Tobacco is firmly entrenched in Cuban culture. The country is famous, of course, for its cigars, and its tobacco crop is one of its largest sources of income from foreign trade. Cuba’s smoking rate, as of 2015, was 37 percent. Although it’s gradually falling, it’s about three times higher than in the United States. Almost 20,000 Cubans die of smoking-related causes each year.

Cuba has experienced a tumultuous relationship with the US, which classifies the country as a “state sponsor of terrorism” alongside only North Korea, Iran and Syria. I was able to travel there on a family-visit visa. But as a Cuban American studying public health, I also wanted to learn more about how communities experience tobacco issues—and tobacco harm reduction, if at all.

I brought my vape along anyway, and was glad I did, because I saw no evidence of vapes on sale in brick-and-mortar stores after I arrived.

Although cigarettes and cigars are ubiquitous, Cuba’s laws around other nicotine products are not always easy to establish. According to the Global State of Tobacco Harm Reduction, marketing of heated tobacco products or nicotine replacement therapy (NRT) is illegal, while there is no available information about snus regulation and “no specific law” around vapes. Sources like the Canadian Government state that Cuban customs will seize vapes if you try to bring them into the country, while other sources say there’s no basis for these seizures under Cuban law. But vaping itself appears to be legal in the country, in the absence of regulation.

I brought my vape along anyway, and was glad I did, because I saw no evidence of vapes on sale in brick-and-mortar stores after I arrived. No one troubled me at the airport or when I vaped in Cuba.

I met Luis* through one of my family members a few days after I arrived. He was smoking cigarettes at a table in a bar in Havana, and I asked if he would be open to an interview about tobacco issues in Cuba.

Luis is Cuban and has lived there for most of his life. He’s smoked for most of his life, too, as have most of his friends. He started at 14. “Kids would just pick up cigarette butts to smoke them in a pipe,” he told me. “That’s how we started smoking.”

Almost 30 years later, he currently smokes two packs a day. “I think it’s stronger than any other addiction I’ve had,” he reflected. “Yes, stronger than drugs, alcohol, and all of that.”

He was pretty clear, too, that he didn’t want to smoke. “I’d like to stop smoking,” he said. The last time he tried, his method, as on previous occasions, was to go cold turkey. “In four days, I was smoking again.”

“I didn’t even know that existed until recently. You don’t see anyone vaping out here.”

Before we spoke, Luis had seen me vaping. He expressed interest in trying it—and did have some knowledge about it.

“Yes, I’d like it, so I don’t have to be anxious when I quit smoking,” he said. “It has nicotine … and it doesn’t harm as much as cigarettes that have millions of harmful chemicals.”

The obvious question, then, was why he wasn’t vaping already. “Well, that’s not available here,” he explained. “There’s no access. You can’t easily reach that. It’s expensive here.”

“I didn’t even know that existed until recently,” he continued. “You don’t see anyone vaping out here.”

That matched my own brief experience of the country—though I later discovered that a small number of people do vape in Cuba, purchasing supplies online. Nobody? I asked.

“Never in Cuba,” he replied, though he had witnessed it when he once spent time in Spain. “I don’t have friends that use it.”

We chatted more about the availability of different nicotine products in Cuba. Luis said that in his experience—and despite Cuba’s status as a major tobacco producer—there’s little-to-no access to forms of smokeless tobacco (like dip or snus) or even loose tobacco. It’s pretty much all cigarettes or cigars.

The government offers people free NRT, including gum, patches and nicotine drops.

However, despite the ban on marketing NRT, the government does offer people free NRT, including gum, patches and nicotine drops—as well as essential oils aimed at reducing nicotine-withdrawal symptoms like anxiety.

“Yes, the government supports those people,” Luis said. “You can go to a place in person, call on the phone, and it’s all free.” The actual gums or patches, in his experience, are scarce. “It’s mostly therapy, they talk to you with a psychologist for example.” (This was contrary to what I would later hear from other Cubans, who said they faced few barriers in accessing NRT products through government smoking cessation programs.)

Some people do find NRT effective for smoking cessation, though the best available evidence shows that vapes, which replicate the hand-to-mouth movements and inhalation of smoking, are more effective for this purpose.

Luis himself had the chance to try NRT while he was in Spain but, “my feeling to smoke didn’t go away.”

Cigarette packs in Cuba display health warnings, much like in other parts of the world. I asked Luis what he thought of these. “It’s something,” he said. “I think a lot of people look at this, especially those who are smoking every day, and say, damn. Maybe for some people it helps but for me it doesn’t help, I still smoke, my friends still smoke. But at least they tell you.”

Returning to something he’d said earlier, I mentioned that I wouldn’t have expected loose tobacco to be unavailable in Cuba, of all places. “Well, there’s sometimes even times of crisis where you can’t get cigarettes,” he responded. “Sometimes there aren’t any.”

I wondered if this reflected tobacco producers prioritizing the more lucrative export market over domestic availability. I asked whether people could still get cigars in those times.

“The people who can smoke all they want are privileged. Most people can’t afford to smoke too much.”

“Oh yeah—I can show you, look.”

Luis then produced several that he had on him. “These cigars right here are bad quality. The worst that there is. The small ones suck, they go for around 1 Cuban peso. They’re for the public, they are sold cheap.”

On the other hand, “The nice big one is made by particulares [a kind of private business]. It’s worth about 100 pesos.”

“When there’s no cigarettes, that’s usually when people smoke cigars,” he explained. “Sometimes people will gut it, and roll it using any paper they can find. That’s very common among people who don’t have funds. They sometimes use bibles to roll their tobacco. Sometimes people use pipes as well. In Cuba, even if you don’t have money you can also figure something out. Find someone who will gift you a cigarette, maybe.”

“The people who can smoke all they want are privileged,” he added. “Most people can’t afford to smoke too much.”

Luis gave more insight into just how central tobacco is to Cuban culture when he described an annual “tobacco day,” a kind of international fair.

I later confirmed it’s called the Habanos Festival. At this year’s event, Cohiba humidor was auctioned for a record $4.4 million. According to festival organizers, proceeds are donated to Cuban health authorities.

“They blindfold people and they are able to tell which tobacco or cigar is which.”

“The fair is huge. It’s a nice fair,” Luis said. “People go to smoke and have fun. Foreigners come to smoke their cigars there. Catadores, too.”

I didn’t know that word. “Those are tobacco experts that try the cigars and rate them. They do competitions of who’s the best catadore. The winner gets a prize.” 

