Category: Harm Reduction

‘Vuse Authorization a Positive for Harm Reduction’

Photo: R.J. Reynolds Vapor Co.
More governments need to follow the science.
By Derek Yach
The evidence is in. For the first time, the U.S. Food and Drug Administration has authorized the marketing of an e-cigarette in the country because it determined the help it offers adult smokers outweighs the attraction such products may hold for youth.
The decision to allow the sale of British American Tobacco’s Vuse Solo closed electronic nicotine-delivery system, along with three tobacco-flavored cartridges, marks the third time in less than two years that the agency, despite vociferous, emotion-driven opposition from politicians and interest groups, has used peer-reviewed scientific evidence to approve tobacco harm reduction (THR) products.
With this latest move, the FDA has signaled a distinct turn in the oft-contentious debate surrounding e-cigarettes, in which opponents claim little is known about what toxic chemicals they contain and that the tobacco industry has a terrible track record when it comes to being forthcoming about its products.
That was not the case here, indicated Mitch Zeller, the director of the agency’s Center for Tobacco Products. “Today’s authorizations are an important step toward ensuring all new tobacco products undergo the FDA’s robust scientific premarket evaluation,” he said in a statement. “The manufacturer’s data demonstrates its tobacco-flavored products could benefit adult smokers who switch to these products—either completely or with a significant reduction in cigarette consumption—by reducing their exposure to harmful chemicals.”
We have said it before, and we’ll continue to say it again (and again and again) in the face of all this misinformed vitriol and distrust: THR products are effective tools to help smokers lessen their risk of developing diseases such as lung cancer and COPD. So says one study after the next, including a recent measured, sober look at the risks and benefits of e-cigarettes that is signed by no less than 15 former presidents of the Society for Research into Nicotine and Tobacco, a leading international proponent of evidence-based science.
The key word here is “evidence.” Although e-cigarettes are not risk-free, they have been found to be up to 95 percent less harmful than combustible cigarettes because they contain no tar and significantly fewer chemicals that make up the toxic stew of smoke in combustible cigarettes.
Evidence, carefully compiled, weighed and debated, is how the FDA reached its earlier decisions to provisionally authorize the sale of Swedish Match’s snus and Philip Morris International’s IQOS heat-not-burn sticks as modified-risk tobacco products (MRTPs), subject to regular review. And “evidence” is how it made its first decision to approve the marketing of Vuse.
It reached its decision through dispassionate, rigorous diligence—a risk-proportionate, microscopic gauging of the potential harm e-cigarettes pose for young people versus their potential therapeutic uses for adults who smoke combustible cigarettes and would like a less damaging alternative. Indeed, the FDA’s approval process is so thorough, it is accepted as the international gold standard for vaccines, pharmaceuticals and medical devices. As Adam I. Muchmore, a Pennsylvania State University law professor, explained last month [August] in an interview with Newsweek about the wait for Covid-19 vaccine approval, “There are a lot of ‘i’s’ to be dotted and ‘t’s’ to be crossed, and these are not simple bureaucratic requirements. Both producing this data, and reviewing it, requires the work of multiple experts in a wide range of scientific fields.”
We hope the FDA will continue to use scientific evidence to approve the sale of menthol-flavored e-cigarettes so that combustible menthol cigarette users, among them the majority of African-American smokers, also have the opportunity to reduce their health risk. And we hope it will consider that nicotine-replacement therapy gums and sprays are already marketed in menthol and other flavors, all to help smokers quit.
One does not need to look far to see the effects of FDA decisions: Following its full approval last August of Pfizer-BioNTech’s Covid-19 vaccine, a “tidal wave” of people were expected to line up for their jabs, spurred by employers and businesses that have been waiting for the green light and at least some doubters who needed more reassurance it is safe.
And the National Institutes of Health’s Anthony Fauci aptly summed up the FDA’s influence in a comment earlier this year about its approval for Aimmune Therapeutics’ Palforzia, the first drug to treat peanut allergy for children. “Science is showing us the path to a future in which new therapeutic options may provide both solutions as well as peace of mind that individuals with food allergies and their families deserve,” he said.
Those words could well apply to the field of THR too, although the FDA’s policy of placing the onus solely on individual companies to prove they contribute to public health (to wit, the 2.3 million pages of evidence PMI submitted on behalf of its IQOS application) has already left some smaller, streamlined companies out in the cold.
That said, governments in lower and middle income countries (LMICs), where the vast majority of the world’s 1.14 billion smokers live, would do well to study all three of the FDA decisions regarding THR products as they work to strengthen their own national research and regulatory capabilities and to take note of the careful steps the agency continues to take as it examines the applications of other companies that manufacture e-cigarettes, including Juul.
These governments and their public health authorities need to review the statistics from places such as the United Kingdom, which has supported e-cigarette use as an effective way to lessen health risks and even quit combustible smoking altogether. Or, conversely, they could take two minutes and 42 seconds to watch a graphic Public Health England demonstration of the viscous, oozing, sticky dark brown residue left in the lungs from the smoke from 16 packages of cigarettes over the period of one month compared to the barely discernible trace of vapor left by the equivalent number of e-cigarettes over the same period.
Right now, a huge gap exists between research output in tobacco control by a few developed countries and LMICs, and when it comes to reduced-risk products, the gap is even greater, a reflection of both the lack of support for homegrown scientific research and a concomitant reliance on advanced industrialized countries for regulatory scientific advice and support. The Foundation is committed to playing its role in closing this gap to allow LMICs to have the scientists able to fully inform their policymakers about the potential benefits of THR.
There appears to be no interest in tobacco harm reduction as a principle or a tendency to unquestioningly accept the warnings by bodies such as the World Health Organization, which itself is mired in a past overtaken by technological advancements and sounds like the proverbial Greek chorus as it points to the lack of long-term testing and the perils such products pose to youth.
The most extreme example of this governmental attitude is in India, where, despite 1.3 million people dying each year from tobacco-related diseases, e-cigarettes were banned in haste by the government, which was urged to do so by The Union, a Bloomberg-funded NGO based in Paris that recommends such extreme measures for LMICs on the supposed grounds that youth in these countries are particularly vulnerable. In turn, this has led to a burgeoning black market that prices these products out of reach of many of the disadvantaged communities who could use them most.
The fact is, the most favored tobacco control measure in India is tax increases, which only serves to exacerbate the difference between the rich and the poor, for the latter group must turn to cheaper, even more dangerous products such as bidis, thin cigarettes composed of unprocessed tobacco that are hand-rolled in leaves and contain higher concentrations of nicotine, tar and carbon monoxide than conventional cigarettes sold in the United States.
In Indonesia, where more than a quarter of the population smokes, including 19.4 percent of young people between the ages of 13 to 15, the local—and significantly cheaper—cigarette of choice is the unfiltered kretek, made from a blend of tobacco, cloves and other additives. Yet, there is little government oversight, with children even exposed to lengthy tobacco advertisements before blockbuster Hollywood films.
Still, the WHO refuses to apply the consequences of harm reduction always being part of the definition of tobacco control in the Framework Convention on Tobacco Control. A good start would be for the WHO to consider recent peer-reviewed research by leading scientists that underpins the FDA submission and not reject it simply because it has been funded by the tobacco industry. In its Report on the Global Tobacco Epidemic—2021, it does not waver from its position, stating that new and emerging products simply chart a “new threat to tobacco control.”
“As they emerge and rapidly evolve, these products can be difficult to characterize and therefore bring with them many regulatory challenges,” it states. “At the same time, the tobacco and related industries behind these newer products pedal misinformation campaigns, marketing them as ‘clean,’ ‘smoke-free’ or ‘safer,’ and claim they are effective cessation aids. By doing so, these industries attempt to appear part of the solution to the tobacco epidemic as opposed to instigators and perpetrators of the epidemic.”
How disheartening! Yes, the tobacco industry has acted unconscionably in the past, lying about the toxicity of cigarettes and shamelessly professing its primordial dedication to the health and welfare of smokers. But, to paraphrase the old saying, change—real change—starts from within. We are seeing signs of that in the tobacco industry, with the results recognized by the FDA, leading health experts and authorities in countries such as the U.K.
It is time for all of us to move on—together.
To stop treating all nicotine products as the same.
To acknowledge that we all have a stake in people’s health and well-being and in a healthy future for our children, their children and for generations to come.
And to start saving up to 4 million lives a year in the interim as the battle—our battle—continues to eradicate combustible tobacco for good.
Derek Yach is the president of the Foundation for a Smoke-Free World.

