Category: Cheryl Olson

  • Slim Chances

    Slim Chances

    Image: Rostislav Sedlacek

    Harm reduction, smoking cessation and weight

    By Cheryl K. Olson

    Before Ozempic and Wegovy, before fen/phen and Xenical, there was nicotine. Cigarettes have long been viewed as appetite suppressants.

    In the early 20th century, advertisements manipulatively cautioned women to “Reach for a Lucky instead of a sweet” to “maintain that modern figure of fashion.” Modern-day military personnel, with employment prospects tied to fitness standards, often turn to tobacco for help.

    “Across the population, nicotine has undoubtedly been the most effective long-term weight control drug in use over the past century,” a review of research concluded. “Unfortunately, nicotine is delivered to most people via cigarette smoke, which is extraordinarily toxic.”

    Nicotine’s slimming effects can make smoking appealing to start and daunting to stop. “Those who are smokers are very afraid of quitting their smoking habit and not being able to control their appetite,” says Diego Verrastro, a physician and tobacco harm reduction advocate based in Argentina.

    A few years ago, Verrastro began encouraging his patients who suffer from obesity to switch to vaping. The results? “We have managed to get them to quit smoking and also lose weight,” he says. “And obviously reduce the risk and morbidity of both associated pathologies.”

    Noncombustible tobacco products are gaining notice as potentially less risky ways to exploit nicotine’s weight loss properties. Earlier this year, social media posts touted nicotine pouches (aka “O-Zyn-Pic”) as cheap alternatives to costly GLP-1 agonist medications.

    What do we know about reduced-risk products (RRPs) and weight? If RRPs can address two problems at once, as Verrastro suggests, why isn’t this getting more attention? 

    How Nicotine Affects Weight

    Nicotine influences eating and weight in multiple ways, from hormones to microbiomes to taste perceptions. The bottom line: Nicotine raises the metabolic rate while also depressing appetite. 

    One way to separate the effects of nicotine from smoking is to look at very low-nicotine (VLN) cigarettes. A smoking cessation trial using VLN cigarettes found that people randomized to the products (who actually used them) gained 1.2 kg over six weeks. In short, removing the nicotine from cigarettes deletes their weight control effects. Researchers noted that “the health benefits of quitting far outweigh the negative health consequences of post-cessation weight gain.”

    Although nicotine is the primary driver in weight reduction, puffing on a cigarette can also be a behavior substitute for eating. (Hence the quit-smoking advice to nibble on carrots or toothpicks.)

    Not everyone gains weight when they quit smoking, but most people do. Smoking puts the brakes on ordinary aging-related weight gain; that ends when the smoking stops. On average, successful quitters gain 4 kg or 5 kg within a year. Some gain a lot more. A 1991 U.S. national study found that after a decade, about one in 10 men and one in eight women gained over 13 kg. Being Black or smoking heavily (over 15 cigarettes a day) increased the risk for extra pounds.

    For some, that added weight contributes to type 2 diabetes and heart disease. Research shows that the health benefits of smoking cessation far exceed the health harms of weight gain. But many people who smoke aren’t willing to make that trade.

    Multiple studies show that fear of weight gain is a primary reason for delaying quit attempts, particularly among women. Also, gaining weight during or after the quitting process is linked to relapse.

    What has worked in the past to make stepping onto the scale less scary? Unfortunately, a Cochrane review of interventions for preventing weight gain after cessation found scant reason for optimism. Most studies were small, results varied widely, and the usual options were unhelpful. For example, varenicline does not limit weight gain. In short, there’s a large unmet need for new approaches.  

    Hints of Benefits

    For decades, there have been intermittent hints that noncombustible nicotine could help control weight. Back in 1988, while studying long-term smoking cessation, Peter Hajek and colleagues at the University of London found an interesting result. Among people who remained smoke-free at one year, those who stuck with nicotine gum had gained significantly less weight than their peers. At that point, most gum users were chewing just a few pieces per day. Moreover, the group of persistent gum users had been heavier smokers, who typically gain more weight.

    Sixteen years later, Brad Rodu and collaborators published results on a study of tobacco use and weight among men in northern Sweden. They found that quitting tobacco—whether cigarettes or snus—led to weight gain. However, those who quit smoking by switching to snus cut that gain significantly.

    Skip ahead 13 years. Vaping is now big news. Marewa Glover in New Zealand and colleagues queried, in the Journal of Nicotine & Tobacco Research, whether e-cigarettes could “be a new weapon in the battle of the bulge.” Along with the effects of nicotine noted above, they wondered if flavor options could positively affect satiety and food cravings. They also acknowledged that any potential for nonsmokers to start vaping for weight control could intensify the alarm of e-cigarette critics. 

    Evidence continues to trickle in. Cristina Russo, Riccardo Polosa and colleagues at the University of Catania have substantiated that e-cigarettes can mitigate weight issues. At one-year follow-up, former smokers who switched to vaping had gained a mere 1.5 percent of their baseline weight.

    “The strategy of recommending a switch to vaping to manage both nicotine dependence and appetite control aligns with our experience with smokers—and their fears of putting on too much weight,” says Polosa. “The potential for the dual benefit for these people cannot be underestimated. Helping them quit smoking, manage their weight and lower their overall risk and morbidity for both obesity and smoking-related conditions can be a significant achievement.” 

    Polosa’s group has completed a systematic review and meta-analysis of available research on the effects of electronic nicotine-delivery systems on weight for people who have either quit or reduced conventional smoking. Results are currently undergoing peer review.

    Might people who smoke be interested in using RRPs for weight management? In 2018, the ongoing Smoking Toolkit Study in England made inquiries. Only 5.7 percent of participants admitted to smoking for weight control reasons. Of respondents who currently smoked, just 8.8 percent had heard that vaping might help keep weight down. But one in eight said this feature would make them more likely to try e-cigarettes. Of people who already vaped, one in 22 said they did so to control weight.

    “If evidence that vaping could help users to control their weight during a quit attempt could be identified and communicated to smokers, they may be more inclined both to try e-cigarettes and to quit smoking,” study authors said.

    Why the Neglect?

    Why don’t we know more about the exciting potential for this dual benefit from novel nicotine products? Despite the documented need for better options, this issue hasn’t been a research priority. Most published studies that look at the health effects of reduced-risk products do not mention appetite or weight. The history of questionable cigarette marketing claims, and concerns about enticing tobacco nonusers, may play a role here.

    This low priority makes it difficult to fund new studies. About six years ago, researcher Erika Litvin Bloom of Brown University became interested in the effects of e-cigarettes on eating behavior. For example, she uncovered intriguing findings in survey data that people who smoked daily to prevent overeating were more likely to report some use of e-cigarettes. 

    “In particular, I was interested in whether sweet flavors like vanilla and cherry would have different effects than traditional tobacco and menthol flavors,” she says. Her grant applications to the National Institutes of Health to study these effects “got pretty good but not quite fundable scores” from the reviewers. After multiple tries, she gave up.

    Cheryl K. Olson is a California-based public health researcher who specializes in behavioral health issues and consults on tobacco product behaviors via McKinney Regulatory Science Advisors. She spent 15 years on the faculty of Harvard Medical School.
  • Warm Reception?

    Warm Reception?

    Photo: Ina

    How heated tobacco might change the US

    By Cheryl K. Olson

    A new kind of nicotine alternative is sidling back onto the U.S. market. Modern heated-tobacco products (HTPs) were gone before most Americans knew they even existed. After a limited test, a patent dispute took them off U.S. shelves in 2021.

    The gradual return of HTPs has just begun, with a single brand. Within a few years, Americans will likely have access to multiple options now sold in other nations. 

    Conversations with a close family friend, a former pack-a-day smoker, piqued my interest in the potential of heated tobacco. While working for the European Union from Spain, he had sought out and rejected cigarette alternatives, from vapes to nicotine gum. For him, heated tobacco was a “radically different” revelation.

    “It soothed my needs. It felt right and reassuring,” he told me. “From the moment I bought my IQOS, in 2017, I never smoked a cigarette again.”

    Here’s a quick introduction to heated tobacco and its potential to attract and benefit Americans who smoke.

    What HTPs Are and Aren’t

    I asked Corey Henry, director of U.S. communications at Philip Morris International, to help me understand this product category. Basically, an HTP involves electronically heating a stick or capsule of tobacco to beneath the point of combustion, so it releases an aerosol but doesn’t burn. The design of the heating element varies.

    The primary difference between an HTP and an e-cigarette? “A heated-tobacco product has to have some tobacco presence, whether it’s a leaf or paste,” says Henry.

    HTP ancestors included Premier and Eclipse from R.J. Reynolds. These products were not electronic. The heat came from lighting a carbon tip (which glowed like a piece of charcoal on a barbecue); it was distributed through a rod. This approach did reduce some toxicants. PMI introduced the first electronic HTPs, including Accord in the U.S. and Heatbar in Germany.

    According to the Financial Times, HTPs have enjoyed steady worldwide growth, exceeding that of vaping. The global HTP retail market value is estimated to reach $38.9 billion this year. The largest markets thus far include Japan, Italy and South Korea. In addition to IQOS, major brands include BAT’s Glo and Japan Tobacco’s Ploom. 

    American Evolution

    The U.S. Food and Drug Administration first authorized the marketing of an IQOS “heat-not-burn” system in 2019. This included a holder and charger device plus several types of heated-tobacco units, called Heatsticks. That year, IQOS was gradually introduced in several Southeastern U.S. test markets by Philip Morris USA/Altria. Due to a dispute with R.J. Reynolds over technology patent infringement, IQOS left the U.S. market after just two years.

    In early 2024, PMI took over from Altria the exclusive U.S. commercialization rights to the IQOS tobacco-heating system. After some delay, the IQOS3 model (authorized by the FDA in 2021) will test-launch in Austin, Texas, this fall. Henry noted that internationally, IQOS launches usually start in one or two cities. “You can make assumptions going in, but then you’ve got to test those assumptions and adjust, adapt.”

    The national rollout of IQOS awaits the FDA’s OK of the latest evolution of IQOS, called Iluma. Applications were submitted to the FDA in October 2023; marketing authorization is anticipated in the second half of 2025. Iluma features various upgrades, including a slightly different heating technology and distinctive tobacco sticks. IQOS Iluma is available internationally in over two dozen markets.

