote more dialogue by creating a new organization, based at the University of Michigan. So far, though, they do not appear to be making headway with the advocacy groups that have taken a hard line against e-cigarettes.
Staunch opponents of vaping include veteran tobacco warrior Matt Myers, the president of the Campaign for Tobacco-Free Kids (CTFK); the aggressive startup PAVE, which stands for Parents Against Vaping E-Cigarettes; Vital Strategies, a Washington, DC-based public health group; and the Truth Initiative, a nonprofit that wants to rid the world of nicotine dependence as well as tobacco use.
Warner and Douglas worked with Myers for years, and they’re well acquainted with Robin Koval, the chief executive of the Truth Initiative. So you might think that establishing a constructive dialogue around vaping would be easy.
It has been close to impossible.
“There’s been much less reaction to the paper than we’d hoped,” Warner told Filter.
“We’re really troubled by the polarized nature of the discussion,” Douglas said. “It’s really difficult.”
The difficulty is, at least in part, because the two sides can’t agree on what they are trying to accomplish.
They are not alone in seeking to bridge the divide over vaping. In a talk at the University of Michigan, Mitch Zeller, the former director of the FDA’s Center for Tobacco Products (CTP), lamented the fact that opponents in the vaping debate are talking past one another, especially on social media.
“Can we get a commitment to seek common ground?” Zeller asked. “So far, that common ground has completely eluded the field of public health and tobacco control.”
“Especially when it comes to the loudest mouths in the field, I don’t see any interest whatsoever in seeking common ground, even on matters of principle,” he said.
His successor at CTP, Brian King, also called for a “constructive dialogue” in a recent interview with Koval.
The question is, why is it so difficult to find common ground, or even to have a productive conversation about vaping?
It is, at least in part, because the two sides can’t agree on what they are trying to accomplish.
The vaping debate revolves around tobacco harm reduction, which in this context means encouraging people who can’t or won’t quit smoking to switch to much less harmful products like e-cigarettes to get their nicotine, even if those products aren’t entirely benign.
Advocates for harm reduction, including Warner, Douglas and other veterans of the anti-smoking campaigns, are clear about their purpose: They want to reduce death and disease caused by tobacco products. Period.
Advocacy groups funded by Bloomberg Philanthropies, which has spent well over $160 million to campaign against e-cigarettes, have laid out different goals.
The name of the Campaign for Tobacco-Free Kids speaks to its purpose. (Though maybe they would be better off changing the name to “nicotine-free kids.”) Still, Myers focuses on young people, as does PAVE’s Meredith Berkman. They have little to offer adults who smoke.
Truth Initiative says that it aims to “achieve a culture where young people reject smoking, vaping, and nicotine.” All things nicotine have become a target.
Others like Margaret Chan, the former head of the World Health Organization (WHO), have declared that their goal is to “make sure that the tobacco industry goes out of business.”
Without agreement on a destination, it’s hard to agree on a path to get there.
The Battle Over Harm Reduction
Consider, for starters, the core issue in tobacco control: whether to embrace harm reduction.
Warner, Douglas and their co-authors, Karalyn Kiessling and Alex Liber, regard e-cigarettes as both a potential problem and an important solution. Their proposals in the Health Affairs paper are designed to strike a balance between their desires to keep vapes away from kids but make them available to adults.
“The goal should be a policy mix that can address both objectives constructively,” they write.
Their recommendations include selling e-cigarettes just in adult-only stores like tobacco shops (and not in gas stations or convenience stores), limiting but not eliminating flavors, curbing advertising and taxing combustible cigarettes higher than e-cigarettes to encourage adults who smoke to switch.
For a time, the FDA, Truth Initiative, Tobacco-Free Kids and Vital Strategies were all seemingly open to tobacco harm reduction.
The FDA’s comprehensive plan for tobacco and nicotine regulation, which was put forth by former FDA Commissioner Scott Gottlieb and Zeller in 2017, recognized that vaping could be a safer alternative to smoking. Its decision last year to permit the marketing and sale of a handful of tobacco-flavored vaping products also reflected harm reduction principles.
The Michael Bloomberg-funded coalition slammed the door to harm reduction when teen vaping grew to what the FDA called “epidemic” levels in 2018 and 2019.
Back in 2016, Truth Initiative invited academics and activists, including harm reduction advocates, to a two-day conference called “Rethinking Nicotine” in Washington.
Meanwhile, Vital Strategies wholeheartedly campaigns for harm reduction policies to help people who use illegal drugs protect themselves from overdoses, HIV or Hepatitis C.