October 14, 2021
UKVIA Partners With Stop-Smoking App

Photo: krsmanovic
The U.K. Vaping Industry Association (UKVIA) has joined forces with the stop-smoking app Smoke Free to encourage more smokers to give up their habit by using a range of evidence-based alternatives to conventional cigarettes.
As part of the collaboration, the UKVIA and Smoke Free have agreed to work on a number of joint campaigns and initiatives that both promote vaping as a successful method to quit smoking and increase access to the app among those smokers looking to kick their habit.
The joint initiatives include a campaign in January, when smokers will be making New Year’s resolutions to quit. Collaborations are also planned during VApril, the UKVIA’s annual vaping awareness month, and on a specific initiative supporting hospital patients with smoking-related conditions and the healthcare professionals that care for them.

This is an exciting collaboration, which is focused on getting smokers to quit completely.
John Dunne, director-general, UKVIA
“This is an exciting collaboration, which is focused on getting smokers to quit completely,” said John Dunne, director-general of the UKVIA, in a statement. “Some 2.4 million former smokers have successfully done this in the U.K. to date, but there are still 1.2 million dual vape/cigarette users and another 6.9 million smokers who have not quit to date.
“By coming together, we want to significantly ramp up support for smokers who are looking to quit.”
“Vapes make quitting easy because they’re a great replacement for cigarettes,” said David Crane, founder of the app. “But habits still need to be changed, which is where the support we provide comes in. We are proud to work with the UKVIA because they share our mission to create a smoke-free world. Together, we stand a great chance of helping people stop smoking for good.”
September 28, 2021
Smokers Unaware of Better Alternatives

Photo: kues1
Misinformation threatens progress toward a smoke-free future, reveals a new international survey released by Philip Morris International.
The survey—fielded among nearly 30,000 adults in 26 countries by independent research firm Povaddo and commissioned by PMI—reveals that many adult smokers remain unaware that better alternatives to cigarettes exist, are unable to access them or are confused by false or misleading information that prevents them from making an informed choice.
Nearly eight in 10 respondents (79 percent) agree that adult smokers who would otherwise continue using cigarettes should have access to and accurate information about smoke-free alternatives. This view is shared by 87 percent of current adult smokers.
“People expect public health bodies and regulators to reach a scientific consensus around innovative smoke-free alternatives and provide adults who smoke with evidence-based information about these products,” said Gregoire Verdeaux, senior vice president of external affairs at PMI, in a statement. “Misinformation about smoke-free alternatives—often based on opinion—is a persistent issue that is having real-world consequences.”

Misinformation about smoke-free alternatives—often based on opinion—is a persistent issue that is having real-world consequences.
Gregoire Verdeaux, senior vice president of external affairs, PMI
The survey also shows the extent of public confusion surrounding smoke-free products. Nearly half the adults surveyed wrongly believe that e-cigarettes and heated-tobacco products are more harmful than or equally harmful as cigarettes (45 percent and 46 percent, respectively, for each product category). Asked why they have not considered switching to a better alternative, around a third of smokers surveyed cited lack of information about how these products differ from cigarettes (33 percent), uncertainty about the science (35 percent) or having easier access to cigarettes (32 percent).
According to PMI, the survey findings also demonstrate how accurate information about better alternatives can help smokers to move away from cigarettes. The vast majority (91 percent) of adult smokers who have switched to a better alternative and stopped smoking confirmed that having accurate information about how these products differ from cigarettes was an important factor in their decision. Of adults who smoke, 63 percent would be more likely to switch to a better alternative (such as e-cigarettes or heated-tobacco products) if they had clarity on how these products differ from cigarettes and the science behind them.
The survey also explores public attitudes toward scientific studies conducted by manufacturers of smoke-free products. A majority of adults surveyed (82 percent) believe their governments have a responsibility to objectively review and consider scientific evidence about smoke-free alternative products coming from manufacturers such as PMI. Additionally, nearly three quarters (72 percent) support tobacco companies working with governments, regulators and public health experts to ensure that smokers have access to and accurate information about smoke-free alternatives.
September 27, 2021
The Time is Now