    “There’s a great level of interest to see how IQOS does in the U.S., so they want to see it launch and expand rapidly,” says Henry. “What we say is patience. There’s 28 million smokers, there’s 50 states—it’s basically like the European Union.”

    U.S. HTP competitors are on the horizon. For example, a BAT submission for Glo has been under FDA review since 2021, along with a modified-risk tobacco product application submitted in 2023. Altria has partnered with JT Group to submit a PMTA to the FDA with the goal of bringing Ploom to the U.S. 

    The FDA’s list of authorized e-cigarettes includes a Logic Vapeleaf product that vaporizes capsules that contain tobacco. This is technically a heated-tobacco product. The product appears to be no longer marketed.

    Attractions and Risks

    One reason for a slow U.S. rollout is the low level of familiarity with heated tobacco. People need to get clear on the basics: It generates an aerosol; it doesn’t burn tobacco.

    “There’s always an initial period of awareness and education that you have to do with adults who smoke, to help them understand what it is and what it isn’t,” says Henry. “When people hear the concept, the reaction is, ‘So … it’s like vaping?’”

    We don’t even know how much awareness or confusion may exist. A large government survey fielded in May 2019 asked whether adults had heard of or tried heated-tobacco products (or heat-not-burn). Overall, 8.6 percent said they had heard of heated tobacco, and one-half of 1 percent had tried it. Here’s the catch: The brands mentioned in the survey questions were IQOS, Glo and Eclipse. Respondents who claimed knowledge of heated tobacco were likely thinking of the outdated Eclipse.

    Responses to the 2023 National Youth Tobacco Survey are another example. One percent of respondents (representing 370,000 teens) claimed to have used an HTP. Given that the category was not sold anywhere in the U.S. at the time, this is impossible; it can only be a misunderstanding. The next few youth surveys in the U.S. will require cautious interpretation of this topic.

    What makes us think people who smoke will switch to HTPs? Randomized controlled studies have shown that vaping works to help people stop smoking, even those without plans to quit. For HTPs, we’re not there yet. That kind of evidence would raise the comfort level of health professionals and public health advocates. An Italian trial found good results for HTPs, comparable to e-cigarettes, for smoking cessation.

    Japan makes a good test of HTPs’ potential; sales of e-cigarettes are restricted, and oral products are culturally unappealing. Reduced-risk products are reportedly close to 40 percent of total tobacco industry volume in Japan, with cigarette sales nearly halved since 2015. The latest estimates suggest nearly 12 percent of adults use HTPs. It’s less clear yet how many switch completely from cigarettes to HTPs.

    According to Henry, PMI’s research finds that internationally, about 72 percent of smokers who switch to IQOS do so fully. He anticipates similar results in the U.S.

    Do people have lower exposure to some toxicants and carcinogens when they use HTPs instead of cigarettes? A Cochrane review of randomized controlled trials found moderate-certainty evidence for that. Also, the FDA authorized IQOS 2.4 and 3.0 versions to be marketed with reduced-exposure messaging. Specifically, “Scientific studies have shown that switching completely from conventional cigarettes to the IQOS system significantly reduces your body’s exposure to harmful or potentially harmful chemicals.”

    ‘Easier to Navigate’

    HTPs are designed to mimic the physical sensations of smoking. “We think that bridge is a little easier to navigate with heated tobacco because there’s a level of familiarity,” says Henry. For example, “Your experience with an IQOS heat stick is six minutes or 14 puffs, about the same time that a smoker will smoke a cigarette.”

    Due to this familiarity, my friend in Spain found switching to heated tobacco a quick and smooth adjustment. “With a coffee, when talking with someone, the routine in which I use IQOS is identical to my routine when I smoked,” he said. He learned to keep an extra charger at his office and in his car.

    “The charger you hold in your hand has a very nice feel,” he said. “It’s light, it fits anywhere. So I didn’t miss having a cigarette in my hand,” he said. He also praised the absence of stale smoke smell in his home, car and clothing.

    What else might attract Americans to heated tobacco? One U.K. survey of nicotine users found that common reasons for trying HTPs included curiosity; lack of smell, smoke and ashes; greater social acceptability; wanting to cut down or quit cigarette use; and enjoying the flavors or taste.

    A Harm Reduction Journal study of the U.S. IQOS experience found that people who switched to the initial version were somewhat more educated and higher-income than the average smoking adult. That’s not unusual for early adopters of a new technology. It will be interesting to see how use patterns evolve as people get familiar with the device and see others switch to it. 

    A Role to Play

    Some health advocacy groups have criticized PMI’s claims, suggesting that benefits of IQOS had been overstated. I’ve often wondered how my public health colleagues would view vaping if it had been framed differently at the start. Vaping burst into wide awareness as the subject of a youth-use moral panic. That first impression is hard to overcome. I applaud a careful, gradual, unflashy U.S. reintroduction for HTPs.

    As one industry observer pointed out to me, the few e-cigarettes now authorized for sale by the FDA represent older technologies. New HTP technologies entering the market may benefit from that contrast. Another unknown affecting the fate of HTPs is whether sticks will be taxed like cigarettes or at a lower rate that encourages switching.  

    Now that nondeadly alternatives to smoking exist, it’s critical to speed up switching for those who can’t or don’t want to quit. More options are most welcome. 

    “There really isn’t a silver-bullet solution for smoke-free product alternatives,” says Henry. “It’s important that we distinguish heated tobacco from e-vapor, but in a way that isn’t disparaging. They each have a role to play.”

    Cheryl K. Olson is a California-based public health researcher who specializes in behavioral health issues and consults on tobacco product behaviors via McKinney Regulatory Science Advisors. She spent 15 years on the faculty of Harvard Medical School.
  • Playing with Numbers

    Playing with Numbers

    Photo: Hafiez Razali

    How research methods distort nicotine effects and risks

    By Cheryl K. Olson

    “The paper seems like a joke.” That’s what Harvard researcher Miguel Hernan said recently to the journal Science about a report linking e-cigarettes and strokes.

    The article was concocted by a dubious research group, founded to help young international medical school graduates get coveted authorship credits. Its analysis of U.S. government survey data claimed that respondents who vaped had a higher risk of stroke, at younger ages, than those who smoked. Its glaring flaws included inflating the number of survey takers by tens of thousands and failing to correct for the relative youth of vapers.

    Despite this, the 2022 paper’s findings found their way into media headlines and anti-vaping advertising. The Science article credits Gal Cohen and Floe Foxon with sounding the alarm on this appalling study.

    Subtler issues that affect research quality, and how research is perceived by the public, are harder to spot. Research methods may seem a dull or arcane topic. But a peek at how the research sausage is made reveals some simple yet surprising ways that the process can go wrong.

    Sometimes old habits or unquestioned assumptions are to blame. Just as typewriters affect how we text on our mobiles, legacy cigarette research methods and mindsets influence how we study noncombustible nicotine products.

    Hours of Vaping?

    Everyone understands cigarettes. When it comes to totting up use, cigarettes are easy. They come in standard units. You light, puff and extinguish. Not so for products such as vapes. How, then, do researchers compare smoking with these new nicotine-delivery systems?

    “There’s a lot of research showing that people who use e-cigarettes graze throughout the day,” says Arielle Selya, who conducts nicotine product research at Pinney Associates. “Unlike cigarettes, there’s no defined stopping and starting. They don’t have to finish a discrete unit; they just puff on and off.” Measuring this kind of variable, intermittent activity is a challenge.

    This problem is not unique to vaping. Studying nicotine pouch use, I found unexpectedly wide variations in what people did and what they thought was normal. Some tossed a pouch in the trash after 10 minutes or 15 minutes. Others kept one in their mouth for a couple of hours. A few sometimes reused a pouch they’d started earlier or cheeked pouches of two different flavors at once.

    As an example of what can go wrong, Selya pointed to a recent study of vaping and respiratory symptoms. To the authors’ credit, they tried to measure heaviness of e-cigarette use. The problem was the poor fit between their question and the behavior. They asked, “How many hours did you use electronic cigarettes per day?”

    “I’m not a vaper, but that seems like such a strange question,” says Selya. “Like asking how many hours do you spend drinking water?”

    Better approaches to measuring nicotine product use include writing down what you’re doing whenever a device pings you (ecological momentary assessment) or in a daily diary.

    Twisted Terminology

    Another holdover from cigarettes is the way tobacco is seen as the default flavor for all nicotine-containing products. “With e-cigarettes, you have to add a tobacco flavor,” notes Selya. “But researchers often say ‘flavored’ when they mean ‘non-tobacco flavored’–in some communications even the NYTS team does this–but tobacco itself is a flavor! This generates misunderstandings.”

    Nicotine research terminology can defy common sense. Consider the concept of “abuse liability.” In everyday English, abuse implies harm. When the U.S. Food and Drug Administration assesses new drugs, stricter regulation may be required if there’s abuse potential, defined as “intentional, nontherapeutic use” to “achieve a desired psychological or physical effect.” An effect like euphoria, hallucinations or distorted thoughts or perceptions. 

    When it comes to reduced-harm nicotine products, abuse potential becomes, weirdly, a plus. A backhanded compliment. If you want to attract someone away from cigarettes, features like rapid nicotine absorption, relaxation and relief of withdrawal encourage that transition.

    Abuse liability also illustrates another nicotine methodology vexation: there is no agreed-on way to measure it. One article looked at comments made by the FDA on manufacturers’ submissions for multiple types of nicotine products. Regulators considered a whole range of measures related to abuse liability, from product chemistry and pharmacokinetics to subjective factors. Of the latter, “liking” the product turned out to be the most reliable and sensitive abuse liability measure!

    Misleading Measures

    Again, cigarettes are simple and familiar. Novel nicotine products, by contrast, come in ever-evolving variations. U.S. government surveys, such as the Population Assessment of Tobacco and Health (PATH) and National Youth Tobacco Survey (NYTS), measure trends in who is using what products. The results are widely used and reported. However, for survey results to make sense, people must understand the questions.

