The report, “Smoking Prevalence Among Indigenous Peoples of the World,” covered 105 countries with Indigenous populations. It found that only five of these countries had definitive information about Indigenous smoking rates. Where such rates are known, they are disproportionately high.

The report was authored by Dr. Marewa Glover, who leads the Centre of Research Excellence in Indigenous Sovereignty and Smoking (COREISS), based in Auckland, New Zealand. Throughout the report, Glover points to how the World Health Organization’s Framework Convention on Tobacco Control (FCTC) discourages the implementation of equitable and compassionate policies impacting Indigenous populations.

“Criminalizing behaviors represents a risk for peoples who may have disproportionately higher smoking rates, and who can be disproportionately targeted by police.”

“Most of the countries in this report have signed up to the FCTC guidelines, and as a result, they are being urged to implement and enforce laws (regardless of the risk of harm) prohibiting the use of any and all tobacco products,” Glover told Filter.

“Criminalizing behaviors associated with tobacco product use represents a risk for Indigenous peoples who may have disproportionately higher smoking rates than other ethnic groups, and who can be disproportionately targeted by police, and incarcerated,” she continued.

Glover, who is Māori, previously wrote for Filter about how, in her native New Zealand, a law banning smoking or vaping in cars when a minor is present exposes Māori women, who have the highest rate of smoking, to racial profiling and a higher risk of being arrested and incarcerated. 

In other countries, it can get even worse, she pointed out. “Whilst a smoking-related ban in one country might not be enforced at all or may result in a manageable fine, in totalitarian countries the offender could be caned or imprisoned.”

Australia is one country that reports disproportionately high rates of smoking among the Aboriginal and Torres Strait Islander peoples. Over 40 percent of Indigenous adults there smoked, which is three times higher than the national average. Indigenous people in Australia are also disproportionately targeted by police and incarcerated.

Another risk of prohibitionist policies focused on eliminating all forms of tobacco and nicotine use is that some Indigenous peoples have long-established traditions of growing and using tobacco for various reasons. The cultivation and use of tobacco dates back at least 8,000 years.

But again, the vast majority of countries do not compile smoking data for Indigenous people. To take one example from the report, overall daily smoking prevalence in Greenland for people aged 15-plus was found, as of 2015, to be 42.7 percent for men and 44.3 percent for women. “This likely slightly underestimates the Kalaallit prevalence,” the report notes, “but they do make up 89.5% of the population.”

Greenland, the vast, thinly populated island between the Arctic and Atlantic oceans, is an autonomous territory, or colony, of the Kingdom of Denmark. And while Greenland isn’t a party to the FCTC, Denmark is—and heavily influences Greenland’s tobacco control policy.

“No data for Indigenous people was found.”

Meanwhile Guyana, in South America, has an Indigenous population estimated at 9.2 percent, most of whom live in rural areas. National daily smoking rates were found, as of 2018, to be 22.1 percent for men over 15, and 2.2 percent for women.

Guyana’s government attempted, in the 1970s and 1980s, to integrate Indigenous groups into national statistics. But according to Glover’s report, when it comes to smoking, “No data for Indigenous people was found.”

“The scale of the task regarding Indigenous peoples is put into context by the fact that they make up 6 percent (476 million people) of the world’s population,” Paddy Costall, a director of Knowledge-Action-Change, an organization that advocates for harm reduction approaches to nicotine, told Filter. “As such, the issue of tobacco use within these communities is a significant one that requires understanding and assessment. The lack of specific data makes this task more difficult.”

Glover concludes in the report that countries with high Indigenous smoking rates need to remember the human rights mandates outlined in both the FCTC and the United Nations Declaration on the Rights of Indigenous Peoples, if they’re to avoid making tobacco control policies that increase inequalities and harms.

“Policies and laws intended to stop tobacco use, including taxing tobacco products, must exclude tobacco growing, manufacture and use where those practices are part of the traditional way of life or a traditional source of livelihood or a craft of an Indigenous people,” she said.