David O’Reilly (Photo: BAT)
Making tobacco harm reduction a reality has never been more important.
Never has tobacco harm reduction been more important than in the wake of the Covid-19 pandemic. Public health bodies are now, more than ever, focusing on broader health issues and how they can optimize outcomes while also making the most of their resources. Minimizing the negative public health impact caused by smoking cigarettes continues to be a major challenge that many are trying to tackle, with some countries, such as the U.K., setting themselves ambitious targets to eliminate cigarettes entirely. The real question is, how can they effectively deliver on this goal?
We know from experience, such as the U.S. prohibition of alcohol, that simply banning popular consumer products does not work. Based on the evidence, we believe that the most effective way to tackle this issue is through tobacco harm reduction. Policies that are bold, progressive, forward-looking and, most importantly, backed up by robust scientific evidence must be created and embedded into society.
The reality is that people continue to smoke despite awareness of the adverse health risks associated with doing so. These are smokers who would benefit from greater access to alternative products that can effectively deliver nicotine and provide an enjoyable and, importantly, reduced-risk alternative to smoking.* It is this group of people for whom effective tobacco harm reduction policy matters most.
BAT is steadfast in its position that the best thing people can do to protect their health is to not start smoking or to quit smoking. We encourage those who would otherwise continue to smoke to switch completely to a scientifically substantiated, reduced-risk alternative. Products that contain nicotine but do not involve combustion (the burning of tobacco at up to 900 degrees Celsius) emit far fewer and lower levels of toxicants compared to conventional cigarettes and have the potential to be significantly less harmful to health.
The availability of scientifically substantiated, less risky products such as vapor products, tobacco-heating products and modern oral products are crucial to effective tobacco harm reduction. Product regulations should recognize the role these alternatives can play in harm reduction by ensuring that high quality product standards are enforced, that consumers have access to information to make informed choices and, critically, that underage use is prevented.
Smokers who wish to continue using nicotine via these less risky alternatives should not be punished by regulations and legislation that deprives them of information and denies them access to these products—a system that does not recognize the rigorous scientific process that goes into developing these reduced-risk products.*
This view is shared by many within the public health community, including Public Health England. However, there are some organizations and public health bodies that disagree with the concept of tobacco harm reduction. Often, this is because the available reduced-risk alternatives are not entirely risk free, which BAT acknowledges. That doesn’t mean that consumers should be denied the choice to make use of alternative products that reduce the risk of harm versus continuing to smoke.
At BAT, we support regulation that is founded on scientific evidence that can effectively reduce the projected health impact of smoking around the world. Tobacco harm reduction underpins our clear purpose to build “A Better Tomorrow” by reducing the health impact of our business. We have been clear for many years that our business needs to be built on outstanding products, informed consumer choice and a drive toward a reduced-risk portfolio, which is underpinned by world-class science. We are doing this by providing consumers who would otherwise continue to smoke cigarettes with a range of less risky ways of consuming tobacco and nicotine.*
We recently conducted a long-term randomized, controlled trial of our tobacco-heating product, Glo, which lends credibility to the harm reduction potential of the entire category of high-quality tobacco-heating products. Surely, even our detractors can see the benefit in this landmark new clinical study showing that the health risks of cigarette smoking may be reduced in smokers who completely switch to using tobacco-heating products.
We advocate for a collaborative, multi-stakeholder approach to advance tobacco harm reduction. We want to see meaningful change in the development of tobacco and nicotine policy. Industry, government, scientists, regulators and governing bodies must put their differences aside and come together in order to create effective tobacco harm reduction policy and provide better alternatives for those who would otherwise continue to smoke. This is not something that can be tackled by one group alone. Engagement, dialogue and communication among all parties is what is required in the development of effective policy. By adopting a more inclusive stakeholder approach to tackling tobacco harm reduction, we can make progress much more quickly.
We have a goal of 50 million consumers of our reduced-risk noncombustible products by 2030. Every one of these individuals matters. So, to me, this is 50 million reasons why tobacco harm reduction matters and 50 million reasons to believe in “A Better Tomorrow.”
* Based on the weight of evidence and assuming a complete switch from cigarette smoking. These products are not risk-free and are addictive.
David O’Reilly is director of scientific research at BAT.