    Discrepancies in results suggest that research participants often misunderstand nicotine products and/or the terms being used to describe them. For example, answers about vaping brands and device types often don’t match. In the NYTS, just two-thirds of teens who said they “usually” used a pod/cartridge brand of e-cigarette (such as Juul, Logic or Vuse) also said they “most often” used a pod/cartridge device. Almost one in five adults in the PATH study had these kinds of mismatched answers about their vaping behavior. 

    Some questions have even larger errors. “The NYTS asks whether your e-cigarette product contains nicotine salts,” says Selya. “And overall, about 50 percent said they don’t know.”

    This is also true for so-called “concept” flavors, she notes. “Not strawberry-banana, but something like cosmic fusion. When youth are asked about concept or ice flavors, they don’t know the characteristics of their product, or maybe don’t understand those words.”

    NYTS first asked youth about tobacco-free nicotine pouches in 2021. That year, just 1.9 percent of teens reported ever using one. Checking the details, I found a flaw: The questionnaire defined nicotine pouches as “flavored.” However, over a third of teen ever-users said the pouch product they used was unflavored. (Perhaps they confused pouches and snus?) 

    A further example: the 2023 NYTS found that 1 percent of youth—an estimated 370,000—had ever used a heated-tobacco product. At the time, that product category was not sold in the United States.

    As Ray Niaura of New York University told me, “That can’t be right. Literally, it’s impossible. So that means it’s measurement error.”

    This suggests young survey takers were befuddled. “Kids aren’t going to know,” says Niaura. “‘Heated tobacco: Yeah. I smoked a cigarette. It’s heated. I light it on fire.’”

    Yet the Centers for Disease Control and Prevention reported the result without comment or explanation.

    If a product is only used by a small percentage of people, these sorts of errors could create unreal changes in year-to-year trends. The reporting of those potentially misleading trends affect the perceptions of academics, regulators and the public. “With that amount of uncertainty and some of the low numbers, it’s hard to figure out what’s the signal versus the noise,” notes Selya.

    Questionable Choices

    Another seemingly simple but complicated issue: Who counts as a current product user? Youth surveys typically ask “have you used e-cigarettes at all, even a puff, in the last 30 days?” Surveys aimed at adults commonly ask, “Do you currently use e-cigarettes some days, every day or not at all?”

    If you assume capturing any youth e-cigarette use is important, then “even a puff” makes sense. But it also makes it difficult to separate teens who are briefly experimenting from teens at risk for problematic ongoing use.

    In studies that look at how using nicotine products affect some aspect of health, researchers choose what outcomes to measure. Their choices can suggest biases or suspicious holes in what’s reported.

    A recent study using PATH data tried to compare e-cigarette use and the age at which people developed asthma. “Why age of asthma onset rather than whether they developed asthma at all?” says Selya. “Often, I read a study and think, did you look at these other related outcomes? If so, why weren’t they published?” This issue of results that may exist but aren’t reported are known as the “file drawer problem.” Preregistering study plans would avoid this issue.

    Researchers, Meet Users

    Before I dove deeply into tobacco harm reduction, my research focused on the effects of violent video games on youth. Finding discrepancies between research reports and what teens told me, I realized that many of the field’s most-cited “experts” had never actually played or even observed the games they studied.

    Similarly, many nicotine researchers seem to have never held or used the noncombusted products they study. This leads to findings that don’t reflect real-world situations. One example is an article by Sebastien Soulet and Roberto Sussman on metal contents of e-cigarette aerosols. They found that researchers were overheating tank vaping devices, generating aerosols that would be “likely repellent to human users.”

    “I think there’s a big disconnect and abysmally low involvement of actual consumers, the people affected by policies,” says Selya. Partnering with people who actually know and use novel nicotine products would be a giant step toward improved research quality.  

    References

    Foxon F. (2023). Discordant device/brand reporting among adolescents who used e-cigarettes in the National Youth Tobacco Survey. Nicotine and Tobacco Research. https://doi.org/10.1093/ntr/ntad228

    Joelving F. (2024). Prescription for controversy. Science. https://www.science.org/content/article/questionable-firms-tempt-young-doctors-with-easy-publications

    Selya A, Ruggieri M, Polosa R. (2024). Measures of youth e-cigarette use: strengths, weaknesses and recommendations. Frontiers in Public Health. https://doi.org/10.3389/fpubh.2024.1412406

    Soulet S, Sussman RA. (2022). A critical review of recent literature on metal contents in e-cigarette aerosol. Toxics. https://www.mdpi.com/2305-6304/10/9/510

    Vansickel A et al. (2022). Human abuse liability assessment of tobacco and nicotine products: approaches for meeting current regulatory recommendations. Nicotine and Tobacco Research. https://doi.org/10.1093/ntr/ntab183

    Cheryl K. Olson is a California-based public health researcher who specializes in behavioral health issues and consults on tobacco product behaviors via McKinney Regulatory Science Advisors. She spent 15 years on the faculty of Harvard Medical School.
  • Quitting Camel Country

    Quitting Camel Country

    Photo: Medwakh

    Dokha, shisha, vapes: THR in the Middle East region

    By Cheryl K. Olson

    Tobacco has been part of daily life in the Middle East since the 1600s. An archeology journal describes excavations in Istanbul uncovering “massive numbers” of broken clay tobacco pipes from the centuries before the rise of cigarettes. Some of the highest smoking rates in the world are found in Middle East nations. Over half of men in Jordan smoke, for example.

    “The Middle East has got an extremely long culture in terms of smoking. That’s going to be really hard to turn round,” says Harry Shapiro, a U.K.-based educator who reports on global tobacco harm reduction. Based on data from the World Health Organization, smoking was projected to decrease among men in the region by less than 2 percentage points, from 33.1 percent in 2010 to 31.2 percent in 2025.

    Most of the top causes of death in countries in the region are either caused or worsened by smoking. New approaches are urgently needed. Yet there is a frustrating lack of information on where and how to start. A 2024 WHO report on global tobacco use trends notes that data in the Eastern Mediterranean region “are the least robust,” i.e., limited or outdated.

    What’s different about the Middle East when it comes to tobacco use? What’s the need for tobacco harm reduction? And what factors might support or block the uptake of reduced-risk products?

    Shisha, Dokha, Shammah

    A U.S. university professor who has studied tobacco use trends in the region (and asked to remain anonymous) shared his local experiences and findings with me. One issue he faced was collecting information on reduced-harm products not yet authorized by regulators. Given Middle East government policies, researchers can’t ask questions about illegal behaviors. “I could be compelled to give individual-level data regardless of what people signed about confidentiality,” he said.

    After the United Arab Emirates legalized e-cigarettes, his surveys found that vapes were widely used. “People shifted back and forth between cigarettes, e-cigarettes and a local tobacco called dokha, which means “dizzy.” Because you can inhale the equivalent of one cigarette’s worth in one or two quick puffs,” he said (see “Old School, Modern Market,” Tobacco Reporter, August 2014.)

    Tobacco use in the Middle East has largely centered on three products. Cigarettes currently dominate, with use rates hovering around 30 percent for men. In most of the region, smoking is culturally unacceptable for women. Given the reluctance to admit to smoking, reported female use rates of about 2 percent may in reality be several times higher. In Lebanon, the professor noted, women can openly smoke. There, use rates are around 30 percent for both genders. Concerningly, his colleagues in that country feel that Lebanon is the tobacco use trendsetter for the region.

    A second popular regional product is shisha tobacco, smoked through a water pipe or hookah. Use reportedly increased in the 1990s when flavored products emerged. “Previously, it was mostly grizzled old men in coffee shops,” the professor noted, “but the new products weren’t harsh or unpleasant in taste and became trendy among young people.” A 2020 review of research found “alarmingly high” use among university students in the region, including by women.

    Hookah smoking is a social activity. A college student in Abu Dhabi might go out with friends and smoke hookah once or twice a week or once per month. However, some users are addicted and will smoke daily.

    What sets shisha apart is the communal pipe. “There might be multiple hoses, but you’re still breathing through the same water and sharing germs,” the U.S. professor noted. “A session might go on for an hour and generate the same volume of smoke as five packs of cigarettes.” This means exposure to a huge quantity of smoke, even at the secondhand level. Even worse? Inhaling toxins and carbon monoxide from the charcoal burned to heat the waterpipe.

    Finally, there is dokha. This powdered tobacco comes in different varieties and strengths and is often mixed with herbs, spices and other substances. Dokha is smoked in a small pipe (usually wooden) called a midwakh. Some users perceive it as a safer alternative to smoking, but the limited research suggests that dokha may give off more toxins than cigarettes. Despite dokha being as common as cigarettes in countries such as the UAE, published studies on dokha use, effects and cessation have been rare.

    A regional oral tobacco product also merits mention and more study. Shammah is reportedly common in Saudi Arabia and Yemen. Locally made by mixing ground tobacco leaf with flavorings (including lime, ash, black pepper and oils), shammah contains a variety of potential carcinogens, including nitrosamines.

    Reducing Risk

    Several countries in the Middle East (such as Iran, Oman and Qatar) still ban e-cigarettes, and others (e.g., Saudi Arabia) ban snus. But in general, the region has bucked the global trend, loosening regulations on vaping and heated-tobacco products. Nicotine pouches are largely unregulated. (See the Global State of Tobacco Harm Reduction website, GSTHR.org, for country-by-country information.)

    More research is critically needed to help channel information and support to those Middle Eastern subgroups most endangered by their tobacco use behaviors. University students who occasionally smoke shisha, for example, likely face minimal risk.

    Most evidence on vaping originates from North America and Europe. As a recent paper on e-cigarettes in the Middle East points out, studies within the region suffer from “overreliance on university-based samples, the overuse of non-user samples, a lack of studies on behavior change, high variance in existing data and a lack of uniform instruments to measure e-cigarette use.”

    Shisha is a good example of the need for cultural sensitivity in promoting smoking cessation or a switch to less risky alternatives. “For hookah, people smoke very much for the social reason. It’s a social construct, not an addiction construct,” said the U.S. professor. “Most cessation interventions have not really worked because most have thought about hookah like cigarettes, with nicotine-replacement therapy and counseling.”