“The experts in tobacco know it by smell,” he continued. “In tobacco competitions, they blindfold people and they are able to tell which tobacco or cigar is which… The last winner I saw was a young woman. With her eyes blindfolded, smoked or smelled, she knows the size, type, everything. It’s crazy.”

I asked what the crowds are like at these events. “It’s mostly people from the government. Those who go are the ones working in Cuba tobacco control. They have the factories. You can go too, but it’s mostly government folks and foreigners who are the ones that buy tobacco.”

“But if I had to choose,” he asserted again, “I would vape. My phlegm is dark and thick.”

*Name changed to protect privacy at source’s request.

All photographs by Kevin Garcia

The Influence Foundation, which operates Filter, has received donations and grants from Knowledge-Action-Change, which publishes the Global State of Tobacco Harm Reduction.

The post Tobacco Fairs, Free NRT and Few Vapes: A Conversation in Cuba appeared first on Filter.

There was also one panel about tobacco harm reduction (THR), in which I participated. Its inclusion was significant, given the divisions sometimes seen between THR and the rest of harm reduction, and conversations about how to align the two.

So I took the chance to ask some of the folks at the conference for their thoughts. The responses they were kind enough to share with me reflect some of the issues that impede better understanding, some personal THR experiences, and some really encouraging interest in including THR in their work.

“Vapes? Those things are horrible for you.”

Unfortunately, after a relentless misinformation campaign against vaping by US nonprofits and public health authorities, some misunderstandings have stuck—even among harm reductionists.

“Vapes? Those things are horrible for you,” said one conference attendee, who was smoking a cigarette and asked to remain anonymous.

The evidence shows that vaping, while it may not be entirely risk-free, is exponentially less harmful than the cigarettes it typically replaces. Harms from long-term vapor inhalation are “unlikely to exceed 5% of the harm from smoking tobacco,” states the UK’s Royal College of Physicians, for example. Other reduced-risk THR options include oral snus and “heat-not-burn” tobacco products.

Nathan Smiddy, a harm reduction educator at A New Path in California, was unclear on some health questions, though he vapes himself. “I don’t know if popcorn lung is a real thing. I’ve never researched it,” he told Filter. (The idea that vaping causes “popcorn lung” is a myth.)

Still, “for me, vaping saved me money [compared with smoking] and I feel better,” Smiddy said.

The fact that Smiddy’s principal motivation for switching was financial is instructive, regarding debates over the taxation of vapes and cigarettes. “To be dead honest, cigarettes are very expensive … and I was like, I can’t afford this right now. So I just bought a vape and I stuck with it,” he related.

“I’ve been smoking/vaping since I was 15,” he continued. “I’m 30 now … I feel like I would say yes, it’s safer, but I don’t have the evidence to prove that. I feel like my overall health and quality of life just from switching is better. I don’t wake up and cough up phlegm.”

The harm reductionists I spoke with tended to be refreshingly frank about what they didn’t know about THR, which is a great starting-point when you’re interested to find out more.

“I have a lot of clients who switch over to vaping instead of smoking cigarettes.”

“I don’t really know a whole lot about the science of it, just to be straight-up,” said Gillian Garton. She works as a medical case manager at the Red Project in Grand Rapids, Michigan, and emphasized that she was speaking purely on her own behalf. “I do know that there are people … who use vaping to cut down on their cigarette consumption or completely switch over, because I know that there are some health aspects that do change … I have a lot of clients who switch over to vaping instead of smoking cigarettes.”

In fact, she did the same. “I used to smoke cigarettes a lot and started when I was about 15,” she told Filter. “I had been trying to quit for a long time so I switched over to vaping mostly for my own health aspects.”

Garton was also aware of the tide of vape bans in recent years and the likely detrimental consequences. “I do know there’s lots of legislation that is trying to ban vapes,” she said. And she noted that people’s reactions could well be, “I don’t have access to this vape, so maybe I’m gonna have to go get cigarettes because I still have cravings for, like, the oral fixation or the nicotine.”

“I see no positives and only negatives when it comes to bans. That’s across the spectrum of drugs,” Presto Crespo, a Bronx resident who identifies as a drug user and coordinates support services for NEXT Distro, similarly told Filter. “People are just gonna revert back to smoking cigarettes … or people are gonna make their own stuff; sometimes they’ll get it right and sometimes it can be extremely harmful.” 

After our panel, in which we debunked myths and discussed the need for THR’s integration in the wider field, some people who attended said they were considering these questions more.

“Before the panel I definitely didn’t think about it too much,” Crespo said. “I think I [had] succumbed to some of the misinformation about vapes, but, I mean, just being a skeptical person in general, I was like, Some of that obviously cannot be true.”

“But I did agree to this idea that this is Big Tobacco’s way of getting a new generation hooked on their products,” they continued. Yet this was countered by the experience of seeing their roommate switch from smoking to vaping: “It was helpful and he felt his lung capacity was larger. He wasn’t coughing and spitting up phlegm all the time.”

Still, when it came to the evidence, “I didn’t know that there was a harm reduction aspect to transitioning from cigarettes to vaping,” Crespo said. “Vapes are everywhere. If they were still exploding … literally everybody would be on fire. They’ve improved the technology, you know?”

“I know one individual that can’t do other drugs because they’re being drug tested because they’re on methadone,” they continued. “Cigarettes are the only option for them. I talk to that individual about vaping and they tell me no, because it’s going to explode in their face. So that person has come to the misinformation; meanwhile they’re ingesting these packs of cigarettes.”

“After the talk, it made so much more sense as to why this is very squarely within the realm of harm reduction.”

“I don’t regularly vape or smoke,” said Dan Coello, program director at NEXT Distro, which ships vital harm reduction supplies like naloxone and syringes online and by mail. “Going into the panel, I had next to zero knowledge about THR … I think a lot of the risks we’re dealing with [in the harm reduction movement] are very immediate overdose or overamping risks. After the talk, it made so much more sense as to why this is very squarely within the realm of harm reduction.”

If so, what about the prospects for integrating THR into harm reduction services for people who use state-banned drugs? After all, nearly half a million deaths are related to smoking in the US each year—more than for any other substance. And people who use illegal drugs smoke cigarettes at high rates.

“Yeah, people don’t see it,” Coello told Filter. “I mean, humans are just very hardwired to look at immediate gains and immediate risks. And long-term thinking is not something we’re very good at. And so I think, this theoretical thought of, like, so many people dying in the future because of lung cancer, can feel not as important as the immediate risk of people overdosing.”