September 1, 2021
Transformation Framework Published

Emmanuel Babeau (Photo: PMI)
Philip Morris International published its business transformation-linked financing framework, which integrates the company’s smoke-free transformation into its financing strategy.
“To strengthen our commitment and further highlight to stakeholders the seriousness of our smoke-free ambitions, we wish to link our most material sustainability priorities to our financing,” said Emmanuel Babeau, chief financial officer, in a statement. “We believe that a business transformation-linked financing framework not only helps reinforce our commitment to reinvent our company but will also allow investors and lenders to engage with and support our industry-leading transformation as we work to accelerate the end of smoking and use our strong capabilities to develop products that go beyond nicotine and have a net positive impact on society.”
The framework outlines the guidelines that PMI will follow in issuing business transformation-linked financing instruments in the debt capital and loan markets, which may include public notes offerings, private placements, loans and other relevant financing instruments.
The key performance indicators (KPIs) selected for the framework directly measure and respond to the focus of PMI’s sustainability and corporate strategy and the company’s most material sustainability topic: addressing the health impact of its products.
The framework includes two sustainability performance targets (SPTs), with an observation date of Dec. 31, 2025: Increase PMI’s full-year 2025 smoke-free/total net revenue percentage to more than 50 percent from the 2020 baseline of 23.8 percent; and increase the number of markets where PMI’s smoke-free products are available for sale to 100 markets by the end of 2025 from the baseline of 64 markets on Dec. 31, 2020.
The framework was validated by S&P Global Ratings, which provided a second party opinion (SPO). The SPO recognized the chosen KPIs and related SPTs as material, measurable, ambitious, regularly reported and externally verified—in line with the June 2020 Sustainability-Linked Bond Principles administered by the International Capital Market Association (ICMA) and the May 2021 Sustainability-Linked Loan Principles administered by the Loan Market Association (LMA). The SPO is also available on the PMI website.
“The framework builds on our genuine commitment to transform,” said Jennifer Motles, chief sustainability officer, “reflecting: a Statement of Purpose issued by the Board of Directors; concrete KPIs for reporting and compensating executives on that purpose (Business Transformation Metrics); business transformation-linked financing instruments tied to targets for select KPIs; and transparent, periodic disclosures on our progress through integrated reporting. I hope this can serve to inspire something bigger within our industry and set an example for other industries also undergoing transformations.”
August 31, 2021
Video: Vaping’s Harm Reduction Potential
Considerable evidence suggests that e-cigarettes are an effective smoking cessation tool for adults in the United States, where hundreds of thousands of people die of smoking-related illness each year.
Kenneth Warner, dean emeritus and the Avedis Donabedian Distinguished University Professor Emeritus at the University of Michigan’s School of Public Health, says, however, that the potential of vaping to increase smoking cessation has been largely overshadowed by media coverage and policies that focus on the potential risk vaping represents for teens.
Warner and 14 other past presidents of the Society for Research on Nicotine and Tobacco co-authored an article that argues that the media, legislators and the general public have developed a negative view of e-cigarettes because of the heavy emphasis public health organizations have placed on protecting kids from vaping while ignoring the potentially substantial benefits of e-cigarettes in helping adults quit smoking. The article is published online in the American Journal of Public Health.
In an interview with Michigan News of the University of Michigan, Warner discusses why the group, all of whom have presided over the top tobacco research society in the world, decided to take on this issue.
What prompted this group to write this article?
In my 45 years in the field of tobacco control research, I’ve never seen an issue that is as divisive as this one, and maybe none that is as important to public health. We have a large group within public health who are very much opposed to vaping because they see it as imposing huge risks on kids. On the other end of the spectrum, we see a number of researchers and members of the vaping community who believe that vaping is a great tool for helping people to quit smoking and that it is far less hazardous than smoking. These polar opposite views have created much of the contention within the tobacco control community.
Our goal in this paper is to try to inject some sense of balance, to get public health organizations, the media and legislators to recognize that their appropriate but singular desire to keep e-cigarettes out of the hands of kids may actually be harming public health. Policies oriented exclusively toward protecting kids may be responsible for more adults smoking than would be if we had policies that also emphasized helping adults to quit with vaping, and frankly, if we had honest characterizations of the risks of vaping.
Exaggerations of the risk have led a majority of Americans, including a majority of smokers, to the erroneous belief that vaping is as dangerous as, or more dangerous than, smoking. The National Academies of Science, Engineering and Medicine has determined that vaping is likely substantially less dangerous.
What do you want people to take away from the AJPH article?
We call for a rebalancing of society’s consideration of vaping and specifically for more attention being paid to its potential to increase smoking cessation. We should continue working to decrease young people’s use of e-cigarettes—of all nicotine products, for that matter—but we must increase our focus on adult smokers.
In the article, my colleagues and I express concern that we have forgotten about the adults who are going to die as a consequence of smoking. We lose 480,000 Americans every year as a result of smoking. Understandably and justifiably, all Americans were enormously concerned by the toll of Covid-19 this past year. Consider that we have a Covid-level disaster created by smoking every year, year after year after year.
How would you characterize the risks associated with e-cigarettes? What are the potential benefits of vaping for adult smokers?