    As one college student in the UAE told him, “People don’t drink alcohol here. There are no drugs. We need a way to hang out with our friends.” Effective reduced-risk substitutes for waterpipe smoking must deliver that.

    Companies have begun creating reduced-harm products specifically for Middle East countries.

    For example, Dubai-based ANDS (short for alternative nicotine-delivery solutions) makes vaping and heated-tobacco products. A company called OOKA has developed a charcoal-free shisha device. Philip Morris International recently acquired a stake in Eastern Co., Egypt’s largest tobacco producer, with a stated goal of providing alternatives to cigarettes for adults who smoke.

    New technologies can make an attractive contrast to smelly old-fashioned cigarettes. “A lot of the vaping devices are really quite geeky—like a fancy electronic gadget that happens to deliver nicotine,” notes Shapiro. “They have touch-screens, and you can chart use on your laptop. So that’s likely to appeal to the younger generation of more wealthy urban groups” in the region. However, such products are likely to reach few lower income or rural people who smoke.

    Shapiro notes that two things are necessary for reduced-harm nicotine to gain a foothold and start displacing cigarettes. First, “Governments have got to be prepared to get tough on smoking: banning smoking in public areas and such.” Second, there needs to be proportionate promotion of novel products, including lower taxes versus cigarettes, and education that supports the option of harm reduction alongside cessation. As a recent Lancet commentary (by former WHO leadership) notes, “In some countries, substantial reductions in smoking prevalence have coincided with novel nicotine products.”

    “If a country does ban safer nicotine products, look at how much it relies on the tobacco industry—in terms of revenue from taxation or whether the country grows tobacco or exports it,” says Shapiro. “If state regulation is sympathetic, then these products will find a way into the shops.”

    The presence of the World Vape Show in Dubai, starting in 2021, sent a message that these alternatives could be acceptable. I will be part of two panels at the 2024 Global Vape Forum, which accompanies this year’s Dubai vape expo. We will stress the need to save lives by moving people off combustible tobacco, whether through cessation or switching to reduced-risk products.

    Getting doctors on board with harm reduction is another important step. Like their colleagues around the globe, Middle Eastern physicians frequently misperceive nicotine as the cause of cancer and other health risks of tobacco. Region-specific studies of doctors’ perceptions and needs are essential. I could locate only one small study. A 2019 Egyptian survey found that doctors were aware of e-cigarettes but viewed them less positively than their patients.

    Cheryl K. Olson is a California-based public health researcher who specializes in behavioral health issues and consults on tobacco product behaviors via McKinney Regulatory Science Advisors. She spent 15 years on the faculty of Harvard Medical School.

    References

    Al-Hamdani M, Hopkins DB (2023). E-cigarettes in the Middle East: The known, unknown, and what needs to be known next. Preventive Medicine Reports. https://doi.org/10.1016/j.pmedr.2022.102089

    Beaglehole R, Bonita R (2024). Harnessing tobacco harm reduction. The Lancet. https://doi.org/10.1016/S0140-6736(24)00140-5

    Fouad H, Commar A, Hamadeh RR et al. Smoking prevalence in the Eastern Mediterranean region. Eastern Mediterranean Health Journal. 2020;26:1. www.emro.who.int/emhj-volume-26-2020/volume-26-issue-1/smoking-prevalence-in-the-eastern-mediterranean-region.html

    Nasser AMA, Geng Y, Al-Wesabi SA (2020). The prevalence of smoking (cigarette and waterpipe) among university students in some Arab countries: A systematic review. Asian Pacific Journal of Cancer Prevention. https://journal.waocp.org/article_88992.html

    Samara F, Alam IA, ElSayed Y (2021). Midwakh: Assessment of levels of carcinogenic polycyclic aromatic hydrocarbons and nicotine in dokha tobacco smoke. Journal of Analytical Toxicology. https://doi.org/10.1093/jat/bkab012

    Raj AT et al (2019). Systematic reviews and meta-analyses of smokeless tobacco products should include shammah. Nicotine and Tobacco Research. https://doi.org/10.1093/ntr/nty144

  • Real-World Quitting

    Real-World Quitting

    Photo: Pressmaster

    What we know, and don’t, about how people stop smoking

    By Cheryl K. Olson

    Skip Murray was a failure at quitting. After trying countless times over the years to stop smoking, she was through. When she chose to try e-cigarettes, she says, “I had no intention of making a quit attempt. The purpose of my vape was to use it only when I could not smoke, as a temporary substitute.” Four months later, Murray realized that she could not remember the last time she’d lit up. She had accidentally quit smoking.

    Randomized controlled trials are the widely acknowledged gold standard in research. They are great for establishing whether a particular approach can create a meaningful effect. Thus, trials of smoking cessation methods typically recruit people who intend to quit, and assign them to use specific products in particular ways. The downside? This approach fails to capture the messy quitting experiences of millions. This includes Murray, a Minnesota-based tobacco harm reduction advocate and writer.

    Reviews by the Cochrane Collaboration that incorporate randomized trials and other planned intervention studies assure us that e-cigarettes have the potential to help people quit smoking. The Centers for Disease Control and Prevention’s National Health Interview Survey says 7.5 million adult Americans stopped smoking completely from 2020 to 2022. But how did they do it? Are people in the real world using reduced-harm alternatives to kick the habit?

    Raymond Niaura, professor of epidemiology at the New York University School of Global Public Health, has been looking into this. “Over the years, there have periodically been reports that have come out talking about methods people use to quit smoking or try to quit,” he says. “But most information is out of date.”

    For example, the 2014–2016 National Health Interview Survey (NHIS) listed 10 possible quit methods. The two most popular were giving up cigarettes all at once (a.k.a., “cold turkey”) and gradually cutting back. Although those unaided methods are popular, they aren’t considered to be evidence-based and often result in relapse down the line. E-cigarettes were a distant third in popularity but ahead of nicotine patches or gum. Most people indicated trying multiple quit methods.

    How We Quit Now

    Niaura and statistician Floe Foxon were already doing some analyses of NHIS data. They decided to detour and look at the latest publicly accessible figures on quitting methods, from 2022. Study participants who had stopped smoking completely in the previous two years were asked whether they had used any of a list of methods. They were also asked whether they had tried “to quit by switching to electronic or e-cigarettes.”

    “We found that use of e-cigarettes was pretty high. In fact, it was the No. 1 method used to quit smoking,” says Niaura. “That caught me a little by surprise.” These results hint at a quiet revolution. E-cigarettes may be playing a larger role than popularly assumed, in both attempted and successful quitting.

    Niaura and Foxon presented a poster of their findings at the March 2024 annual meeting of the Society for Research on Nicotine and Tobacco. Updated and expanded results will be published shortly. (Foxon consults for Juul through Pinney Associates. The poster and paper received no funding.)

    Survey Letdowns

    The NHIS is unusual in that it directly asks people how they stopped smoking. Most studies simply don’t ask. Nationally representative data on this question is surprisingly scarce. The alphabet soup of U.S. government studies such as NHANES, BRFSS and NSDUH inquire only about whether someone smokes now or used to smoke.

    Even the NHIS doesn’t ask annually about quitting. Because the survey covers a massive range of health issues, questions are often dropped or altered. The 2024 version asks whether in the past 12 months “a doctor, dentist or other health professional advised you about ways to stop smoking or prescribed medication to help you quit.” This is a worthy variation, but the approach thwarts year-to-year comparisons of change.

    Researchers are left to puzzle over what little information they can get. For example, the U.S. Food and Drug Administration’s Population Assessment of Tobacco and Health (PATH) survey asks about past-30-day use of cigarettes and electronic nicotine-delivery systems (ENDS). Because participants complete a series of PATH surveys over time, we can see that the link between quitting smoking and using ENDS has gotten stronger over time.

    Another problem with surveys? Varying or missing options for answers. In the 2022 NHIS, says Niaura, “We don’t know how many people quit cold turkey with no assistance. They didn’t ask that.” Instead, the response options included a variety of nicotine-containing medications and several behavioral help options, such as telephone quit lines and counseling. NHIS asked about ENDS but didn’t inquire about quitting smoking via other nonmedicinal reduced-risk products, such as pouches, snus or heated tobacco.

    Shifting response options do give glimpses into how assumptions change over time. “Back in the 1950s and 1960s, people were interested in things like, did you switch to a pipe or cigar to help you quit smoking,” notes Niaura. Oddly, the 2014–2016 NHIS questionnaire included the discredited cessation option of “switched to ‘mild’ cigarettes.”

    A third problem with nationally representative surveys is that they can’t tell us how people go about quitting. “We don’t really understand the whole process,” says Niaura. “The high numbers in the [NHIS] survey mean this is a frequent occurrence, that smokers are using e-cigarettes and quitting. How come there’s not a ton of research being conducted on those kinds of questions?

    Harking back to Murray’s experience, Niaura notes that many smokers “didn’t set a quit date, make a plan and go out and buy some e-cigarettes. And it still worked.”

    “So, what’s happening there?” he wonders. “What’s their experience along the way? What difficulties do they run into? Where are they getting advice?”

    Finally, Niaura ponders how e-cigarettes might be made even more effective, perhaps with some form of counseling and support, such as vape shops have provided to customers. With vape shops closing due to regulatory restrictions, this question deserves urgent attention.

    Regardless of what the government says or doesn’t say, in many ways, we are in a golden era of quit methods.

    Raymond Niaura, professor of epidemiology, New York University School of Global Public Health

    Success Factors

    A few studies have looked at factors linked to successful quitting with e-cigarettes. In a 2021 online survey, vaping more often throughout the day was linked to good outcomes. So was an abrupt switch from smoking to vaping rather than a gradual one. Using a newer device type (e.g., rechargeable pods) rather than older cig-a-like products also helped. Researchers also noted that “most people reported trying more than one e-cigarette flavor and more than one device type when trying to quit smoking.”

    A qualitative study used online individual interviews with people who had quit smoking with e-cigarettes, looking for factors that separated long-term success from short-term attempts. Those who gave up had trouble finding a vape they could stick with that met their needs and prevented cravings.

    I asked Murray for a reality check. To her, it makes sense that newer vaping devices could more effectively help people quit smoking. “I tried a cig-a-like. I didn’t like anything about it—how it felt, what the hit was like or how it tasted,” she says. “It was more satisfying to smoke!”