“With anything, especially in America, our first thing when we talk about people who use drugs is complete abstinence, you know what I mean?” Smiddy pointed out. “It’s not ideal for a lot of people. Most people aren’t going to go that route. …. With the HR community I would say, especially with fentanyl and the ever-changing drug supply, we’re always so focused on that, that [THR] is left on the backburner.”

“I would say that tobacco isn’t a priority for people [in the harm reduction movement],” Garton concurred. “Additionally, stigma with smoking tobacco is nowhere near the stigma for people who use … other substances. Focusing on the issue where it’s more stigmatized is where the disconnect is from. It’s not that I think that harm reductionists don’t care about THR, I think it’s that we have a bigger problem at hand with stigma when it comes to other substances.”

“I feel like THR has to be taken more seriously amongst the HR community,” Crespo said. “We’re very much focused on the situations where an overdose happens, where it’s rapid onset and we’re trying to prevent those things from happening, but we also have to focus on long-term HR as well. I don’t think it’s discussed enough.”

“Even in NEXT specifically, I think there needs to be a wider role to be played,” they continued. “Because you know, people who use drugs are polydrug users normally, so if you’re doing whatever your drug of choice is and you’re also smoking cigarettes… Alcohol and tobacco are the underlying drugs that don’t get talked about too much in HR and … are more prevalent than some of the other drugs we focus on. For me, I just totally forgot that nicotine is a drug, and if it’s a drug, there are HR tactics that can be used.”

“Communicating with people who use tobacco is something we can very much pivot into.”

“I think the call to action within the community isn’t fully fleshed out yet, like what exactly we can do,” Coello said. “What we can start doing is just linking up to like, these two kind-of separate worlds. Like there being communication between people who are very invested in tobacco harm reduction and the other wings of harm reduction …. So first, I think that solid communication and camaraderie needs to be there. And then, I think aligning values of reducing harm overall, despite the legal status of the drug … Everyone needs to be on the same page about what it is and what can be done to reduce harms.”

“We already know and understand how to communicate with people who use drugs, and communicating with people who use tobacco is something we can very much pivot into,” he continued. “I’m sure a lot of our participants smoke or use vapes; we can leverage our ability to reach those folks and provide safer alternatives to smoking or combustion-based methods of using tobacco or getting nicotine.”

“I personally want to learn more and better understand THR, and how NEXT specifically could start doing things like this,” Coello concluded. “I’m not sure we’re at a point yet where we can make meaningful changes, but I’m hopeful in the future NEXT can play a role.”  

Photograph by Vaping360 via Wikimedia Commons/Creative Commons 2.0

The post People in Wider Harm Reduction Discuss Integrating Tobacco appeared first on Filter.

They found that an additional 3.4 million cigarette packs were sold through convenience stores across the three states during a three-month study period.

Using state-level cigarette sales data, the researchers found that Massachusetts, which enacted a full ban on nicotine vapes, had 7.5 percent higher-than-expected per capita cigarette sales. Rhode Island and Washington, which enacted bans on non-tobacco flavored nicotine vapes, had an average estimate of 4.6 percent higher-than-expected per capita cigarette sales as well. Based on actual and estimated cigarette sales, the researchers suggested that an additional 3.4 million cigarette packs were sold through convenience stores across the three states during a three-month study period starting from the effective date of each respective ban.

The study was funded by Juul Labs, and has so far made little impact, perhaps due to the fact that many in tobacco control now dismiss any industry-supported research as effectively biased. That debate, which likely has its origins in Big Tobacco’s decades-long suppression of data, has been reinvigorated as of late: The Society for Research of Nicotine and Tobacco (SRNT), for example, has explicitly barred industry from presenting at its conferences—a move that has led to some resignations and condemnation that it’s now tobacco control that is “anti-science.”

The researchers looked at data from the fall of 2019, when lawmakers became concerned about “EVALI”—a string of then-mysterious lung illnesses that politicians quickly linked to vaping. Though the Centers for Disease Control and Prevention (CDC) subscribed most cases to tainted, illicit THC cartridges by November 2019, state governments leaped on the drummed-up panic and sought emergency vaping bans that, in some cases, eventually became permanent.

In response to the EVALI outbreak, Massachusetts instituted an emergency ban on all nicotine vapes starting on September 24, 2019. Rhode Island and Washington followed suit and instituted four-month emergency bans on non-tobacco flavored nicotine vapes on October 4, 2019, and October 10, 2019, respectively. (Massachusetts has since permanently banned the sale of flavored vaping products, including menthol, and the emergency bans in Rhode Island and Washington have each expired, though permanent flavor bans always seem to remain on the table.)

Past studies have found similar results to the Value in Health paper.

Vaping nicotine has not been medically associated with any “EVALI” diagnosis, but misinformation swirled: Led by policymakers and sensationalist reports in the media, concerns of youth vaping rates crashed straight into fears about fatal vaping products. The misleading message was simple: Teenagers were using vapes, and in some cases, dying from it. More than two years later, the CDC has still not issued any sort of formal correction that nicotine vapes had nothing to do with the lung injuries.

Past studies have found similar results to the Value in Health paper: One in the Harm Reduction Journal by co-authors at Boston University suggested that misperceptions about EVALI, which led to Massachusetts’ ban, appears to have increased cigarette consumption throughout Boston. Another, by Dr. Abigail Friedman of Yale in JAMA Pediatrics, found that after San Francisco’s ban on flavored vapes and tobacco products, teens in the city’s high schools were more likely to take up smoking than teens in comparable US school districts.

Photograph by Tomasz G. Sienicki via Wikimedia Commons/Creative Commons 2.0 

The Influence Foundation, which operates Filter, has received grants from Juul Labs. Filter’s Editorial Independence Policy applies.  

The post Evidence Mounts That Cigarette Sales Surge After Vape Bans appeared first on Filter.

There is overwhelming evidence that vaping is an effective tobacco harm reduction tool and quitting aid.

Not only did the takeaways from the JAMA study misrepresent its actual findings, but the study itself was flawed. In a field where misinformation is rife, it’s worth looking into how this happened.

To begin with, the study didn’t find e-cigs uniquely ineffective at preventing recurrence of cigarette use. Instead, it found that former smokers who switched to any “tobacco product”—a category deemed in this case to include e-cigarettes, but not limited to them—were 8.5 percent more likely to resume cigarette use over the next year compared to former smokers who didn’t use any product at all.