Vaping is clearly not risk-free, but it is also substantially less dangerous than cigarette smoking. Inhaling combusted tobacco smoke, which includes over 7,000 chemicals, is what causes the disease and death associated with tobacco use.
Multiple types of evidence, identified in our article, demonstrate that vaping can increase smoking cessation. The highly respected Cochrane Review has concluded that it is likely that vaping is more effective than FDA-approved nicotine-replacement products like gum and patches. The CDC has also found that more smokers use e-cigarettes than other aids in attempts to quit smoking—and with a higher self-reported success rate.
Still, the public is largely unaware of the potential vaping has to aid in smoking cessation. As I mentioned previously, a majority of adults, including a majority of smokers, believe that vaping is as dangerous as, or more dangerous than, cigarette smoking. This misunderstanding has actually worsened over time. That reflects, in part, the media’s coverage of vaping.
A recent study cited in our article found that 70 percent of U.S. news coverage on vaping mentioned vaping’s risks to kids while only 37 percent noted the potential benefits for adult smokers. As such, it’s likely that fewer smokers are trying e-cigarettes as a method of quitting smoking than would be the case if they were accurately informed about its potential to help them quit and its smaller health risk compared to smoking. That means fewer people are quitting smoking.
Put simply, research shows that the potential benefits of vaping for adult smokers are substantial. Those benefits are not being fully realized in today’s environment of misinformation and a singular focus on the welfare of kids, to the detriment of the health of adults who smoke.
What is known about the risks of youth e-cigarette use?
Vaping does have risks for kids, including the potential of addicting some to nicotine. But in our article, we point to evidence that the percentage of kids being addicted to nicotine by vaping is much smaller than popularly believed.
We also note that while prospective studies have found that vaping by kids who had never smoked increases their risk of trying cigarettes 6–24 months later, much of this may be explained by what is called “common liability,” meaning that kids who try e-cigarettes are more prone to risk-taking than are kids who don’t vape, so the former may be more likely to try cigarettes anyway, even if e-cigarettes had never existed.
Further—and very importantly—even if there is an increased risk, doing the math indicates that this factor would increase overall smoking initiation by kids by only a very small amount. However, even that seems unlikely since we’ve seen smoking rates fall among young people (both adolescents and young adults) at unprecedented rates precisely during the period of vaping’s ascendancy. That certainly is not consistent with the idea that vaping increases smoking.
Why has e-cigarette use in adults not been a focus in policy or the media?
First, the concern for young people’s welfare is a compelling one, and the rapid increase in youth vaping in 2018 and 2019 understandably created a great deal of anxiety. The focus on youth drowned out attention to the welfare of adults who smoke. Youth vaping decreased significantly in 2020. We will have to monitor future years’ trends closely.
Second, I think a lot of people may believe that the problem of smoking is pretty much resolved. I’m referring mainly to the higher education, upper socioeconomic status population. They don’t smoke, their friends and colleagues don’t smoke, there’s no smoking in their workplaces, and there’s no smoking in the restaurants and bars that they frequent. They don’t see smoking and thus may believe the problem has largely been solved.
And yet one out of seven adult Americans is a smoker today. When we take a look at who’s smoking, it’s the underprivileged members of our society, those who don’t have a voice in politics. African Americans as a group, although they don’t smoke more, have higher rates of smoking-produced disease and death than do [white individuals]. There are groups like low socioeconomic populations, people with mental health problems and the LGBTQ community that all have higher than average smoking rates.
My fear, frankly, is that many nonsmokers are ignoring smokers because they may not care that much about them. There is a very large life expectancy differential between the rich and the poor in the United States, and perhaps the single most important behavior-related variable is differences in smoking. The data show that low-income, low-education populations smoke at much higher rates than the high-income population, and they die at much younger ages. If we could reduce smoking among these often marginalized populations, we might be able to reduce the gap in life expectancy. This is fundamentally a matter of social justice.
What are some policy changes that might help achieve a more balanced approach to e-cigarettes?
Currently, we have very unbalanced policies that are directed exclusively at trying to reduce youth vaping. Two of the most prominent are eliminating or seriously restricting flavors in e-cigarettes and trying to equalize the taxation of e-cigarettes and cigarettes. Both of these policies can have adverse consequences for adult smokers. Adult smokers like flavors just like kids do, and in fact, they tend to like the same flavors.
Banning flavors would eliminate adult smokers’ access to the flavored e-cigarettes that they prefer in attempts to quit smoking. So that’s a real concern. We propose restricting the sale of e-cigarettes to adult-only establishments, such as vape shops. This is a compromise—flavors are a significant attraction to vaping for kids, and our recommended policy would not eliminate flavors; at the same time, the policy would restrict access for adults, thereby creating an inconvenience for them. But this policy would strongly limit youth access to flavored e-cigarettes while allowing adults to get the flavored e-cigarettes they want to aid in their attempts to quit smoking.
We also suggest a substantial increase in excise taxes on cigarettes and other combusted tobacco products, and a much more modest tax on e-cigarettes. This is the opposite of what is happening now, with states imposing “equalizing” taxes on e-cigarettes without raising taxes on cigarettes. Significantly raising the tax on cigarettes will discourage both adults and kids from smoking. A big differential in price between very expensive cigarettes and less expensive e-cigarettes creates an incentive for adults who don’t quit smoking to switch to e-cigarettes. For kids, a modest tax on e-cigarettes will discourage them from vaping because they’re the most price-sensitive group when it comes to nicotine and tobacco products.
August 25, 2021
Study: Vaping Better Than NRT for Cessation