Photograph by Oleg Dubyna via Wikimedia Commons/Creative Commons 3.0

The COREISS RAUPO Podcast, hosted by Marewa Glover and Michael McGrady, is available on Spotify, Apple Podcasts, Audible, Amazon Music, and Google Podcasts.

COREISS, Knowlege-Action-Change and The Influence Foundation, which operates Filter, have received grants from the Foundation for a Smoke-Free World. Both The Influence Foundation and Michael McGrady have received tobacco harm reduction scholarships from Knowledge-Action-Change. Filter‘s Editorial Independence Policy applies.

The post Very Few Countries Track Smoking Rates Among Indigenous Peoples  appeared first on Filter.

But tobacco harm reduction’s most important battleground, where more than half of the world’s smokers live, is Asia. The continent is home to a diverse range of nicotine policies, ranging from innovative approaches that the world should watch to harsh prohibitions.

Taiwan has chosen the latter path. Nicotine vapes are broadly banned in the country of 24 million off the coast of mainland China—although there are legal complexities and gray areas, with one lawsuit by vape sellers succeeding against the government and legislative amendments pending.

Last year, smoking among Taiwanese youth reportedly increased for the first time in a decade. Vaping, despite the restrictions, rose even faster, however—and was duly described as a “stepping stone” to smoking by government sources. It’s tempting to wonder whether youth smoking would have increased in an environment where vapes were unequivocally more readily available than cigarettes.

Danny (Yu-Yang) Wang is a human rights activist who leads VAPE Taiwan—a tobacco harm reduction media and advocacy organization that he founded in Taiwan’s capital of Taipei in 2017. Filter reached out to him to learn more about his work and the challenges that he and his allies face.

Michael McGrady: What are the current laws in Taiwan governing e-cigarettes and other tobacco harm reduction products?

Danny Wang: Electronic cigarettes are banned in accordance with Taiwan’s Tobacco Hazard Prevention and Control Law, the Pharmaceutical Affairs Law, and the Drug Control Regulations. [Large fines can apply to those who manufacture or import banned products.] The government’s position on heat-not-burn products is unknown and, as far as I can tell, there is no clear regulatory management method.

Some legal loopholes allow the industry to exist here, however. For example, there’s the practice of selling nicotine-free products openly, while selling nicotine products under-the-table. And while Taiwan’s Tobacco Hazards Act specifically prohibits cylinder-shaped devices, it’s less clear when it comes to other shapes.

Many products are smuggled into Taiwan. Some people here also manufacture vaping devices and e-liquids for export, using other names for their products, or claiming their e-liquids are nicotine-free. I’ve heard of vaping devices being exported as “heating devices.”  

What is your background, Danny, and how did you become involved in tobacco harm reduction?

I worked in health promotion in the past, mainly in the field of physical fitness. I was engaged by an international exhibition company from 2014 to about 2017. At that time, I became the first international vaping exhibition agent in Taiwan, selling overseas exhibition booths to vaping business owners here. That’s how I started contacting participants in Taiwan’s growing and dynamic vaping industry.

I was personally able to switch from cigarettes to e-cigarettes. I then started participating in tobacco harm reduction advocacy. 

What’s the current smoking rate in Taiwan? How embedded is smoking in Taiwanese culture, and which demographics smoke the most?

According to our government’s data, the smoking rate in Taiwan in 2018 was 13 percent. It is much higher among men than among women. Data from the Ministry of Health and Welfare depicts smoking among men aged 36 to 40 years as high as 35.4 percent. You see smoking culture as a feature of business sales settings, for example.

Data indicate that the rate of smoking among men with junior high educational levels is at 39.6 percent. But the real disparities in smoking in Taiwan occur among men without income. Their rate is 65.3 percent.

How commonly do you think Taiwanese people understand the options that are out there for reducing the harms of tobacco?