    She noted that, as with all new technologies, vaping devices have improved along the way. “There were issues with earlier products that leaked or weren’t reliable.”

    Based on her experience as a former vape shop owner, Murray found that for people who smoked heavily, the newer pod systems that use nicotine salts can be a game changer. “Those products provide enough nicotine to replace what they got from combustible tobacco,” she states.

    “A Golden Era”

    Niaura finds it frustrating that the FDA does not do more to promote the visibility of studies like these, including ones that use the FDA’s own PATH survey data. “Regardless of what the government says or doesn’t say, in many ways, we are in a golden era of quit methods,” he points out. “The good news is there are more ways to stop smoking than ever before: e-cigarettes and other reduced-risk products as well as tried-and-true conventional methods.”

    “Go and try something,” he urges. “And if it doesn’t work, try something else.”

    “The one valuable lesson that society should have learned is that there is no one-size-fits-all solution to the smoking epidemic. So no one product is perfect for all consumers,” concludes Murray.

    “Someone who smoked six cigarettes a day for a couple of years has drastically different needs than someone who has smoked two packs a day for 30 years,” she adds. “What part of smoking was most important to them, why they smoked and when or where they smoked are all parts of the equation when it comes to finding what will work best to help them stop.”

    Cheryl K. Olson is a California-based public health researcher who specializes in behavioral health issues and consults on tobacco product behaviors via McKinney Regulatory Science Advisors. She spent 15 years on the faculty of Harvard Medical School.
  • Taking Stock

    Taking Stock

    Image: blacksalmon

    Where are we with ESG?

    By Cheryl K. Olson

    It was once novel, even radical, to talk about making good environmental, social and governance (ESG) practices central to business and investment decisions. Today, ESG is literally front and center on the websites of major tobacco companies.

    Under the heading “Winning with ESG,” Turning Point Brands states, “We recognize that incorporating ESG into our business strategy will support our operating principles of winning with accountability, integrity and responsibility.” Altria has set up a Responsibility Progress Dashboard to track and manage ESG issues.

    Sustainability is now the trending term. Witness Philip Morris International’s Sustainability page, which begins, “For PMI, sustainability is more than just a means to minimize negative externalities and mitigate risks while maximizing operational efficiency and resource optimization.” At Universal Leaf, the first-listed “core belief” is “We believe in our responsibility to make a sustainable impact on our planet.”

    Whether ESG or sustainability, is something meaningful going on here for the nicotine product industry? What are the biggest concerns on the “E” side of things? Below are several perspectives.

    Investor Viewpoints

    Pieter Vorster, managing director at Idwala Research, focuses on tobacco harm reduction and industry transformation. When it comes to tobacco companies, says Vorster, investors may look at ESG from several angles. One is the Tobacco-Free Portfolios perspective, which assumes that there are no good tobacco companies, and all should be excluded from portfolios. Another approach, he says, is “to encourage companies to change, as with the oil industry, and invest in the least bad ones.”

    A third viewpoint looks more at process than product. Tobacco companies can end up in ESG portfolios via “good credentials on other measures like carbon footprint and water,” says Vorster. “BAT, for example, has been in the Dow Jones Sustainability Index for over 20 years.”

    Why the shift from ESG to sustainability? “From an investor perspective, the whole ESG movement is probably slowing,” Vorster says, because it’s no longer a differentiating factor. Rather, environmental and social consciousness is something that’s assumed by both investors and consumers.

    This is why he feels that measures of movement toward reduced-risk nicotine products, such as the Tobacco Transformation Index, can benefit industry. They can help companies stand out on another dimension of ESG. (More on this later.)

    “I think the sustainability label is a bit broader than ESG,” says Vorster. “For me, from an investor perspective, sustainable would be, how long can this business exist? How long can it grow?”

    “Ultimately, most investors care about performance,” Vorster says. “If a company’s environmental credentials are going to impede their share price performance, then they will care.”

    He adds, “That’s also why they care about tobacco companies transforming, because they want a more sustainable business long term. You know, it’s not good business if your products kill half your customers.”

    Investors care about tobacco companies transforming because they want a more sustainable business long term. You know, it’s not good business if your products kill half your customers.

    Pieter Vorster, managing director Idwala Research

    The Litter Issue

    When I was a child, environmental awareness meant “Keep America Beautiful” (KAB) campaigns, telling us “every litter bit hurts.” This included cigarette ends tossed from car windows. To my surprise, KAB is still going. Its website says that “cigarette butts account for 88 percent of litter four inches or smaller.”

    Concerns about cigarette litter have shifted from aesthetics to preventing chemical and plastic pollution. Cigarette filter waste was on the agenda this year at the 10th session of the Conference of the Parties (COP10) to the World Health Organization Framework Convention on Tobacco Control (FCTC). Citing a 2010 study, a COP10 news release says, “An estimated 4.5 trillion cigarette butts are thrown away annually worldwide, representing 1.69 billion pounds of toxic trash containing plastics.”

    Cigarette filters are also the focus of most research literature on tobacco and sustainability. A 2022 editorial in the journal Addiction on the environmental impact of tobacco products advocates banning the sale of filtered cigarettes, or having industry pay for cleanup. As an example of the latter, the writers point to a San Francisco “cigarette litter abatement fee,” which is currently $1.50 per pack, paid quarterly by local cigarette retailers.

    The European Union’s Single Use Plastics Directive has helped spur efforts to develop biodegradable filters. Experiments in recycling are underway, such as a project in Slovakia that plans to mix recycled cigarette filters into asphalt for surfacing roads.

    Sidelining of cigarettes by noncombustible alternatives should gradually reduce filter waste. What about litter issues with newer nicotine alternatives?

    “Next-generation, or reduced-risk, products were generally not a major source of concern on the environmental side until the rise in popularity of disposable vapes,” says Vorster. Waste from disposables is particularly difficult to address because so many are sold illicitly.

    The website of the U.K. Vaping Industry Association (UKVIA) criticizes the lack of interest in and resources for vape recycling from local councils. The UKVIA will host a webinar on April 15 to address the future of vape waste management.

    Concerns about e-cigarette waste have yet to catch fire (pardon the pun) in America. Sustainability is not listed among the “top issues” on the website of the Truth Initiative. Their brief 2023 report on “tobacco and the environment” mentions disposable e-cigarette waste and battery risks but zooms in on pollution and litter from cigarettes.

    David Sweanor, who chairs the advisory board of the Centre for Health Law, Policy and Ethics at the University of Ottawa, views this issue skeptically. “People look for something new to beat up nicotine companies on,” he says. “But your real concern isn’t about disposable e-cigarettes; it’s about batteries. Something less than 5 percent of household batteries sold in the U.S. are properly disposed of. So don’t throw it at the nicotine business or consumers.”

    During a visit to Finland, Sweanor happened upon a creative art installation that turned out to be a battery recycling station. “Because batteries are all different colors, as the container filled up, it’s a beautiful sculpture,” he recalls. “Whoever puts these in hockey arenas and shopping malls—why aren’t we doing things like that?”

    Waste from disposables is difficult to address because so many are sold illicitly. (Photo: Bennphoto)

    Concern About Carbon/Water Footprint

    Nowadays, we care less about “litterbugs” and more about carbon footprints. In her 2024 closing address to COP10, Adriana Blanco Marquizo, head of the FCTC Secretariat, emphasized environmental protection. She cited the “historic decision” to “take account of the environmental impacts arising from the cultivation, manufacture [and] consumption of tobacco products as well as the waste they create.”

    Six years ago, a groundbreaking report from Imperial College London turned attention from smoking’s health harms to the environmental harms from producing 6 trillion cigarettes per year. Researcher Maria Zafeiridou and colleagues looked at “resource needs, waste and emissions of the full cradle-to-grave life cycle of cigarettes” across the globe. As Imperial College’s news release noted, those 6 trillion cigarettes required 22,200 megatons of water, 5.3 million hectares of land, 62.2 petajoules of energy and 27.2 megatons of material resources.

    Synthetic nicotine maker Zanoprima Life Sciences recently released a report comparing the environmental impact (from the raw materials to the factory gate) of their laboratory-made nicotine and nicotine from plants. The report’s author, Eric Johnson of Atlantic Consulting of Zurich, routinely does life cycle assessments of products and services.

    “In some of the work I do, I know what the answer will be before I start,” says Johnson. “But I hadn’t looked at this issue closely.”

    Drawing on data used in the Imperial College study, Johnson found that tobacco-based nicotine (especially when fuel cured) had a substantially larger carbon footprint. Also, synthetic nicotine production doesn’t use up water.

    Johnson was struck by the size of the difference. “When it’s ‘this product has a 15 percent lower footprint than the other guy’s product,’ it’s hard to know,” he says. “But tobacco nicotine’s footprint is multiple times larger. Even with normal error and uncertainty, the result is solid.”

    Clearly, from an ESG standpoint, the big issue has to be that cigarettes are killing 8 million people a year. Not the carbon costs.

    David Sweanor, chair, advisory board of the Centre for Health Law, Policy and Ethics at the University of Ottawa

    What We Can’t Say

    As someone who makes his living as an investor, Sweanor views all of the above as relative trivialities. “Clearly, from an ESG standpoint, the big issue has to be that cigarettes are killing 8 million people a year,” he says. “Not the carbon costs.”

    A “good ESG” cigarette company would move aggressively into reduced-risk nicotine products. But that’s just the first step, says Sweanor. Such companies also have an ethical and legal responsibility to warn their customers.

    “If you’re selling products that are two or three orders of magnitude more hazardous than viable alternatives, you need to tell them. That’s basic ESG standards,” he says. “However, the laws in many countries, including the U.S. and Canada, make it illegal to do that.”

    Educating about and promoting reduced-risk products could create shareholder value and make it easier to hire good employees. “You’d also want to differentially price and have other incentives to nudge consumers toward the less hazardous nicotine products,” he adds. “But companies are precluded from doing all that.” Sweanor calls this “insane.”