When it comes to e-cigarettes specifically, the authors wrote: “Results for those who switched to any e-cigarette use compared with those who were tobacco-free were not statistically significant.”

“It was deliberately pushed, appearing everywhere. Current media bias is profound.”

And yet, in the press release, first author and UC San Diego Professor John P. Pierce described the findings like this: “Switching to e-cigarettes made it less likely, not more likely, to stay off of cigarettes.”

This message was then “deliberately pushed, appearing everywhere,” Dr. Charles Gardner, executive director of INNCO (International Network of Nicotine Consumer Organizations), told Filter. “Current media bias is profound.”

Second, the study defined “relapse” as just one to two puffs of a cigarette in a 12-month period. Other studies define abstinence as something more along the lines of smoking no more than five cigarettes in two weeks after the target quit date. Many also assess reductions in cigarette use, which the JAMA study did not.

“We know that, within the US, lung cancer rates have been coming down quite quickly since the late 1980s,” Pierce told Filter. “However, no one has yet shown that reducing the number of cigarettes smoked, without quitting entirely, is associated with reduced health effects.” 

There is ample evidence that suggests that tobacco, like all harmful substances, has a dose-dependent effect. Reduction in cigarette smoking is associated with reduced morbidity—and among dual users, more frequent vaping is associated with greater decreases in cigarette smoking.

“Smokers are known to be able to titrate the amount of nicotine (and tar) they get so that a reduction in the number of cigarettes does not necessarily mean a reduction in nicotine (or tar),” Pierce responded. “I agree that this is an important question that needs to be addressed.”

Crucially, the study mischaracterized harm reduction.

The study’s categorization of e-cigarettes as “tobacco products,” placing them in the same category as cigars, cigarillos, filtered cigars, pipes, hookah, snus or smokeless tobacco, would also strike many as misleading. Nicotine vapes contain no tobacco, although the nicotine within them is typically (but not always) derived from tobacco. This categorization—if the logic were followed, it would also class nicotine replacement therapy patches and gums as “tobacco products,” which it doesn’t—has become normalized in the United States, despite efforts at pushback.

“In the US, the FDA classifies e-cigarettes as a tobacco product,” Pierce said. “It seems that the UK and the US authorities read the evidence differently.”

Perhaps more substantively in terms of this study, it included no group for those who didn’t use e-cigs and instead exclusively used other non-cigarette “tobacco products,” both combustible and noncombustible. It would seem a key distinction.

Crucially, the study mischaracterized harm reduction.

“The potential for harm reduction with e-cigarettes requires that those attempting to quit successfully switch completely away from cigarettes,” the authors wrote in the study, ”and not become dual-product users.” 

If someone is using fewer cigarettes, then they are effectively reducing the associated harms. Research shows that rather than portraying dual use of combustible cigarettes and vapes as problematic, it would be more appropriate to consider it as a journey toward smoking reduction and cessation.

Quitting or recovering from any harmful behavior is not a linear path and recurrence of use is a part of the recovery process. Harm reduction is about cutting risks on a spectrum that includes both abstinence and continued use. In a nicotine context, that may mean quitting all nicotine, smoking fewer cigarettes, or replacing some or all cigarette smoking with lower-risk alternatives.

The evidence is still clear: E-cigs are an effective tobacco harm reduction intervention for cigarette smokers, and should be offered in the THR toolbox alongside other options. In the United Kingdom, which sees this issue very differently from the FDA, vapes will soon be prescribed to smokers through the National Health Service.

Photograph via Pixabay

Both INNCO and The Influence Foundation, which operates Filter, have received grants from the Foundation for a Smoke-Free World.

The post A Study Was Claimed to Link Vapes to Cigarette “Relapse”—Let’s take a Look appeared first on Filter.

On December 6, the Denver City Council voted in favor of a ban on sales of flavored “tobacco products”—including flavored e-liquids and vaping products. The ordinance, which has been vehemently opposed by the vaping community and local small business owners at a series of fiery hearings, will take effect on July 1, 2023.

The decision is a major policy victory for co-sponsors Councillors Amanda Sawyer and Deborah Ortega. Anti-vaping organizations, including the Campaign for Tobacco-Free Kids, Parents Against Vaping E-cigarettes and Flavors Hook Kids, lobbied hard for the ban.

The ordinance passed by eight votes to three. At the meeting, Councillor Robin Kniech said of the ban, which she supported, “this is not prohibition.” She added, “I agree that prohibition is not an effective strategy,” while voting to restrict access to harm reduction products.

Kniech asserted that “there are still multiple chemical products in vaping products and we did have vaping-related illnesses prior to this pandemic.”

Research has shown that the so-called “EVALI” outbreak in 2019 was due to vitamin E acetate in illicitly manufactured THC products, not to nicotine vapes. Nicotine vaping is proven to carry vastly fewer risks than smoking, making it a huge health win for people who switch. Additionally, most people who make the switch prefer non-tobacco flavors.

Several amendments to the ordinance were proposed. One approved amendment—to not ban premium cigars or hookah and pipe tobacco, led by Councillors Jolon Clark and Paul Kashmann—means, among other things, that hookah lounges will be allowed to stay open.

Two other amendments, from Councillors Kevin Flynn and Kendra Black, were denied. These amendments proposed an exemption for menthol cigarettes—the prohibition of which is deeply controversial for reasons including racial equity concerns—and an exemption for specialty vape shops and tobacco stores affected by the flavor ban.

“We’re telling responsible adults 21-plus that they aren’t responsible enough to use flavored tobacco,” Councillor Black told Filter in an email, “but they can buy a pack of Marlboros, marijuana and alcohol?”

At the meeting, Black, who voted against the ordinance, had expressed other concerns. “It will not prevent kids from getting vaping products, but it will shut these businesses down,” she said. “They have leases, they have employees, they have bills, and they are willing to come to the table to work with us to address the real problem, so I encourage people to vote no.”

“Adults use flavored vape products to quit smoking cigarettes. I had the choice as an adult to use a flavored vape product and I like flavored vapes.”

“It is concerning when folks can go to Aurora or Commerce city and buy products,” said Councillor Stacie Gilmore, who also voted against the ban. “What’s to stop them from bringing them back into Denver and selling them at a park?”

“I would prefer us to look at a regulatory path,” Gilmore continued. “We’ve successfully, in Denver, regulated marijuana and alcohol, and we want to keep kids safe but we also want to allow adults to be adults.”