Rarely. The Taiwanese government and anti-tobacco groups still claim that harm reduction is the rhetoric of the tobacco industry, which is unbelievable.

Have Taiwan’s media and government raised the alarm about youth vaping, as has happened in the US?

Yes. The government, the media, anti-smoking groups, and opposing medical physicians continue to emphasize that taking up e-cigarettes will abduct young people to start smoking. [The city of] Taipei urged a clampdown on heated tobacco shops, too.

What measures do you hope the Taiwanese government will take to reduce tobacco harms?

It is hoped that the national government can accept the scientific evidence around tobacco harm reduction. This also includes [emulating] advanced national examples of tobacco control and tobacco harm reduction, with these strategies working hand-in-hand to achieve the goal of a smoke-free Taiwan by the year 2040. 

How likely do you think it is that your government will do this?

Frankly, I expect the difficulty to be extremely high. Funding for our health and welfare policies comes from the taxation of cigarettes. At least 70 percent of the funding for long-term public health care policy comes from the same funding.

Can you describe your advocacy organization? Do you accept industry funding? 

We established VAPE Taiwan Media in 2017, which is the only Mandarin media for the tobacco harm reduction “industry.” I am an independent advocate, because our government stops me from organizing an NGO, so I can only establish a media company—that’s why I call myself “for the industry.”

As the leading Mandarin tobacco harm reduction media organization, VAPE Taiwan collects, analyzes, translates and disseminates the latest international industry news, research, and national data to help achieve the goal of a smoke-free Taiwan. Presently, we aren’t accepting industry sponsorships. 

MM: How does your organization work with groups in other Asian countries to promote tobacco harm reduction? What is your international goal?

The VAPE Taiwan system includes the Taiwan Tobacco Harm Reduction Association, the Foundation for a Smoke-Free Taiwan, and the Alliance of Banning Cigarettes Taiwan. We exchange information with other Asian tobacco harm reduction advocacy groups, mainly through Facebook, WhatsApp, Line, and other social networks. We are also currently affiliated with the International Network of Nicotine Consumer Organisations (INNCO) and the World Vapers’ Alliance (WVA). We hope to become a leading media outlet in the field of tobacco harm reduction for the Mandarin language and to bring forth awareness and factual information.

Photograph of Danny Wang launching a legal challenge against Taiwan’s Ministry of Health and Welfare, courtesy of Wang/VAPE Taiwan

Both INNCO and The Influence Foundation, which operates Filter, have received grants from the Foundation for a Smoke-Free World. Both The Influence Foundation and the author have received Tobacco Harm Reduction Scholarships from Knowledge-Action-Change.

The post What It’s Like to Be a Tobacco Harm Reduction Advocate in Taiwan appeared first on Filter.

It is unsurprising, therefore, that tobacco harms have been largely overlooked amid the unfolding political drama. Yet almost half a million Americans—more even than have so far died of COVID-19—lose their lives to smoking-related causes every single year.

The Biden-Harris administration will take office with a mission to promote public health based on scientific evidence. While tobacco harm reduction (THR) remains controversial in the US, the lower risks of nicotine products like e-cigarettes and snus compared with smoking are well demonstrated. Objections to THR seem, therefore, to be based on ideological opposition to harm reduction—an inclination which, troublingly, both Biden and Harris have sometimes shown in non-tobacco arenas.

US tobacco harm reduction advocates have endured numerous legislative defeats during the Trump presidency—from the January 2020 imposition of nationwide partial vape flavor ban to several state-level prohibitions and further recent restrictions on online vape sales. Will things get better, or worse?

To help us assess the outlook, Filter reached out to numerous experts with a variety of relevant specializations and perspectives. We asked them to elaborate on one simple question—what should Joe Biden realistically do to promote US tobacco harm reduction during his presidency?—or to comment on related issues of their choice. Here are their responses.