    Recent surveys show that ever-fewer people, including those who smoke, think that noncombustible nicotine products are less hazardous than cigarettes. Sweanor imagined what health authorities would do if similar proportions of adults disbelieved that driving drunk increased car crashes. “They’d be totally freaking out and running a major campaign,” he says. “And probably force any companies involved to be part of that effort.”

    He stresses that this is out of industry’s hands. “The responsibility I would lay on the companies,” he concludes, “is that they are not making a big deal out of this.”

    ESG From the Inside

    I asked an industry insider, who’s had senior roles at several major companies, for their unvarnished anonymous view. “There is a lot of snark around the value of things like ESG,” they admitted. “I’ve heard it called ‘window dressing.’”

    They personally disagree with that view, noting that “unsexy” things like constant efforts to reduce manufacturing waste and water use get little publicity.

    “I’ve even heard THR (tobacco harm reduction) called window dressing. But I don’t think that’s true where I work,” they said. “We’d like to stay around for a long time, and we’ve got to do something very different to make that happen. And there is a real sense of pride about this transformation.”

    Cheryl K. Olson is a California-based public health researcher who specializes in behavioral health issues and consults on tobacco product behaviors via McKinney Regulatory Science Advisors. She spent 15 years on the faculty of Harvard Medical School.

    Citations

    Zafeiridou M et al. (2018). Cigarette smoking: An assessment of tobacco’s global environmental footprint across its entire supply chain. Environmental Science & Technology. https://pubs.acs.org/doi/10.1021/acs.est.8b01533

    Zanoprima Lifesciences Ltd. (2024). Carbon and water footprints of tobacco-based vs. synthetic nicotine. https://www.zanoprima.com/updates

    Truth Initiative (2024). Tobacco and the environment. https://truthinitiative.org/research-resources/harmful-effects-tobacco/tobacco-and-environment

    Morphett K et al. (2022). The environmental impact of tobacco products: Time to increase awareness and action. Addiction. https://onlinelibrary.wiley.com/doi/10.1111/add.16046

  • Putting Faith in Cessation

    Putting Faith in Cessation

    Image: doidam10

    The role of religion in encouraging smoking cessation

    By Cheryl K. Olson

    The start of a new year is a perennially popular marker for initiating change. This includes fresh attempts to quit smoking. To that end, the U.S. Centers for Disease Control website features a multilingual “New Year, New Possibilities: Start Living a Smokefree Life Today!” advice and resources page.

    A study of 2018–2020 social media posts expected to find the Covid-19 pandemic linked to more posts on quitting. Nope. Instead, New Year’s resolutions made a difference.

    There’s nothing magic about a new year, of course. But setting some sort of targeted quit date does seem to increase motivation to follow through. A date in the near future—say, a couple of weeks away—seems best. Making a public commitment to quit, and preparing coping aids and skills, may also help.  

    The best thing about New Year’s resolutions is that they provide another chance to try. Research suggests that encouraging more quit attempts adds up to more success. Finding ways to do this is especially important for people who aren’t particularly motivated to quit in the near future.

    One often-overlooked path to encourage the discouraged or unmotivated to make quit attempts comes from religious observations. Major world religions have days every year where smoking is discouraged or forbidden.

     “Jews don’t smoke for 25 hours on Yom Kippur,” says Derek Yach, a physician who focused on smoking cessation at the World Health Organization and the Foundation for a Smoke-Free World. “Muslims refrain during daylight for the month of Ramadan. Some Christians stop during Lent.”

    “This raises the question of how people who smoke can continue quitting post the fast,” Yach adds. “How could you build on that?”

    The role of religion in encouraging smoking cessation deserves a closer look. And what, if anything, do we know about how major religions feel about tobacco harm reduction, including vaping?

    Religion and Smoking: The Basics

    “Systematic evidence of religious affiliation differences in tobacco use is surprisingly limited,” says a recent paper on religion’s role in smoking and vaping. One problem is distinguishing between the effects of religious affiliation, general religiosity and specific beliefs. Overall, studies show that people with no religious affiliation are more prone to smoking. Faiths with clear anti-tobacco positions, such as Seventh-day Adventists and Latter-day Saints, are less likely to smoke.

    Things get murky beyond that. Regular church attendance is often linked to lower smoking, for example. People more engaged with religion may have more nonsmokers in their social networks. Religious doctrines feed into social norms that affect smoking behavior.

    Of course, the texts of most major religions were written before tobacco spread across the globe. This means that religious scholars have had to interpret those texts and issue decrees regarding how smoking (and more recently, vaping) fits or clashes with their doctrines.

    Islam is one example. Until the early 20th century, according to an article in the BMJ, most Muslim jurists did not believe that smoking had any negative health effects. Some thought it might even aid digestion or reduce stress. As evidence of health risks increased, smoking became discouraged (mukrooh). Some scholars and institutions went further and declared smoking to be prohibited (haram). 

    Smoking is not explicitly banned by Christianity, Judaism, Hinduism or Buddhism. But religious values that promote avoiding deliberate harm to the body, and disapprove of addiction, mitigate against smoking.

    At times, religion has been a smoking promoter. The website of the U.S. Conference of Catholic Bishops notes that the Catholic Church played a major role in bringing tobacco to Italy and spreading its use. In 2017, Pope Francis, stating that “No profit can be legitimate if it puts lives at risk,” announced plans to ban Vatican cigarette sales. The Vatican City State reportedly earned €10 million ($10.97 million) per year in profit from smokes sold (sans Italian taxes) through duty-free shops to its citizens and employees, who could purchase 50 or more discounted packs a month.

    Yach has long been intrigued about the potential of religious organizations to combat smoking. “In 1999, when I was at WHO, I convened a meeting through the World Council of Churches,” he recalls. Despite the name, the council represented a range of major religions. The meeting focused on what religions say about tobacco control and smoking.

    “What were the commonalities that suggested they supported tobacco control?” he wondered at the time. “We found there were three: Thou shalt not kill; thou shalt not kill others; and you should tell the truth.”

    Yach has recently returned to studying the issue of faith and health, with a new emphasis on tobacco harm reduction. Religious doctrines are still unsettled on that point. However, Yach notes that in most religions, “to save a life” is the highest value and ought to be supportive of harm reduction.

    In most religions, “to save a life” is the highest value and ought to be supportive of harm reduction.

    Derek Yach, global health expert

    Hitting Pause

    A review of studies on religiosity and smoking cessation found that few actually focused on quitting. There are a handful of published studies on smoking and Ramadan. In most Muslim-majority nations, religion and culture discourage smoking during the daytime fast, both in public and at home. Many Muslims perceived quitting smoking to be easier during Ramadan.

    One Malaysian study of 61 men who smoked found decreased Fagerstrom nicotine dependence scores during and shortly after Ramadan. The Ramadan environment, with most Muslims abstaining from smoking, was credited with helping men to reduce the number of cigarettes smoked or to stop smoking completely. The authors suggested that cessation support from health professionals might boost this effect.

    During Ramadan in 2015, a cessation effort targeted Malay men working in public offices who smoked. The intervention group got a booklet educating on smoking-related health effects and religious rulings as well as practical and motivational tips and religious encouragements. All participants had reduced nicotine dependence scores and saliva cotinine levels during Ramadan, and these remained significant for the intervention group after Ramadan.

    A study in Croatia focused on the first day of Lent, which some Christian groups observe for roughly six weeks leading up to the Easter holiday. Lent is a period of self-denial, which might involve fasting or giving up favored activities. A television and radio campaign for this “smoke out day” led to high awareness, and a quarter of people in the study abstained from smoking for 24 hours. People with lower levels of education were more likely to participate. 

    Religion Meets Technology

    Religion-based smoking cessation efforts could potentially reach groups that conventional methods have failed to help. In the U.S., older adults are more likely to attend religious services, and their smoking rates have been stagnant for the past two decades. The combination of faith communities and new technologies is particularly intriguing.

    One recent study sent twice-daily text messages (half religiously tailored) to 50 Somali Muslim men in Minnesota during Ramadan. Research participants saw the messages as appropriate and encouraging, and they smoked fewer cigarettes per day. Seven quit smoking.

    A published protocol for a new study describes a “Christian faith-based Facebook intervention for smoking cessation in rural communities.” Researchers plan to create and test a private moderated online group that uses peer and pastoral support, accessible to people who lack access to city resources.

    Ideally, we will eventually see studies that add harm reduction innovations, such as e-cigarettes, reduced-risk shisha and heated-tobacco products, to this mix of faith and tech.

    Religion and Harm Reduction

    Religious perceptions regarding reduced-harm nicotine options, such as vaping, are still evolving. Research on vaping and religion is extremely limited. Several studies found that religiosity bears no relationship to e-cigarette use among teens and young adults.

    The Malaysian study that looked at ways to encourage smoking cessation during Ramadan in 2015 was disrupted by the “vaping phenomenon,” with some subjects in both study groups starting to vape. Because vaping was not part of the protocol, it was ignored. A 2023 paper on e-cigarettes in Malaysia grouped “e-cigs, electronic shisha and shisha pens” as haram, along with cigarette smoking, due to perceived health risks.

    Perceptions of effects on health may be important. For example, a 2019 article on Judaism and e-cigarettes gives multiple perceived reasons for prohibiting their use, including that e-cigarettes are dangerous, are a gateway to smoking and are addictive. Further, “even if medical literature has not firmly and definitively established the long-term dangers of e-cigarette use independent of combustible cigarettes, the suspicion that these products are dangerous is sufficient to prohibit their use.”

    Clearly, strong evidence that reduced-harm nicotine products are a positive for health would be needed to overcome these concerns. Spreading credible information, such as the Cochrane review showing that vaping can successfully promote smoking cessation, might show that reduced-risk alternatives can fit with religious doctrines.

    Encouragingly, two recent studies (with the same lead author) looked favorably at e-cigarette use during Ramadan. One looked at vaping preferences and reasons for using e-cigarettes in the United Arab Emirates. A majority reported starting vaping to quit smoking. Over half reported no withdrawal symptoms during the Ramadan fasting time. The second study had a similar focus and findings but took place in Jordan. It noted that “Ramadan offers a good opportunity for smokers to quit, as the reported physical and psychological e-cig withdrawal symptoms were found to be relatively weak.” In both studies, e-cigarettes were accurately perceived as less risky than smoking.