“We can do better for our kids. This ban doesn’t fix that,” said Phil Guerin, a father, vaper and local business owner, at an earlier hearing on November 29. “Adults use flavored vape products to quit smoking cigarettes. I had the choice as an adult to use a flavored vape product and I like flavored vapes.”

“The police have choked people to death for selling loosies, loose cigarettes,” he continued. “If you think loosies are a problem, imagine the problem on the street with vapes. … We’re the ones that make sure that kids don’t have these products. Bans don’t work.”

“Out of all the places where these bans have passed, there are no provisions that do anything for the users,” added drug policy consultant Art Way at that earlier hearing. “It’s all about how we can punish the sellers. In this case, the sellers that you’re punishing are the mom-and-pop tobacco harm reductionists that are based in Denver. You’re not punishing Big Tobacco with these bans.”

E-cigarettes and the flavors that most ex-smokers prefer represent a breakthrough in smoking cessation, and are significantly more effective as cessation tools than traditional nicotine replacement therapy options, like patches and gums. The campaign against them—based largely on stoked-up concerns over youth use, which is overwhelmingly not daily use and has been declining steeply—is an egregious example of drug-war fear-mongering. Prohibition, as we should know by now, creates many harms. Sadly, Denver’s ban is likely to encourage an illicit market, increase criminalization and deter people from quitting the cigarettes that cost so many lives. 

Screenshot of one of the hearings leading up to the vote via Denver City Council

The post Denver Passes Ban on Sales of Flavored Vaping Products appeared first on Filter.

The Denver City and County chamber was packed, and councillors remarked that they hadn’t seen a meeting so full since COVID. Advocates on both sides were fired up, frequently breaking into applause or reacting with obvious anger as various points were made.

In attendance were doctors, lawyers, students, vape and convenience store owners, people who vape and representatives of anti-vaping organizations—including the Campaign for Tobacco-Free Kids (CTFK), Parents Against Vaping E-cigarettes (PAVE) and Flavors Hook Kids, whose members were highly visible in bright red T-shirts.

“We don’t know how harmful vaping products are because they are not FDA-approved,” said Sawyer, speaking before the agency for the first time authorized a (non-flavored) vaping product that it deemed “appropriate for the protection of public health” on October 12. “What side of history do you want to be?”

Sawyer proposed the bill after her 12-year-old daughter was sold vaping products by another child in her class. “Children start smoking because they are initially attracted to flavored tobacco,” she added, without reference to concerns that bans will create new forms of criminalization and incentivize use of riskier products.

“Vaping more than triples the odds that kids will use cigarillo or cigar products,” she added. Yet that odds ratio only indicates a measure of association, not causation. Additionally, research, together with the experiences of millions of former smokers, suggests that vaping is typically a “gateway” out of—not into—smoking. And the overwhelming majority of teens who vape daily are either already smoking or have previously tried it.

“She was physically addicted and was using two and sometimes three pods a day, which is equivalent to 40 to 60 cigarettes.”

Genene Brown, a volunteer for PAVE, spoke, like Sawyer, about her daughter’s experiences of vaping. “She was physically addicted and was using two and sometimes three pods a day, which is equivalent to 40 to 60 cigarettes,” she said.

The term “equivalent” may fit when it comes to the amounts of nicotine involved. However, when it comes to harms, nicotine is not the cause of them. Nobody is advocating for children to use nicotine. But vaping has been found to be around 95 percent less harmful than smoking. And if vapes weren’t available, research suggests that more kids would be smoking instead.

Councillor Ortega stated that she became involved in the effort when students presented a massive poster showing all the different chemicals in nicotine products. However, while e-liquids may contain chemicals that are dangerous at high doses, such as diacetyl, these are present only in trace amounts that represent greatly reduced toxicity compared with cigarettes.

Some members of the public cited racial justice in supporting the ban. “I am passionate about health and achieving health equity,” said Dr. Terry Richardson, a retired medical doctor and the vice chair of the Colorado Black Health Collaborate. “Big Tobacco has spent the last 60 years targetting the Black community. Tobacco use is the number one cause of preventable death among Black Americans.”

Almost 80 percent of Black smokers use menthol cigarettes, and there is no doubt that this is a result of tobacco companies’ historical marketing of menthols to Black communities. Smoking takes a heavy and disproportionate toll on Black health. Yet research shows that menthols are not more harmful nor more addictive than regular cigarettes.

And when it comes to banning menthols, as has been proposed federally, a key point is that the criminalization of drug sales and possession has always targeted people of color. Eric Garner, for example, was killed by police after being accused of illegally selling loose cigarettes on the street. And nearly 80 percent of people in federal prison and nearly 60 percent of those in state prison for drug convictions are Black or Latinx.

“Prohibition does not work. Please do not pass this.”

Some influential voices in the room asserted the futility of such an approach.

“Prohibition does not work,” said Jesse Lashawn Parris, who is running for Denver mayor in the May 2023 municipal election.” People are just going to go to other municipalities to get these products … You’re literally trying to ban tobacco products that adults smoke on a daily basis to supposedly keep them out of youth hands, but they’re still going to have access to these products. They will find a way. Prohibition does not work. Please do not pass this.”

“I feel strongly that adults who are over 21 should be able to legally purchase alcohol and tobacco products,” said Councillor Kendra Black. “I do not think kids should have access to these products.” 

“One study said that both smoking and vaping are going down in the general public and among kids,” she continued. “I’m trying to take that knowledge with what I’m hearing that vaping is going up and more kids are smoking, because I can’t get those two things to come together.” She was correct that recent youth vaping rates have declined significantly, together with a long-term decline in smoking.  

One of Black’s Council colleagues similarly struggled to reconcile the proposal with the evidence. “We like to work from data,” said Councillor Kevin Flynn. “We don’t want any kids to smoke … What is the data that shows this [ban] is effective? Because I’m having trouble seeing this as accomplishing what we all want.”

“Did you take a meeting with Tobacco-Free Kids?“

Sawyer responded that her data came primarily from a presentation created by the Denver Department of Public Health & Environment and their partners at CTFK, an organization funded by billionaire vaping opponent Michael Bloomberg.

“Did you take a meeting with Tobacco-Free Kids?“ she asked Flynn. “I would recommend that you do, and a lot of our data has been provided to us by them.”

Recent evidence shows that San Francisco, where flavored vapes are banned, saw an increase in youth tobacco use after the policy was enacted. Sawyer said of this that “SF data says it didn’t stop all kids from smoking … I know we’re not gonna stop all kids from smoking with this ban. That’s not the point. The point is to stop access to this product.”