David Abrams is a professor of social and behavioral sciences at the New York University School of Global Public Health. He has previously directed institutions including the Centers for Behavioral and Preventive Medicine, Warren Alpert Medical School at Brown University, and the Office of Behavioral and Social Sciences Research at the National Institutes of Health.

“The most important thing the Biden administration can do to improve public health is to help the public understand the differences in risk between nicotine itself and nicotine delivered in smoke. We must support those who want or need nicotine to find a much less harmful non-combustible option.

Especially neglected are those smokers at disproportionate risk who smoke the most and have lower income and education, less access to or no affordable health care and have comorbidities, such as suffering from mental health and substance use problems and chronic diseases are that made much worse by smoking.”

Azim Chowdhury is a partner at Keller and Heckman LLP, where he helps lead the Washington, DC-based legal firm’s award-winning food and drug regulatory practice.

“The Biden-Harris administration has indicated that it will move quickly to reinstall science as a foundation for government policy; hopefully, that remains the case with respect to tobacco harm reduction. In addition to enforcing age and marketing restrictions to prevent illegal underage use, the new administration should emphasize the important goal of reducing, and hopefully eliminating, combustible cigarette use–which has dropped to historical lows (among all age groups), but seems to be on the rise again, in part due to misinformation and fear-mongering over ENDS [electronic nicotine delivery systems] and other reduced-harm nicotine products.

President Biden has also made clear that he is a ‘Presidency for all Americans.’  In this regard, in addition to following the science, the Administration should make [the] effort to listen to all of its constituents—including the nearly 10 million American adults who rely on ENDS to stay off of cigarettes. Not doing so will have serious consequences for the nation’s public health.”

Samrat Chowdhery is the president of INNCO (International Network of Nicotine Consumer Organizations), which works to support the rights of nicotine users worldwide. He lives in Mumbai, India.

“The direction the US takes has global impact—the ‘teen epidemic’ and EVALI scares in America were directly responsible for the rise in flavor ban legislation across Europe and outright ban of e-cigarettes in some countries, including India. The Biden administration should consider the weight of its actions, paying strong heed to science on tobacco harm reduction and its effectiveness in helping curb tobacco death and disease—and not fall prey to emotional hooks, which ultimately does a disservice to over a billion tobacco users.”

Alex Clark is the CEO of CASAA, a consumer advocacy group, affiliated with INNCO, which promotes the rights of US nicotine users. He lives in New York.

“While on the campaign trail, president-elect Biden committed to following the science, so the important thing is that the Biden/Harris administration knows which science to pay attention to.

There are currently tens of thousands of premarket applications for new nicotine products pending with [the] FDA which are supported by some of the best science in the world. Following such a dismal roll-out of the deeming regulation, it feels a bit off to suggest that deferring to the FDA is the best course of action, but it makes more sense than basing policy on fear and prejudice.”

Gregory Conley is a New Jersey-based attorney who is the founder and president of the American Vaping Association. He commented on Biden’s pick to head the Centers for Disease Control and Prevention.

“Dr. Rochelle Walensky is a respected professional with a background of work that suggests an understanding of the benefits of harm reduction strategies in public health. She has a tough task ahead of her; not just advising America through a pandemic, but rebuilding the CDC’s trust with the American people. Part of that process should include studying not just what went wrong with the CDC’s response to COVID-19, but also the CDC’s failures before the pandemic, when it blamed EVALI on nicotine vaping products.” 

Stefan Didak is a California-based THR advocate who was one of the founders of Not Blowing Smoke, an industry-backed vaping advocacy committee, and also founded the consulting agency Ignyter.  

“I think what the Biden administration should do is to avoid embracing prohibition-style policies while allowing the regulatory approval process to take its course, without making it worse than it is. The best way then to promote safer nicotine alternatives would be to ensure federal preemption applies so that states and local municipalities are not allowed to restrict adult access to these products.