Photo: bedya
A new study by Queen Mary University of London, published in Addiction, shows that e-cigarettes are more effective in achieving long-term smoking reduction and cessation than nicotine-replacement therapies (NRT).
The study randomized 135 smokers who had been unable to stop smoking with conventional treatments into two groups—one received an eight-week supply of their choice of NRT and the other received an e-cigarette starter pack with instructions to purchase further e-liquids of their choice of strength and flavor. Products were accompanied by minimal behavioral support.
After six months, 27 percent of those in the e-cigarette group had reduced smoking by at least half compared to 6 percent in the NRT group. Of the participants in the e-cigarette group, 19 percent had stopped smoking altogether versus 3 percent in the NRT group.
“These results have important clinical implications for smokers who have previously been unable to stop smoking using conventional treatments,” said Katie Myers Smith, lead researcher and health psychologist, in Eurasia Review. “E-cigarettes should be recommended to smokers who have previously struggled to quit using other methods, particularly when there is limited behavioral support available.”
“This study shows e-cigarettes can be a very effective tool for people who want to stop smoking, including those who’ve tried to quit before,” said Michelle Mitchell, CEO of Cancer Research U.K., which funded the study. “And research so far shows that vaping is far less harmful than smoking. But e-cigarettes aren’t risk free, and we don’t yet know their long-term effects, so people who have never smoked shouldn’t use them.”
July 1, 2021
Industry Welcomes Draft U.K. Vaping Guideline