It seemed a strange priority.

Small business owners were among the most outspoken participants. “We open 16 hours a day, seven days a week,” said Hoa Loung, who immigrated from Vietnam and has owned a gas station in Denver since 1994. “The flavored tobacco is 30 percent of my tobacco profit. The customers that buy tobacco usually also buy gas and food … As the result [of the ban]… I will have to lay off my employees and eventually close my business since I cannot work 16 hours a day, seven days a week by myself.”

“I don’t think the ban is going to stop young people from getting their hands on it.”

A ban “would put people out of business,” echoed Black, “and not let people over 21 purchase those products … 12-year-olds can walk to Glendale or get their friends that are 21 to drive to Glendale … I ordered a blueberry vape online and it only asked me my birthday but not any sort of verification, so I don’t think the ban is going to stop young people from getting their hands on it.”

Towards the end of the hearing, Flynn proposed extending the discussion period. Sawyer disagreed, stating that “Ortega and I have met with every single councilmember with the exception of one and we’ve had these conversations.”

“It would be appropriate to make a motion to postpone until the first available date,” Flynn insisted. “We have not had the opportunity to meet as a body and discuss … we’ve had one-on-ones and we’ve reacted individually and that’s not the best way to do it.”

He got his way, with a short delay agreed to allow more conversations to take place. The Committee will now decide on October 27 whether the bill should advance to a full Council vote.

Screenshot of the hearing via Denver City Council

The post Heated Denver Council Hearing Debates Vape Flavors Ban appeared first on Filter.

In the United States, the political and media fixation has been on a supposed youth vaping “epidemic,” despite a steep recent decline in youth vaping. This narrative ignores the predominantly marginalized adults who are dying of smoking-related causes at a rate of almost half a million a year. Yet to many opponents of tobacco harm reduction (THR), nothing other than abstinence from nicotine should be our goal.

Surely it would make sense for every smoker who benefits from syringe access to be offered vapes as well?

As a harm reductionist, I am particularly perplexed that many harm reductionists and harm reduction organizations do not fully embrace vaping. I recently reported, for example, on the anti-vaping positions of some syringe programs in Colorado. Surely it would make sense for every smoker who benefits from syringe access to be offered vapes as well? Yet THR has been sidelined in wider harm reduction discourse and provision.

How can we do better at integrating THR into “drug” harm reduction programs (HR)? I put this question, among others, to three people with different expertise and experience.

One of them has an extensive background of working in harm reduction and grassroots drug-user advocacy; his current position at a state health department means that he spoke on condition of anonymity. We’ll call him “Mike.”

I also spoke with Art Way of Equitable Consulting; before becoming a drug policy consultant, he advocated around cannabis and criminalization, among other issues, for the Drug Policy Alliance. Finally, I put these questions to Kat Humphries, a well known harm reductionist who is the programs director of the Harm Reduction Action Center in Denver. Their responses have been lightly edited for length and clarity. 

Kevin Garcia: What made you start thinking that we needed to pay attention to THR?

Mike: It’s something I’ve thought about here and there. I first became involved in the international THR scene about 15 years ago and was exposed to some Australian work. In the States, I’ve been engaged with service delivery and a group of us conducted a THR group for people using cocaine. 

Art Way: Nobody wants to represent the tobacco industry or users, and the death of Eric Garner [killed by the NYPD in 2014 after being accused of illegally selling “loosies”] was problematic. At that time, I worked with the Drug Policy Alliance. It was about police accountability, marijuana legalization and menthol bans. 

Kat Humphries: I don’t typically think of harm reduction in terms of specific substances, but rather as a movement to support and empower the safety and wellbeing of all people who use drugs. THR hasn’t been a prominent component of my harm reduction career; however, I absolutely believe people deserve access to tools that allow them to use substances in a way that lowers negative health outcomes. Many harm reduction agencies have historically prioritized opioid-centric harm reduction, but ensuring appropriate harm reduction tools are available for all people who need them is imperative.  

“Harm reduction tends to work well by maximizing pleasure, not just minimizing harm.”

What would bringing THR to HR look like for you? How can we bridge the gap?

Art: That’s what I’m trying to do. I don’t know if it can happen in regards to organizations right now. We need to build a base of harm reductionists as individuals to advocate for THR. Harm reductionists within the public health space, willing to cut through politics and stigma. 

Kat: Education! I think the biggest barrier to implementing THR is the lack of education around the options. The evidence is definitely out there, but a lot of misinformation has also been pervasive, causing confusion about the facts. Harm reductionists respond well to evidence, and I love that you’ve taken on highlighting the importance of THR.

I would start by defining the most effective THR options for people interested in implementing them, providing different levels of potential interventions for already-existing harm reduction agencies to integrate (with a focus on low-barrier, low-cost options for severely underfunded organizations or [those that] receive no formal funding), and working to provide sustainable long-term funding for those interventions. Further, I would define a specific population that is interested to start applying those interventions, and then scale up. 

Mike: Good HR gets the approach of putting drug use in context with life. Also HR tends to work well by maximizing pleasure, not just minimizing harm.

Smoking after a long time comes with lots of side effects. There’s no naloxone for cocaine or meth, so what do we do? Cardiovascular health education for people who use stimulants, hypertension screening, linking people to care. Providing access to nicotine replacement products, including vapes [works on the same principle].

Have THR integrated into health promotion groups and counseling. Provide real options for people, like free access to nicotine replacement that is desirable to them. Link THR to other drug harm reduction information: [for example] lung health is important for avoiding fatal overdoses. 

Where would be a good place to start?

Mike: States are giving out safer smoking kits for meth and crack using federal funding. The same could probably be done for vapes. States that have embraced harm reduction and have committed to resources like naloxone access would be the best places to start.

Art: It comes down to having the will to advocate on behalf of users of these products. A will to go beyond the politics surrounding the tobacco industry. Organizational perspective can get tricky, but it’s doable from an individual perspective.

“Providing education about low-barrier options for trying out THR could mitigate some of the resistance.”

Do you see any potential issues or complications with integrating THR into HR? If so, do you think they can be mitigated? 

Kat: In spaces that have historically been underfunded, there will always be resistance to change from people who have had to sacrifice for resources and make hard decisions about what to prioritize. Providing education about low-barrier options for trying out THR could mitigate some of the resistance.