This may not be the answer that’s expected but … realistic goals. Expecting anything like UK-style promotion along with radical simplification of the regulatory requirements would be unrealistic, and taking vapor products out of the tobacco regulation also would be unrealistic at this point. But if the administration stands behind approval of products that meet the incredibly high requirements then it’s only fair that banning legal and approved products, with appropriate sales restrictions, should be prohibited.”

Abigail S. Friedman is an assistant professor in health policy and management at the Yale School of Public Health. Her career has focused on the public implications of health regulations, including those pertaining to products like vapes. She commented on the US Food and Drug Administration’s regulatory process.

“Companies need clearer guidance on the type of data and analyses that need to be provided to meet FDA benchmarks, and the FDA needs more funding so that the (thousands of) applications they have already received can be reviewed in a reasonable amount of time. The current approach asks regulators to perform an almost Herculean task, whereas the submission fees needed to maintain it give large, well-established companies a clear advantage over smaller ones.”

Michael Landl is the director of the World Vapers’ Alliance, which advocates for the rights of vapers and nicotine users in the European Union and elsewhere. He’s based in Vienna, Austria.

“The new administration must be led by science and not by ideology on this issue. Instead of idealized goals, it needs to put practical solutions center stage. Harm reduction has proved to be effective and is accepted in many countries. To effectively reduce the burdens of smoking, harm reduction such as vaping needs to be actively endorsed. It is also essential that the affordability and variety of vaping products are ensured. The US needs to avoid higher taxes and burdensome regulation, like liquid flavor bans, on vaping products on every level.”

Michelle Minton is a senior fellow at the Competitive Enterprise Institute in Washington, DC. She is an advocate for THR, as well as in areas like cannabis legalization and gambling.  

“Biden has already endorsed reduced forms of harm reduction in some cases, for example supporting the use of treatments like methadone for opioid use disorders. The evidence is clear that low-risk nicotine products have a similar life-saving potential for smokers. If Biden is truly committed to science, his team will have to disregard media narratives, solicit input from a wide array of experts in the field—not just the politically-connected few—and make decisions based only on what will benefit public health most.”

Ethan Nadelmann founded the Lindesmith Center in 1994, which he merged with another organization to form the Drug Policy Alliance in 2000. He was DPA’s executive director until 2017, spearheading many drug policy reform successes. His advocacy has increasingly focused on THR in recent years. He lives in New York.

“Biden can learn from the mistakes he made in promoting the War on Drugs. He can insist that tobacco policy be grounded in science, compassion, health and human rights. He can seize the political advantage to be gained by treating with respect the 34 million Americans who still smoke, and encouraging those who can’t or won’t quit to try whatever works.”

“And, just maybe, he can persuade his old cigarette-addicted friend, Barack Obama, to publicly advocate for a harm reduction approach to tobacco.”

Yaël Ossowski is the deputy director of the Consumer Choice Center—a Washington-DC headquartered NGO that operates in Europe, Latin America and other regions as well as the US. He co-authored the center’s United States Vaping Index, which measures each state’s public-policy friendliness to vaping. 

“President-Elect Joe Biden has said he wants to better apply scientific knowledge to public policy, especially health policy, and that is to be applauded. But that will also mean listening to the science on the innovations in tobacco harm reduction, such as vaping and oral nicotine alternatives to smoking. These market alternatives have already proven successful in prolonging the lives of millions of Americans, and will continue to do so as long as the federal government promotes smart regulation and recognizes the studies that have proven they are less harmful.

Consumers deserve to have public officials who will not only make decisions on the science, but also respect and protect their wishes to improve their lives how they see fit.”

Riccardo Polosa is a professor of internal medicine at the University of Catania, Italy, and the founder of the university’s Center of Excellence for the Acceleration of Harm Reduction (CoEHAR). His research specializations include respiratory diseases, clinical immunology and THR. He was instrumental in persuading the Italian government to exempt vape stores from the country’s COVID-19 lockdown.