Photo: pavel_shishkin
The U.K. Vaping Industry Association (UKVIA) has welcomed the publication of draft guidance by the government’s top health advisory body to support health workers in helping smokers transition successfully to vaping.
The National Institute for Health and Care Excellence (NICE) has published draft guideline recommendations, currently out for consultation, which make the case for healthcare workers to inform patients where they can find vaping products, proactively promote the fact that vape products are substantially less harmful than conventional cigarettes and provide advice on how to use vape devices correctly.
This announcement follows fast on the heels of National Health Service (NHS) trials that were announced recently, whereby vaping devices are given to smokers in A&E departments. These are already under way in some NHS hospitals in England and Wales.
These developments coincide with a new campaign being planned by the UKVIA to support frontline workers in helping smokers successfully quit smoking using vaping through the advice they give.
“It’s great to see that the NHS is embracing the huge public health potential of vaping,” said John Dunne, director general of the UKVIA, in a statement. “Pro-vaping actions such as NICE’s draft guideline recommendations and the NHS trials are key to ensuring the government meets its target for a smoke-free Britain.
“Our own campaign, which we will be launching in July, will provide a much-needed resource to help frontline healthcare staff give the right advice to smokers on how best to quit using vaping.
“A one-size-[fits]-all approach is not the way to maximize quit rates amongst smokers from taking up vaping. It depends on their level of smoking, which in turn determines the flavors, nicotine levels and devices that they should be using. We are using the many years of experience amongst our members to equip the NHS with advice that is proven to get results.”
June 27, 2021
Survey: Harm Reduction Gains Momentum