    Faith-Based Harm Reduction

    The challenge now, as Yach sees it, is to think through how to explain harm reduction in clear and meaningful ways to faith-based groups. “People say, well, we don’t want to get into religion. But health is not merely the absence of disease. And the word ‘spiritual’ should be included alongside mental, physical and social well-being.”

    As a parallel, Yach points to the success of faith-based HIV/AIDS programs run through churches: “What’s at the core of an AIDS program? Harm reduction.” Given the billions of people who identify with religious groups, he says, the potential benefit could be huge.

    Cheryl K. Olson is a California-based public health researcher who specializes in behavioral health issues and consults on tobacco product behaviors via McKinney Regulatory Science Advisors. She spent 15 years on the faculty of Harvard Medical School.
  • A Widening Gap

    A Widening Gap

    Image: WindyNight

    Tobacco harm reduction for people with mental health needs

    By Cheryl K. Olson

    “I firmly believe a lot of us, people like me, are self-medicating, pure and simple,” says Skip Murray. A Minnesota-based tobacco harm reduction specialist, Murray began smoking at age 10. She was diagnosed initially with autism and attention deficit/hyperactivity disorder (ADHD) and later with depression, anxiety and post-traumatic stress disorder (PTSD) as well. She vapes to manage her symptoms.

    Brian King, director of the U.S. Food and Drug Administration’s Center for Tobacco Products, has called for greater focus on health equity. One group he cited as disproportionately affected by smoking is people living with mental health conditions. If you’re among this crowd, you are more likely to smoke (and smoke heavily) and less likely to quit compared to the general population.

    Plenty of research details this serious disparity. Among U.S. adults scored as having serious psychological distress (SPD) in the National Health Interview Survey, nearly 40 percent smoked. That’s compared to 13 percent of people without SPD. Of all cigarettes consumed by U.S. adults, nearly one-third are smoked by someone with a mental illness.

    A new analysis of Population Assessment of Tobacco and Health survey data found that among adults ever diagnosed with psychosis, 41 percent had used any kind of tobacco in the past month, and 31 percent had smoked. Having multiple mental health conditions is linked to higher smoking rates.

    The disparity is growing. U.S. national surveys find that smoking rates for those with mental health diagnoses are either stagnant or are declining more slowly compared to the general population. In particular, smoking rates for black and Hispanic adults experiencing serious psychological distress have not budged in years.

    What stands in the way? How can we better support tobacco harm reduction for people with mental health needs and persuade mental health professionals to take smoking seriously?

    A Culture of Smoking

    Historically, mental health care systems tolerated or even encouraged a smoking culture. Smoking breaks helped build relationships between patients and providers. Cigarettes were used as rewards for “good” behavior or for complying with treatment.  

    Studies find that mental health professionals frequently believe that their patients who smoke aren’t interested in quitting. Or that giving up cigarettes is too much to take on when also dealing with mental illness. Many therapists view smoking as not part of their turf but belonging to the physical health side of things.

    Amid the stresses and crises of mental health practice, granting lower priority to smoking cessation may seem practical. But ignoring cigarettes costs their patients years, even decades, of life. A recent editorial in the British Journal of General Practice called smoking the single biggest contributor to the seven-year to 25-year reduced life expectancy for people with mental health conditions.

    “To ignore their smoking, and only focus on their mental health, in the long run harms their overall health,” says Murray. “Why aren’t we looking at why they smoke? Do they not have healthcare, a home, enough food?”

    “I’m more than my mental illness,” she continues. “We need to treat the whole person.”

    Another barrier to encouraging smoking cessation has been lack of research on, and provider knowledge about, effective interventions. People with schizophrenia are at highest risk for earlier death, and their rates of smoking are especially high. Randomized trials suggest that smoking cessation medications are not risky for them to use. The issue is not safety but effectiveness.

    For example, a large Canadian community-based smoking cessation study found that many people with schizophrenia who smoke want to stop. They were as able as others to reduce their smoking but much less successful at quitting altogether.

    For people living with mental health conditions, as with the general population of people who smoke, there is an urgent need for more effective cessation approaches. A 2002 commentary titled “Smokers with Schizophrenia Will Benefit From More Flexible Treatment Approaches” put it this way: “New and creative NRTs [nicotine-replacement therapies] and pharmacological and psychosocial interventions are needed to compete with the high reinforcement value of smoking.”

    Today, we have nicotine alternatives undreamed of in 2002, including e-cigarettes.

    A Role for Vaping?

    In a 2017 review on Smoking, Mental Illness and Public Health, Stanford researchers wrote that “Additional data are needed to more fully understand the long-term potential of [e-cigarettes] for harm/harm reduction, particularly in vulnerable groups of smokers, including those with mental illness.”

    Six years later, many in public health are unfortunately still on the fence about whether vaping causes or reduces harm. We now have high-certainty evidence from a respected Cochrane review of research that vaping works better than NRT to help people quit smoking.

    But what evidence do we have for persons with mental illness in particular? The studies summarized in the Cochrane review either didn’t mention mental health or specifically excluded people with conditions such as depression, anxiety and psychosis from participating.

    More often than not, even the newest studies on helping people with mental illness quit smoking ignore the existence of vaping and other non-NRT nicotine options. However, evidence from recent population surveys that give results for people with mental health conditions suggests that vaping merits a closer look.

    A 2023 report analyzed data on people reporting depression and anxiety from the 2018 and 2020 Four Country Smoking and Vaping Surveys. The authors state, “It appears that smokers with depression are motivated to quit smoking but were less likely to manage to stay quit and more likely to be vaping if successfully quit.”

    A 2020 English population survey report by Brose and colleagues found that smokers with mental health problems were just as likely as others to successfully quit smoking if they tried. People who had ever had a mental health diagnosis were nearly four times more likely to choose vaping over nonprescription NRT (37 percent versus 9.8 percent) when making quit attempts—more than the sample overall. The authors suggest that “e-cigarettes used in quit attempts currently are more likely to positively affect inequalities than other smoking cessation interventions,” especially if their reach among people with mental health problems can be increased.

    Wanted: Better Studies

    Caponnetto and Polosa have summarized the results of some small but promising studies, involving first-generation or second-generation e-cigarettes, to help people with schizophrenia spectrum disorders stop smoking. Vaping showed potential as an acceptable substitute even among people with severe mental illness who don’t intend to quit smoking. Are larger studies in the research pipeline?

    A 2021 research letter in JAMA Psychiatry describes registered clinical trials looking at e-cigarettes to reduce or stop smoking. Just eight of the 66 ongoing or completed trials recruited individuals who smoke who have a psychiatric condition. The authors note that very few studies (and no completed ones) tested “newer e-cigarette devices that are designed to deliver nicotine more similarly to cigarettes.” They call for more, higher quality studies. We’ll keep an eye out.

    Ways to encourage harm reduction after inpatient mental health treatment also need more study. A 2023 U.K. study by Shoesmith and colleagues in Nicotine & Tobacco Research describes the development of a complex behavior change intervention to follow discharge from a smoke-free mental health stay. You have to dig into the supplemental material to find that mental healthcare worker training in use of e-cigarettes is part of the recommended intervention.

    We need more research to better understand what may block or encourage people with mental health conditions from trying and switching to vaping. A 2017 study analyzed discussions on Reddit by people with mental illness about motivations and limitations associated with vaping. Self-medication was a common theme.

    One person who reported PTSD and anxiety wrote, “For me, vaping is pretty much the same as smoking, in terms of how it helps me calm down and handle stress.”

    Many wrote on Reddit about the importance of education about and support for vaping from friends, family and online communities. Informed mental health professionals could likely play a critical role in saving lives. A U.K. study found that among people who have used tobacco, those with serious mental distress are more likely to have inaccurate harm perceptions of nicotine and nicotine products, including vaping.

    “A Clear and Definite Message”

    A U.K. government-funded community interest company, the National Centre for Smoking Cessation and Training, just released a much-needed guide to vaping for health and social care professionals. The guide states that “some people from disadvantaged groups may vape for temporary abstinence (e.g., at work or while in a mental health inpatient setting) before deciding to switch completely.” Also, “it is important that people from disadvantaged groups receive a clear and definite message that vaping is much less harmful than smoking.”

    Some mental health professional associations have endorsed vaping, however grudgingly or conditionally. For example, the Royal Australian and New Zealand College of Psychiatrists issued a sensible e-cigarette position statement in 2018 (due for updating soon). Acknowledging the high smoking prevalence and low quit rates among people who live with mental illness, they say that “e-cigarettes and vaping devices may provide a less harmful way to deliver nicotine to those who are unable or unwilling to stop smoking tobacco.”

    The college would like more data on vaping’s long-term health effects and on switching success. However, “This does not justify withholding what is, on the current evidence, a lower-risk product from existing smokers while such data is collected.”

    The position of the U.K. Royal College of Psychiatrists is similarly pragmatic. Vaping devices, they note, have become the most popular real-world quit-smoking aid. Although using neither is preferable, “using an EC [electronic cigarette] is always better than smoking a cigarette.”

    By contrast, a 2022 position statement on vaping products from the American Psychiatric Association does not mention harm reduction. They focus only on potential risks to youth.

    Knowledge can flow the other way, from patient to mental health professional. Murray received counseling for a year from a therapist who was initially highly skeptical of vaping. “She was one of those who believed that nicotine causes cancer and depression,” Murray recalls.

    After seeing the difference in Murray’s focus when she had forgotten her vape at work and gone without nicotine for hours, the therapist became curious. “That’s when we figured out that nicotine helps my ADHD,” Murray says. Upon request, she shared published studies on nicotine and mental health with her therapist.

    Adds Murray, “It was cool to meet somebody who was willing to look at information and think about if what they believed was actually true.”

    Cheryl K. Olson is a California-based public health researcher who specializes in behavioral health issues and consults on tobacco product behaviors via McKinney Regulatory Science Advisors. She spent 15 years on the faculty of Harvard Medical School.
  • Surprising Successes

    Surprising Successes

    Image: chokniti

    The uncelebrated triumphs of tobacco harm reduction

    By Cheryl K. Olson

    U.S. smokeless tobacco users are no more likely to die from cancer than people who never touched tobacco products. This unexpected news comes courtesy of the National Longitudinal Mortality Study. Compared to those who never used tobacco, current users of smokeless products do not have elevated mortality risks from all cancers combined.