Mike: It bugs me that HR in some ways carries over weird vibes from rehab culture, and doesn’t have an issue with people smoking. I smoked for 25 years. When I quit, I used vape pens as a bridge to stopping; [for me] it was more effective than anything else, with the partial exception of Chantix. 

Art: A lot of it comes down to [Michael] Bloomberg and the financing of nonprofits and the Democrats. It’s not within political whims to stand up for vapers and people looking to reduce harms from tobacco use. Bloomberg’s main goal is prevention for youth and hurting the tobacco industry. They have a blind spot with young adults and smokers. It’s a punitive approach. It won’t help in the long run with prevention. If you strengen the illicit underground market, what does that mean for youth prevention? When you have people selling products for supplemental income,they don’t care how old you are. It isn’t a solid move towards cessation and it’s just a lazy policy. 

Drug decriminalization movements are gaining traction, but with nicotine it’s going in the opposite direction. What are your thoughts on the cause of this? How does it harm THR efforts in HR spaces?

Art: It’s unfortunate. It speaks to the fact that we can’t be universal and fundamental in our approach. So called “hard drugs” policy goes in one direction. But when it comes to Democrats specifically, because of Bloomburg, momentum is going the other way and restricting nicotine products. They’re following the money.

Bans and prohibition aren’t the way. We need to focus on demand. Public health and law enforcement always focus on supply and the users are left out of the approach, unless they’re first criminalized. We don’t have a public health infrastructure that isn’t connected to law enforcement. We need to decriminalize drugs … you have to deal with the demand and you have to deal with the user. 

Mike: Anti-vaping hysteria has taken important tools off the table. It’s 100 percent true that we’ve had a whacko, unregulated vape market. That doesn’t mean you can’t make it safer—especially safer than tobacco.

Kat: Prohibition has always disproportionately impacted communities of color in the United States. And taxation as a form of reducing access to a substance is only a preventative measure for people without expendable income—meaning that I think ultimately it’s both racist and classist to deny evidence-based harm reduction interventions for certain substances if people are seeking those resources, particularly while advocating for the decriminalization of other substances.

What are your thoughts on overcoming public health’s blind spot concerning THR?

Kat: I think a lot of people have historically used tobacco, and cigarettes specifically, to self-soothe and help manage stress, anxiety, and a myriad of other mental health conditions. In my time working in harm reduction, I haven’t had participants regularly ask me for harm reduction resources to reduce their smoking, but we’ve had things like nicotine gum available and would certainly expand that if requested by the population we serve.

However, until we start the conversation about other options, people may not be prioritizing lessening tobacco consumption (from the perspective of someone working in a syringe exchange), or they might not have considered it as an aspect of harm reduction. Alternatively, they might not see it as a realistic option when over 75 percent of people we serve are experiencing homelessness and are often victims of theft, which makes holding onto anything of value challenging.

I think starting the conversation is an important step, to see how it is received, which populations might be most interested—and to provide non-judgemental information and access to those interventions … or walking public health and community-based harm reduction organizations through accessing sustainable funding for those interventions.

“We need to adopt an approach like the UK, which has a reality-based nicotine policy that accepts vapes alongside other options.”

Art: My whole goal is to avoid blanket bans, and to take a scalpel to the issue of youth prevention, as opposed to a sledgehammer. Things have gotten better in public health in the last 20 years or so. About 33 million fewer are smoking tobacco [than 50 years ago] and it’s a slow step in the right direction.

We need to adopt an approach like the UK, which has a reality-based nicotine policy that accepts vapes alongside other nicotine replacement options. The US needs to get off of the prohibition approach. We’re doing it with the decriminalization movements but it’s a slow process.

Mike: FDA-approved [vaping] products would be ideal. It would be a big breakthrough in THR for medical and public health purposes. 

Photograph by Lindsay Fox via Wikimedia Commons/Creative Commons 2.0

The Drug Policy Alliance previously provided a restricted grant to The Influence Foundation, which operates Filter, to support a Drug War Journalism Diversity Fellowship. Art Way’s consulting clients have included Reynolds American, Inc, which has also provided unrestricted grants to The Influence Foundation.

The post How Can We Integrate Nicotine Into Harm Reduction Programs? appeared first on Filter.

A study published in Addiction assessed the efficacy of e-cigs compared to NRT among smokers who had tried previous treatments, including NRT. It was conducted as a follow-up to an earlier study by many of the same researchers, which found vapes to be more effective than NRT for smoking cessation among people who hadn’t previously tried any treatments.

These findings add to the growing evidence of vaping’s efficacy for reducing or quitting smoking—but show that it can be especially useful for people who haven’t gotten the results they wanted from NRT.

After six months, only 3 percent of the NRT participants had maintained abstinence from smoking, compared with 19.1 percent of the vaping group.

Participants in the study had previously and unsuccessfully, tried NRT, varenicline (a drug commonly sold under the brand-name Chantix) or both to quit or reduce smoking. They were divided into an NRT group and a vaping group. Those in the NRT group were offered a choice of nicotine patches, chewing gum, nasal spray, microtabs, inhalators and mouth spray; those in the vaping group were offered e-cigs in the flavor and nicotine strength of their choice. 

While the previous study found that e-cigs were more effective for smoking cessation than NRT when both products were accompanied by substantial behavioral support, the followup found this to be true for both cessation and reduction—and even when behavioral support was limited. 

After six months, only 3 percent of the NRT participants had maintained abstinence from smoking, compared with 19.1 percent of the vaping group. And while only 6 percent of people using NRT had reduced their smoking by at least 50 percent, that figure was 26.5 percent for the participants using e-cigs.

“Many dependent smokers have tried and tested many products and been unable to stop. E-cigarette use should be encouraged by health care professionals and stop-smoking advisers,” lead author Dr. Katie Myers Smith told Filter. “Harm to the user, even if they continue to use in the longer term, will be drastically reduced compared to continuing to smoke.”

Allowing the e-cig participants to choose their own preferred strength and flavor is likely to have been crucial to their success rate. Patient choice and autonomy is a backbone of harm reduction—it’s an evidence-based pathway toward finding the treatment option most likely to benefit someone trying to stop or reduce their substance use. Harm reduction practices don’t force people into certain treatment paths, not least because we know that coerced treatment has a greatly reduced chance of success.

“Anyone wanting to stop should consider using an e-cigarette.”

The habitual and ritual aspect of drug use must be considered when presenting options intended to reduce harm. E-cigs, involving inhalation and hand-to-mouth movement, are a much closer approximation than NRT of combustible cigarettes, helping people maintain the social functions of their nicotine use.

