Targeting tobacco risk communications
By Cheryl Olson
On August 22, the U.S. Food and Drug Administration’s Center for Tobacco Products will take live comments from the public to help develop its five-year strategic plan. One of the strategic goal areas involves improving public health via knowledge: “timely, clear and accessible health communications and education to diverse public audiences.” Along with discouraging youth initiation, the CTP wants to “encourage cessation and to inform adults who smoke about the relative risks of tobacco products.”
This is welcome news. Misinformation is killing people. For example, U.S. cigarette users who believe nicotine is harmful to health are less likely to try nicotine-replacement therapies (NRTs) or e-cigarettes to help them quit and (no surprise) are less likely to quit successfully.
“If someone believes that using reduced-risk products is just as bad as smoking, why bother switching?” says Jeffrey S. Smith, a senior fellow in harm reduction at R Street Institute in Washington, D.C.
Let’s help the CTP get rolling. What tobacco-related misconceptions deserve immediate attention? And which groups are in particularly dire need of lifesaving actionable knowledge due to persistently high smoking rates and low quit rates? I asked several colleagues for their nominations.
Confusion about tobacco product relative risks is a huge concern. Clifford Douglas, who directs the Tobacco Research Network at the University of Michigan, alerted me to an article he and six distinguished experts wrote recently for the journal Addiction. It responds to the U.S. Surgeon General, who called stopping the spread of trust-destroying health misinformation “a moral and civic imperative.” The article targets two huge myths about e-cigarette risks that federal authorities unfortunately helped promote and failed to correct.
First is misinformation about e-cigarette or vaping product use-associated lung injury (EVALI), which turned out to be linked instead to vaping illicit THC products. The authors contrast the CDC’s approach to EVALI to its handling of food-related illness outbreaks. With lettuce-linked listeria, authorities are quick to share brands, dates and locations of concern, which products are probably safe and when to stop worrying. That hasn’t happened with EVALI. Not even the name has been corrected, perpetuating confusion among researchers, clinicians and the public.
The second myth is the persistent insistence that youth e-cigarette use is a gateway to smoking. Not only is evidence lacking for a causal link, but studies support the reverse: that vaping reduces youth smoking rates. This information has not been shared by health authorities.
“I’ve heard researchers tell me that we still don’t know the relative harm of e-cigarettes compared to smoking,” says Bethea (Annie) Kleykamp, assistant professor in psychiatry at the University of Maryland School of Medicine. “I’ve seen [healthcare] providers very nervous about talking about harm reduction at all. I don’t know if that’s because they’re misinformed or they’re reading information that is different from what I’m reading.”
Smith, a brain researcher with deep experience in both academia and industry, shares these concerns. “I could understand this error if it was coming from nonscientists,” he says. “But it is in the messaging from academics, policymakers and national health organizations.”
He is frustrated by the way the link between smoking and nicotine is used to tar all reduced-risk products. “If cigarettes contain nicotine, then any nicotine-containing product must be equally bad,” is how he sums up that mistaken theme.
As a neuroscientist, Smith sees an additional overlooked benefit from correcting misperceptions of nicotine. “The potential of nicotine to improve health in nonsmokers has really lagged behind due to its association to smoking,” he says. If nicotine could be destigmatized, research may lead to treatments for traumatic brain injury, Alzheimer’s disease and age-related memory loss.
The Greatest Need
At the University of Maryland, Kleykamp works with a long-established Baltimore addiction clinic. Smoking rates are at 70 percent or higher among people with opioid use disorder (OUD).
“A little over half of people in addiction treatment will actually die of tobacco-related disease, not other addictions,” she says. People with OUD seldom quit smoking with prescription medicines or NRTs. Preliminary evidence suggests that e-cigarettes may be a more acceptable substitute.
Kleykamp notes that addiction professionals typically focus on immediate risks: stabilizing patients and making sure they don’t overdose. And for younger patients who smoke, the biggest tobacco dangers are decades down the line. But the pattern is changing.
“A lot of patients in opioid treatment are aging,” Kleykamp notes. “In our clinic, over 50 percent are over 55 and above. So tobacco harm reduction is becoming equally urgent.”
Kleykamp’s other research focus is on longtime adult cigarette users. Among Americans over age 65 who smoke, quit rates have been stagnant since the turn of the century.
“Older adults who smoke are the least informed on relative harms and more likely to think that nicotine is a cause of cancer,” says Kleykamp. “Yet they are the most likely to get the cancer and heart disease.”
There is little research on how to change the minds and behaviors of longtime smokers. Kleykamp is working to fill that gap. She’s preparing to publish research based on the Population Assessment of Tobacco and Health study data from adults aged 55-plus who have smoked for decades. In this sample, more people had tried e-cigarettes than had tried NRT. Based on such findings, Kleykamp speculates that longtime smokers “don’t want to use these medicines. They want something that’s more the look and feel of a cigarette.”
“It seems to me that if you smoke that long and have difficulty quitting and don’t want to quit, then a product that replaces the nicotine and is pleasurable is your best hope,” she says.
Wanted: Consistency and Trust
From studies and expert opinions, one message is clear: We need consistent, clear messaging on the relative risk of smoking. Kleykamp thinks that the FDA is a trusted source of information for researchers and healthcare providers. She would like to see educational interventions geared toward providers on the basics: nicotine’s non-role in cancer, and the tobacco product continuum of risk.
For the larger public, the FDA may need to work through other avenues. Surveys suggest that many Americans, and particularly people who smoke, don’t trust information from the FDA or the Centers for Disease Control.
“Aging and tobacco use is correlated with being not white and low socioeconomic status, so you also have a correlation with historic mistrust of providers,” Kleykamp says. “An interaction with a clinician that they trust could help. Maybe in the context of a relationship that’s already been built.”
Smith also advocates one-to-one education. “I think the medical and public health community could be the source of credible information, but on the local level, not large and expensive national campaigns,” he says. “I feel that there is mistrust everywhere. And without personal connection, it will be hard to drive change.”
Smith would like to see this consistent message coming from all sources: “Combustion is the problem, not nicotine. Stop smoking—through any means, quit or switch—and your health will improve.”
Finally, he calls for more communication among researchers. “I would argue today that regardless of source—academic, regulatory or industry—the only way to solve the health problems that exist around smoking is to listen, argue, discuss, agree and disagree as a single scientific community,” says Smith. “Science is what will drive change.”