Photo: Тарас Нагирняк
The concept of tobacco harm reduction is gaining momentum in Europe, according to a new report by the European Tobacco Harm Reduction Advocates (ETHRA). On July 8, ETHRA published the results of its 2020 EU Nicotine Users Survey.
Launched online by ETHRA in the last quarter of 2020, the questionnaire addressed consumer use of nicotine products. Topics included smoking and the desire to quit, use of safer nicotine products and barriers to switching caused by European and national regulations. More than 37,000 people, including more than 35,000 EU residents, participated in the ETHRA survey.
According to ETHRA, more than 27,000 of the survey participants had completely quit smoking. Vapes, snus and nicotine pouches are the main harm reduction products used to quit. Among the respondents who had ever smoked, 83.5 percent of vapers and 73.7 percent of snus users had successfully stopped smoking.
Over 93 percent of vapers and 75 percent of snus users cited harm reduction and improvements to health as their reasons for adopting these products. The report shows that the reduced cost compared to smoking, the availability of flavors, the availability of products and the ability to adjust vaping products are other major factors for consumers when switching to harm reduction products.
The lack of availability of low-risk nicotine products presents a major obstacle to consumers wishing to quit smoking.
ETHRA
However, smoking remains the predominant way of consuming nicotine in Europe. More than 67 percent of the current smokers who responded to the survey want to quit, but the ETHRA report shows they face barriers in their desire to be smoke-free.
The lack of availability of low-risk nicotine products presents a major obstacle to consumers wishing to quit smoking. The EU ban on the sale of snus (which exempts Sweden), illustrates this barrier, with 31 percent of current smokers indicating that they would be interested in trying snus if its sale were legalized in the EU.
A quarter (24.3 percent) of those who smoke but who want to quit cited the high price of safer alternatives as a barrier to quitting smoking. This number rises to 44.7 percent in countries with a high tax on vaping products, such as Estonia, Finland and Portugal.

The EU Tobacco Products Directive (TPD) restrictions of a maximum nicotine concentration of 20 mg/mL and a maximum bottle volume of 10 mL have driven vapers to very low nicotine e-liquids. More than 30 percent of people who vape and smoke (“dual users”) believed they could completely quit smoking if the EU nicotine limit were increased.
Meanwhile, harm reduction advocates are anxiously awaiting pending amendments to the TPD. If the EU bans flavors, 28 percent of vapers are likely to restart smoking, and 71 percent would consider using the black market or other alternative sources, according to the survey. In the 16 EU countries without a vape tax, only 1 percent of vapers are currently using alternative sources.
If the EU repealed the 10 mL bottle limit, 89 percent of vapers said they would buy larger bottles of e-liquid to reduce plastic waste. Eighty-three percent of vapers are in favor of having access to an EU database on e-liquid ingredients.
Considering the results from the EU Nicotine Users Survey 2020, ETHRA recommends the lifting of the EU ban on the sale of snus, revising upward the 10 mL refill bottle and 20 mg/mL nicotine concentration limits and the publication of databases on vaping products.
The organization also urges a repeal of vaping taxes in 12 countries and the lifting of flavor bans in Estonia, Finland and Hungary to give European smokers the freedom to quit smoking using low-risk products.
June 10, 2021
Clifford Douglas: Let’s End War on Vaping

Photo: pavelkant
It is time to end the internecine warfare over vaping, according to Clifford Douglas, former vice president of Tobacco Control at the American Cancer Society and founder of the Center for Tobacco Control.
In a recently published commentary, Douglas writes that the U.S. tobacco control community is “letting down tens of millions of adult smokers, their families and friends, healthcare providers and government decision-makers.”
“I refer to my community’s approach to dealing with electronic cigarettes,” Douglas writes. “We are now neck-deep in intractable internecine warfare between the mainstream tobacco control community, whose primary focus is on protecting youth from the dangers of vaping, and the tobacco harm reduction (THR) community, some of whose scientists are also committed participants in mainstream tobacco control efforts. The THR community emphasizes the potential benefits of vaping for adult smokers who cannot or will not quit smoking otherwise. It seems that ne’er the twain shall meet.”

There are ways to prevent youth use that won’t inflict harm on adult smokers.
Darryl Tempest, executive director, CVA
Vapor advocates welcomed Douglas’ comments.
“The Canadian Vaping Association (CVA) commends Douglas for trying to bridge the gap between tobacco control and vape advocates,” the CVA wrote in a press note. “In the end, we all have the same goal of a tobacco-free society. The past practices of tobacco companies have caused distrust of the vape industry with regulators and the public. It is important to remember that this industry was created by smokers, for smokers. We don’t want youth vaping and have proposed many reasonable solutions. There are ways to prevent youth use that won’t inflict harm on adult smokers,” said Darryl Tempest, executive director of the CVA.
Douglas has also formerly served as a special counsel on tobacco issues in the U.S. House of Representatives, as a tobacco control policy advisor for the U.S. Assistant Secretary for Health and the U.S. Surgeon General, and as a lawyer representing injured smokers and state attorneys general in litigation against the tobacco industry.
June 7, 2021