Even Matt Myers has expressed support for alternative delivery mechanisms for nicotine. Long before vaping came to the US, Myers said:
The challenge to me is not to eliminate smoking, but the death and disease from smoking. That should be the end goal. If you had a product that addicted 45 million people and killed none of them, I would take that deal. Then you’d have coffee! I have to believe that if the marketplace incentives were such that over time someone could devise a product that would give the same satisfaction as tobacco but didn’t kill them, people would flock to it.
Of course, we now have that product: the e-cigarette.
The Michael Bloomberg-funded coalition slammed the door to harm reduction when teen vaping grew to what the FDA called “epidemic” levels in 2018 and 2019. Since then, even though youth use of e-cigarettes has fallen, Myers and his allies have fought vaping at every turn, taking what is close to a prohibitionist stance.
Tobacco-Free Kids calls for sweeping bans on flavored vaping products, citing the risks to young people.
Truth Initiative warns that e-cigarettes threaten to “undo all the progress that the public health community and government have made over decades to reduce cigarette smoking.”
Vital Strategies urges the FDA and legislators to prohibit flavors and restrict marketing, access and sales of e-cigarettes.
King emphasized that “when it comes to enforcement and compliance, nothing is off the table.” The FDA has since shown that it was no idle threat.
Most importantly, the FDA’s Center for Tobacco Products has not authorized the sale or marketing of any flavored vapes, aside from tobacco flavors, which are unappealing to many adults who want to quit cigarettes.
In his recent conversation with Robin Koval, the FDA’s Brian King stressed the agency’s commitment to young people. “Anything we can do to continue to reduce use among youth is a good thing,” King said, “and I’m committed to making that happen with the full arsenal of resources that FDA has.”
Anything we can do? At a conference in September, King emphasized that “when it comes to enforcement and compliance, nothing is off the table.” The FDA has since shown that it was no idle threat. That does not signal a balanced approach.
Meantime, the FDA’s The Real Cost anti-vaping campaign has demonized e-cigarettes with commercials like this one (“vaping can deliver toxic metals like nickel and lead into your lungs”) and this one, showing a school girl writhing in agony (“are you possessed by nicotine?”).
Rarely, if ever, do anti-vaping crusaders acknowledge the benefits of safer nicotine products to adults who smoke. Unless they do, finding common ground will be next to impossible.
The Role of Industry
The longtime tobacco warrior and researcher Stanton Glantz put it plainly, once saying he’d “like to just destroy the tobacco industry… It has no business existing.”
While Glantz’s influence has waned amid scandals, Big Tobacco continues to be cast as the villain by the Bloomberg-funded coalition. Antipathy toward the industry excludes informed, influential voices from dialogue about tobacco control.
Journals and academic societies, including the esteemed Society for Research on Nicotine and Tobacco (SRNT), will not publish research by scientists at tobacco companies, including e-cigarette companies. Those employed by the industry cannot attend SRNT meetings, and independent scientists who take industry funding are denounced as shills.
At a recent Food and Drug Law Institute (FDLI) event, Myers described e-cigarette companies as “an industry that, based on its behavior, appears willing to go after kids any time regulation and enforcement allows it to do so.” Certainly some bad actors in the industry fit that description.
“People who have given much of their careers to public health are being criticized, ostracized and branded as traitors because they embrace the idea of stakeholder engagement.”
But Scott Ballin, a former vice president of the American Heart Association who has worked collaboratively on tobacco issues for decades, argues that industry is not a monolith.
“Industry is all kinds of different people,” Ballin told Filter. “Big Companies. Little companies. The vaping industry. Growers. Distributors.”
Academics with even the slimmest ties to e-cigarette makers risk reputational damage, Ballin said: “People who have given much of their careers to public health are being criticized, ostracized and branded as traitors because they embrace the idea of stakeholder engagement.”
Matthew Holman, a tobacco scientist who spent 20 years at the FDA, most recently as chief scientist at CTP, was sharply criticized when he left in July to join Philip Morris International (PMI). PMI says that it is building its future “on smoke-free products that are a much better choice than cigarette smoking.”
Several months after beginning work at PMI, Holman says he takes the company at its word. “These people are just as committed to public health as I am,” he told Filter. “They’re just as dedicated as I am. That has been a wonderful realization.”
PMI and other tobacco companies have begun to shift their product mix away from combustible cigarettes and toward reduced-harm alternatives.
Given the right incentives, Bates told Filter, tobacco companies can be persuaded to see vaping “as a good corporate strategy that gets them out of the merchant of death business.”