“E-cigarettes provide smokers with a device that can be tailored to be a close match to the nicotine levels they got from smoking but without the toxins,” Myers Smith said. “NRT is often underused due to the limited delivery of nicotine and satisfaction [and] enjoyment they get from the products.”

Some people who use e-cigs to quit combustibles are using them as a short-term aid, with the intent of subsequently quitting e-cigs, too. Others are using them as a sustained replacement. Long-term e-cig use needs to be seen in the context of hard-to-reach cigarette smokers who would have otherwise been subjected to higher health risks from continued smoking.

According to the study, about 80 percent of smokers previously treated in clinical trials and provided with intensive treatment in routine care had continued to smoke one year later. If smokers are unable to quit with the best treatments currently available, and providers want the best outcomes, why not offer approaches that are shown to still reduce the harms from smoking without quitting nicotine?

“Vaping poses only a small fraction of the risks of continuing smoking,” Myers Smith said. “Anyone wanting to stop should consider using an e-cigarette.”

Photograph via United States Food and Drug Administration

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“Among never-smokers, the use of electronic cigarettes is not associated with an increased risk of having a heart attack,” Dr. Michael Siegel, a community health sciences professor at Boston University and one of the authors of the new study, told Filter.

A 2018 study, also published in the American Journal of Preventive Medicine, claimed that daily vapers increased their odds of heart attack. Yet it only included participants who used both e-cigarettes and combustible cigarettes—none who used e-cigarettes alone. Suspicious of that methodology, a different group of researchers published a reply, arguing the importance of examining the purported link among people who had never smoked combustible cigarettes. Authors of the original study then published a reply to that reply, arguing that such a distinction wasn’t necessary.

In the meantime, two other papers were published based on the original paper’s claims, lending further harmful legitimacy to the idea of a link between e-cigs and heart attacks.

The second of those two papers—one of whose coauthors, prominent tobacco harm reduction opponent Dr. Stanton Glantz, had once been Siegel’s mentor—was retracted in 2020 for basing its claim that vaping caused heart attacks on evidence that included heart attacks from before the participants had even started vaping.

What’s clear is that the previous conclusion—that e-cigarette use in itself causes heart attack—was wrong. 

The new study, authored by Siegel and University of California, Berkeley, business professor Dr. Clayton Critcher, analyzed data from 175,546 respondents to the annual National Health Interview Survey from 2014 to 2019. They found that daily e-cigarette use was only associated with higher heart attack incidence among people who were also currently smoking combustible cigarettes—and that there was no evidence at all for increased risk among vapers who had never smoked combustible cigarettes. Meaning, the initial study had drawn its conclusions about a perceived cause (vaping) and effect (heart attack) without factoring in a key variable (smoking).

Seemingly inexplicably, the original 2018 paper omitted data from the year 2015, as did the subsequent papers based on it. “It does seem odd that they would just omit data from that year when the data are readily available,” Siegel said.

Reanalysis of the dataset used in the original study, with the addition of the most recently available data as well as the missing 2015 data, revealed that the association between e-cigarette use and heart attack depends on one’s history of smoking.

Correlation is not causation, and it’s concerning when researchers fall into such pitfalls.

Critcher and Siegel acknowledge that a more thorough analysis of previous research would have noted that e-cigarettes are relatively new, limiting our ability to assess long-term health effects and make comparisons with combustible tobacco smoking. But what’s clear is that the conclusion of the previous research—that e-cigarette use in itself causes heart attack—was wrong. 

Bad research has already led to bad policy in the tobacco harm reduction field, making it unnecessarily harder for smokers to switch to a much safer option. Correlation is not causation, and it’s concerning when highly qualified researchers fall into such pitfalls—at the expense of accurate public health messaging. A correlation between e-cigarette use and heart attack incidence cannot be used as evidence that e-cigarette use will increase heart attack incidence.

“By analogy, if one models height as a function of weight, one cannot then use that output to play out counterfactual scenarios to learn how much shorter a person will become upon losing weight,” Critcher and Siegel wrote.

Photograph via National Institutes of Health

The post Vaping Does Not Cause Heart Attacks, Study Finds, Refuting Previous Claims appeared first on Filter.

Published in the International Journal of Environmental Research and Public Health, the paper assessed the impact of question wording on physician perceptions about nicotine use.

Researchers led by Dr. Michelle Bover Manderski used the data from 926 physicians who received one of two versions of a questionnaire. They were asked about the “extent to which they agree or disagree that ‘nicotine’ (Version 1) or ‘nicotine, on its own,’ (Version 2) directly contributes to birth defects, CVD, cancer, depression and chronic obstructive pulmonary disease (COPD).” Apart from that difference, the surveys were virtually the same.

For Version 2, with the “nicotine, on its own” wording, 69.6 percent and 67.3 percent of physicians “strongly agreed” that nicotine directly contributed to cancer and COPD, respectively. For Version 1, 85 percent and 85.2 percent of physicians strongly agreed with those incorrect statements.

“The proportion of surveyed physicians who believe that nicotine directly contributes to these health outcomes is alarmingly high.”

Wording matters, given the lower percentages of physicians who answered incorrectly about nicotine “on its own.” There were also differences between medical specializations—with pulmonologists generally the least likely to hold misperceptions about nicotine and family medicine physicians the most likely.

Nonetheless, the misperceptions were common across the board. “Even after accounting for question version, the proportion of surveyed physicians who believe that nicotine directly contributes to these health outcomes is alarmingly high. It is possible that participants are conflating the addictive effect of nicotine with the comparatively more harmful effects of tobacco use” the authors wrote.

“It is very important for physicians to understand the relative harm between nicotine and the other 7,000 toxins in tobacco smoke,” Dr. Manderski told Filter. “This is especially important as physicians play a key role in recommending and prescribing FDA-approved nicotine replacement medications.”

It is crucial, as Dr. Manderski further emphasized, so that physicians can provide patients who smoke or use nicotine in other ways with accurate information and help. This research unfortunately indicates that many patients are likely being failed.

The public-awareness implications apply not only to nicotine patches and gums, but to nicotine vapes, which research has found to be the more effective quit-smoking tools. The FDA may well approve some vaping products as “appropriate for the protection of public health” as soon as September, under its Premarket Tobacco Product Applications process.

The researchers suggest something that’s clearly needed in a country with around half a million deaths each year caused by smoking tobacco, not by nicotine itself: the prioritization of health provider education in this area.

Photo by National Cancer Institute on Unsplash

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