    This was just one happy fact I ran across when writing articles for doctors summarizing alternative nicotine product risks and benefits. I felt a similar “Wow! Really?” writing recently for this magazine about today’s astonishingly low youth smoking rates. 

    It’s time to stop, notice and give a cheer for good news about tobacco harm reduction (THR) that doesn’t get enough attention. Interesting evidence from research studies, natural experiments and everyday life observations ought to be shared.

    This is not just about raising smiles. The accumulated weight of these bits of information can change mindsets. They can influence how future studies are framed and which policies are proposed and implemented.

    I asked colleagues involved in harm reduction to suggest examples to celebrate. They include:

    • reduced-risk options that knocked down smoking in a particular nation or subgroup;
    • unexpected positive shifts in behavior, such as people who try vaping and notice one day that they no longer smoke;
    • harmful behaviors we were worried about that, to our relief, don’t seem to be happening (i.e., vaping as a gateway to youth smoking);
    • and finally, personal observations about the effects of THR.

    Transforming the Map

    We can’t say it often enough: cigarette smoking is still the leading preventable cause of disease and death in the U.S. It kills millions worldwide every year. Preventing cigarette use and helping people who don’t quit to consider lower-harm alternatives are medical and moral imperatives.

    As pioneering nicotine researcher Karl Fagerstrom has said, “Realistically, no single alternative nicotine product category will be able to reduce smoking rates and the associated disease burden.” Individuals and nations will find different options appealing and acceptable. His article “Can Alternative Nicotine Products Put the Final Nail in the Smoking Coffin?” highlights five nations’ successes. In the U.K., Sweden, Norway, New Zealand and Japan, higher uptake of alternative nicotine products has meant lower smoking rates compared to their neighbors.

    According to the Associated Press, “Sweden, which has the lowest rate of smoking in the Europe Union, is close to declaring itself ‘smoke-free’—defined as having fewer than 5 percent daily smokers in the population.” As of 2022, they had reached 5.6 percent. Thanks in large part to snus, Sweden has the lowest tobacco-related mortality among men in Europe.

    David Sweanor of the Centre for Health Law, Policy and Ethics at the University of Ottawa regularly monitors tobacco company behavior. When Japan Tobacco released their second-half results in July, he noted the “extraordinary” shift in Japan’s tobacco use.

    “Overall, the cigarette market has declined by half since heated products were introduced,” Sweanor says. “It is important to note that Japan has achieved this dramatic decline in cigarette smoking without policies actively encouraging the change.” 

    Roberto Sussman of the National Autonomous University of Mexico UNAM challenges us to look at the inverse proposition. “In the last 20 years, is there one case—a country, a subpopulation—of a significant reduction in smoking prevalence in which any effect or influence from usage of noncombustible products can be absolutely ruled out?” he asks. “I doubt there is a single case.” 

    Natural experiments created by bans on e-cigarettes in some U.S. states offer added noteworthy support for vaping as an effective substitute for smoking. Compared to “control” states with no full or partial e-cigarette bans, the states of Massachusetts, Washington and Rhode Island saw increased cigarette sales.

    Inadvertent Quitting

    Personal stories and research have shown that taking up vaping can mean putting down cigarettes—for people who initially had no plans to quit. This includes analyses by Karin Kasza and colleagues of widely respected ongoing studies such as the Population Assessment of Tobacco and Health (PATH) and the International Tobacco Control Four Country Smoking and Vaping surveys (of the U.S., Canada, Australia and England).

    A recent systematic review by Elias Klemperer and colleagues found little evidence that conventional smoking cessation methods induce quit attempts among those without plans to do so. “The optimal treatment (or treatment combination) for this population remains unclear,” the authors state.

    “No one ever ‘quit by accident’ with a nicotine patch, nicotine gum, nicotine lozenges, nicotine inhalers, Chantix/Campix, bupropion or smoking cessation counseling,” says Charles A. Gardner of Harm Reduction Strategies. “But millions of smokers who had no intention to quit have ‘quit by accident’ with nicotine vapes.”

    Gardner believes this point deserves more attention. “If 75 percent of smokers claim they want to quit, then obviously 25 percent have no intention to quit,” he says. “No approved smoking cessation intervention will ever reach them. Nicotine vapes do.”

    A related finding that deserves notice: Researchers at the U.S. Food and Drug Administration’s Center for Tobacco Products published evidence that mint/menthol ENDS users were more likely to switch and quit than tobacco-flavored e-cigarette users. The authors refer to additional research that identified better switching odds with nontobacco-flavored products.

    Gateway or Diversion?

    I previously reported on the unanticipated and little-lauded plunge in U.S. youth smoking rates (“Where’s the Parade?,” Tobacco Reporter, March 2023). The 2022 National Youth Tobacco Survey found that one in 10 (10.9 percent) high school students had ever tried a cigarette. Just 2 percent reported smoking in the past 30 days.

    Although youth vaping is down from its 2019 peak, e-cigarettes are the most common nicotine product used by teens. Past-month use stands at 14.1 percent. Concerns have persisted among researchers and policymakers that vaping could lead youth who wouldn’t otherwise smoke to start.

    Recently, more sophisticated assessments have challenged that connection. PATH study analyses by Kenneth Warner of the University of Michigan and colleagues show that few teens become established smokers regardless of previous e-cigarette use. When other known risk factors for youth smoking are taken into account, it turns out that ever-use of e-cigarettes makes a trivial difference. 

    Rather than leading teens down a path to smoking, e-cigarettes seem more likely to divert teens away. A new article by Christine Delnevo and Andrea Villanti of Rutgers University does a deep dive into national trends in high school student smoking since 1991. They found that “the most rapid declines in cigarette prevalence have occurred in the past decade, when e-cigarettes emerged as a popular product among youth.”

    THR in Daily Life

    A scientist who has worked in harm reduction inside and outside of industry points to an under-praised behavior shift in one important subgroup: people who work in nicotine product companies. At both the offices of a large e-cigarette maker and at a legacy multinational tobacco company, “I’ve never seen or known someone to smoke,” they said. “Even at a bar or outside of the office. But plenty of people vape or use other alternatives. And most, if not all, were former smokers.”

    Their conclusion? “Reduced-risk product availability and a culture of acceptance actually change behavior.”

    Christopher Greer, CEO of TMA and president of The GTNF Trust, described how tobacco harm reduction principles benefited his health in unexpected ways. “When I met my wife, I was very heavy—coming up on 260 pounds. I had a dependency on food for stress relief, and a stressful job.” He found that the typical advice from health professionals (e.g., cut out junk foods and fast food) didn’t fit his situation. Nor did a pharmaceutical option.

    “Utilizing principles I knew from THR, I crafted a risk reduction plan for my eating,” Greer says. For example, he identified and targeted situations that put him at high risk for overeating. “It was incredibly difficult, but a decade later, I’m a much healthier, stable weight.”

    Greer likens his transformation to transitioning to reduced-risk tobacco products: “another form of people finding agency in their own health decisions, when standard treatment isn’t working.”

    Citations

    Chang JT et al. (2023). Characteristics and patterns of cigarette smoking and vaping by past-year smokers who reported using electronic nicotine-delivery systems to help quit smoking in the past year: Findings from the 2018–2019 Tobacco Use Supplement to the Current Population Survey. Nicotine & Tobacco Research. https://doi.org/10.1093/ntr/ntac199

    Delnevo CD & Villanti AC (2023). Dramatic reductions in cigarette smoking prevalence among high school youth from 1991 to 2022 unlikely to have been undermined by e-cigarettes. International Journal of Environmental Research and Public Health. https://doi.org/10.3390/ijerph20196866

    Fagerstrom K (2022). Can alternative nicotine products put the final nail in the smoking coffin? Harm Reduction Journal. https://doi.org/10.1186/s12954-022-00722-5

    Kasza KA et al. (2021). Association of e-cigarette use with discontinuation of cigarette smoking among adult smokers who were initially never planning to quit. JAMA Network Open. https://jamanetwork.com/journals/jamanetworkopen/article-abstract/2787453

    Kasza KA et al. (2023). Associations between nicotine vaping uptake and cigarette smoking cessation vary by smokers’ plans to quit: longitudinal findings from the International Tobacco Control Four Country Smoking and Vaping Surveys. Addiction. https://onlinelibrary.wiley.com/doi/10.1111/add.16050

    Klemperer EM et al. (2023). A systematic review and meta-analysis of interventions to induce attempts to quit tobacco among adults not ready to quit. Experimental and Clinical Psychopharmacology. https://psycnet.apa.org/doi/10.1037/pha0000583

    Sun R et al. (2023). Association of electronic cigarette use by U.S. adolescents with subsequent persistent cigarette smoking. JAMA Network Open. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2802764

    Sun R et al. (2022). Is adolescent e-cigarette use associated with subsequent smoking? A new look. Nicotine & Tobacco Research. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8962683/

    Timberlake DS et al. (2017). A longitudinal study of smokeless tobacco use and mortality in the United States. International Journal of Cancer. https://onlinelibrary.wiley.com/doi/10.1002/ijc.30736

    Xu Y et al. (2022). The impact of banning electronic nicotine-delivery systems on combustible cigarette sales: Evidence from U.S. state-level policies. Value in Health. https://doi.org/10.1016/j.jval.2021.12.006

    Cheryl K. Olson is a California-based public health researcher who specializes in behavioral health issues and consults on tobacco product behaviors via McKinney Regulatory Science Advisors. She spent 15 years on the faculty of Harvard Medical School.
  • Correcting The Record

    Correcting The Record

    Photo: Yeti Studio

    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.

    Dangerous Misinformation

    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

    “Diverse public audiences” who smoke and die at unacceptably high rates should get top priority attention from the FDA. These include people in custody and persons with serious mental illnesses.

    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.”

    Cheryl K. Olson is a California-based public health researcher who specializes in behavioral health issues and consults on tobacco product behaviors via McKinney Regulatory Science Advisors. She spent 15 years on the faculty of Harvard Medical School.