Clive Bates, the former director of UK anti-smoking charity Action on Smoking and Health, says they can help end death and disease from smoking. Given the right incentives, Bates told Filter, tobacco companies can be persuaded to see vaping “as a good corporate strategy that gets them out of the merchant of death business.”
Some industry leaders are willing to accept regulation. Tony Abboud, the executive director of the Vapor Technology Association, which represents vape shops, says his group would accept reasonable restrictions on where e-cigarettes can be sold and how they can be marketed.
Abboud also said: “We’ll sit down with anybody.”
But Amanda Wheeler, the president of the American Vapor Manufacturers Association (AVM), says the point-of-sale restrictions put forth by Warner and Douglas go too far. Wheeler owns a vape shop in Arizona, but she believes that e-cigarettes should be available in gas stations and convenience stores so that they remain easily accessible to adults who smoke.
The trouble is, gas stations and convenience stores have low rates of compliance when it comes to selling to underage individuals, according to a study of retailer compliance in the state of New Jersey.
Christine Delnevo, the director of the Center for Tobacco Studies at Rutgers and an author of the research, says underage consumers were able to buy tobacco products more than 40 percent of the time.
“I’m strongly in favor of [the] proposal that all tobacco products, including e-cigarettes, be sold in adult-only outlets,” she told Filter.
Nothing About Us Without Us
With the occasional exception, dialogues about tobacco are dominated by elites—the leaders of advocacy groups, government regulators and academics. Adults who smoke or vape are not often heard, except on Twitter, where they are very active.
Imagine, instead, if an FDA chief or CDC scientist or Matt Myers sat down with, say, Kim “Skip” Murray, who smoked for decades before switching to e-cigarettes and formerly owned a vape shop in rural Minnesota.
Murray says she’d begin by thanking them for their efforts over the years to end death and disease from smoking. She would then voice her concern that “we have forgotten that too many people die from smoking.” Then she’d probably talk about her son. “About his smoking, about his being a dad and having a heart attack at age 29. And how vaping helped him quit smoking,” she told Filter.
Warner and his co-authors write in Health Affairs that the neglect of adults who smoke “is a matter of social justice.”
They note: “African Americans suffer disproportionately from smoking-related mortality, and Americans with lower educations and incomes, members of the LGBTQ community, and people with mental health conditions constitute a disproportionate share of the smoking population.” These people, they say, stand to gain from harm reduction.
You may wonder what the anti-vaping groups have to say about all this. I did, too, so I reached out by email to the Campaign for Tobacco-Free Kids, Truth Initiative, PAVE and Vital Strategies. None responded. (The editor of this article also separately reached out to all four organizations, and received no response either.)
As for Bloomberg, the billionaire whose money is funding anti-vaping campaigns, he, too, has been unwilling to engage with critics. Some of the world’s leading experts on tobacco and public health—including Warner, Douglas and Steven Schroeder, the former president of the Robert Wood Johnson Foundation—tried for months to arrange a meeting with him and share evidence showing that his foundation’s opposition to flavored e-cigarettes is doing more harm than good.
They were rebuffed.
They’re a little like a political candidate with a comfortable lead in the polls who feels no pressure to debate an opponent.
It’s hard to know why the groups that oppose vaping are reluctant to engage with critics. Perhaps it’s because they are mostly winning the debate. They have support in Congress, at the regulatory agencies and at the state and local level. Residents in California voted to ban the sale of most flavored nicotine products on election day this year.
They’re a little like a political candidate with a comfortable lead in the polls who feels no pressure to debate an opponent.
In the court of public opinion, the anti-vaping groups, for now, have won. Most Americans now believe, wrongly, that e-cigarettes are just as dangerous or more dangerous than combustible cigarettes. The relentless anti-vaping messaging from the CDC, FDA and the Bloomberg-funded coalition government has been effective.
But to what end? Misperceptions about the dangers of e-cigarettes surely will discourage adults who smoke from switching to vapes, which reputable scientists agree are much safer. That’s tragic.
It’s for this reason that Douglas has decided to create a new platform that will bring together independent experts to engage in what he calls “respectful and collaborative conversation” about smoking and alternative ways to deliver nicotine. The new organization, which does not yet have a name, will be based at the University of Michigan and aim to provide trusted information and analysis to policy makers and the media. Douglas and colleagues are seeking foundation funds to get the project off the ground.
Some anti-smoking advocates will root for him to succeed. No one expects it to be easy.
Photograph by Marl Clevenger on Unsplash
R Street Institute supported the production of this article through a restricted grant to The Influence Foundation, which operates Filter. The Influence Foundation has also received grants from PMI. Filter’s Editorial Independence Policy applies.
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