US Smoking Hits Record Lows. What Will Regulators Make of It?

    Smoking in the United States has declined to the lowest percentage rate in more than half a century, according to the Centers for Disease Control and Prevention (CDC). In 2020, 12.5 percent of the adult population, still well over 30 million people, were current cigarette smokers.

    In an article published on March 17 in the CDC’s Morbidity and Mortality Weekly Report, the agency found that adult use of all “tobacco products”—a category that includes vapes in federal terminology⁠—dropped from 20.8 percent in 2019 (50.6 million people) to 19 percent (47.1 million people).

    The specific prevalence for cigarettes, which stood at 42 percent back in 1965, fell from 14 percent in 2019 (34.1 million people) to 12.5 percent (30.8 million). Cigar use dropped fractionally as well—from 3.6 percent to 3.5 percent—and pipe use modestly increased, from 1 percent to 1.1 percent.

    The use of tobacco harm reduction products also declined from 2019 to 2020⁠. The adult vaping prevalence fell from 4.5 percent (10.9 million people) to 3.7 percent (9.1 million), the CDC found. The prevalence for smokeless tobacco use inched down from 2.4 to 2.3 percent, too.

    The paper additionally notes major demographic disparities.

    (The CDC defines current cigarette smoking as a person having smoked at least 100 cigarettes in their life who reports smoking every day or some days at the time of the survey; and current use of all other tobacco products as reported use every day or some days at the time of the survey).

    The paper additionally notes major demographic disparities: 34.9 percent of Non-Hispanic American Indian/Alaska Native adults used a tobacco product, for example⁠—as well as 25.2 percent of adults with annual household income below $35,000 than those with a higher income; 25.1 percent who identify as lesbian, gay or bisexual; and 35.6 percent who have regular feeling of depression.

    “We have made significant progress in preventing and reducing tobacco product use in this country by using proven strategies and implementing effective policies,” Karen Hacker, the director of CDC’s National Center for Chronic Disease Prevention and Health Promotion, said in a statement. “Despite significant declines in adult tobacco use, our work is far from over. We must continue to address tobacco-related health disparities and inequities to ensure everyone has the opportunity to be as healthy as possible.”

    Tobacco harm reduction didnt get a mention.

    In a press release, the CDC emphasized that more could be done, including the “implementation of tobacco price increases, comprehensive smoke-free policies, high impact antitobacco media campaigns, and barrier-free access to cessation services.”

    Tobacco harm reduction didnt get a mention. Its proponents contend that many adults who formerly smoked transitioned to vaping, a safer nicotine alternative—sometimes by accident and typically with the use of flavors—and that poor policy will dissuade others from switching. One notable example comes from Dr. Abigail Friedman of Yale, who published a study in JAMA Pediatrics that found that after San Francisco’s ban on flavored vapes and tobacco products, teenagers in the city’s high schools were more likely to take up smoking than teenagers in other US school districts.

    How, then, could a national decline of close to 2 million adult vapers from 2019 to 2020 be explained? It won’t escape harm reductionists’ notice that the highly misplaced and publicized “EVALI” scare around nicotine vaping reached its height in the second half of 2019. They’ll note, too, state-level evidence that has associated EVALI-driven bans and restrictions on vapes with increases in cigarette smoking—likely through vapers switching back to combustibles.

    There is also a subset of people who use vapes to transition off cigarettes, and then go on to quit vapes. Data from the United Kingdom have shown that the overwhelming majority of vapers there are either ex-smokers or current smokers in the process of switching. But there is a real lack of US national-level data on such motivations.

    Will the FDA consider that a record-low smoking prevalence should be credited, in part, to the availability of vapes?

    At the moment, the Food and Drug Administration (FDA) is still mulling such considerations, as it agency continues to sort through what’s expected to be a growing pile of premarket tobacco product applications (PMTAs) from vape companies, issuing marketing denials or (rarely so far) authorizations. The agency has separately signaled that it will soon move forward with a controversial plan to ban the sale of menthol cigarettes.

    Will the FDA consider that a record-low smoking prevalence should be credited, in part, to the availability of vapes? Despite numerous US restrictions, vapes remain far more available than in countries with outright prohibitions, and the vaper-to-smoker ratio is higher in the US than it appears to be for the world as a whole.

    Or will the agency take the decline in use of all tobacco products as encouragement that preventing or reducing all such use, as Hacker suggested, is a realistic national goal?

    “The question is whether the FDA will think defensively,”  one industry insider, speaking on condition of anonymity so as not to affect the PMTA process, told Filter, “or whether they will remember their obligations under the statute to perform their reviews faithfully and not try to make essentially political judgments about what may or may not happen in the future.” 



    Photograph by Sudipto Sarkar via Flickr/Creative Commons 2.0

    • 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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