“Although ideology and politics will continue to maximize the risk (and minimize the benefit) associated with vaping, in a perfect world Biden should listen to unbiased science on how vaping can reduce the harmful effects of tobacco. Biden needs to listen to all the voices (and particularly to consumers) and just pull away from those who continue to spread fear, confusion and doubts.

The new administration should first of all appoint a strong leader for the Food and Drug Administration, not just another bureaucrat. Then the new leader should revisit the pre-market requirements for all lower-risk tobacco and nicotine products. In their current form, these regulations act as a barrier to entry for all companies except the established tobacco corporations who have the money to go through the approval process.

Then the Health and Human Services branch should form a committee to address the use of tobacco products and tobacco harm reduction should be considered as a strategy.” 

Helen Redmond is Filter’s senior editor. She’s a journalist, documentarian and social worker, and an adjunct professor at the New York University Silver School of Social Work.  

“I’m tempted to say President-elect Biden just needs to get out of the way of the vaping revolution in America that is saving millions of lives, but I can’t. That’s because the groups that oppose tobacco harm reduction have created a war on nicotine and some of the most obnoxious drug warriors are Democrats like Chuck Schumer and billionaire Michael Bloomberg. They have whipped up a classic drug panic and succeeded in passing a variety of bans on vaping products, making it increasingly difficult for adult smokers to switch.

The reality for 2021 is the Biden administration, as well as state and local governments, will need to be publicly and relentlessly pressured by pro-vaping organizations and the vaping industry to repeal all anti-vaping legislation.”

Lindsey Stroud is a board member of the Smoke-Free Alternatives Trade Association, a consultant to vaping companies and the manager of THR101.org. She lives in Chicago.

“President-elect Joe Biden has positioned himself as a man of science and has consistently reiterated to the American public to listen to science. I truly hope that as president, he himself will listen to the science and embrace tobacco harm reduction products, especially electronic cigarettes and vapor devices which are effective tools in helping smokers quit—despite the fact that the FDA is still lagging in promoting the efficacy of their role in cessation.

Undoubtedly, the Biden administration will be plagued by the anti-vaping zealots that have pursued on through virtual hearings in every possible locality to restrict access to these products, even though youth vaping has decreased from 2019 and 2020. If the Biden administration truly wants to listen to the science, he will take time to speak with the industry, including the small vapor product manufacturers whose products are not overwhelmingly associated with youth use, to develop a robust policy that will address youth use of age-restricted products while maintaining adult access.”

Michael Siegel is a professor of community health sciences at the Boston University School of Public Health. His THR-related work has been published in many academic and non-academic sources, and he has testified to Congress on vaping legislation.

“President-elect Biden should prioritize three actions to promote tobacco harm reduction: First, the Biden administration should immediately rescind the FDA regulatory requirement that all e-cigarette companies submit premarket tobacco applications (PMTAs). The PMTA requirement would decimate the vaping market, eliminating close to 99 percent of the products on the market, greatly limiting choice for adults, and invariably leading to many ex-smokers switching back to smoking.

Second, in lieu of the burdensome PMTA requirement, the Biden administration should force the FDA to issue safety regulations regarding e-cigarettes and vaping products. These regulations should address concerns such as battery safety, temperature regulation, additives, nicotine formulations, and maximum nicotine levels. The proper way to regulate e-cigarettes is to regulate them, not to effectively ban them.

Third, the Biden administration should direct the CDC and other health agencies to endorse e-cigarettes and vaping as a legitimate and effective method of smoking cessation for adult smokers. Under the past two administrations, e-cigarettes have been demonized by the CDC and other agencies within HHS (and by HHS itself), invariably resulting in deterring many smokers from quitting and causing some ex-smokers to return to smoking. Such an action would also provide a much-needed stimulus for physicians to actively recommend vaping as a smoking cessation alternative for patients who are unable to quit using other methods (which represent about 90 percent of patients).”

David Sweanor is an adjunct professor of law at the University of Ottawa, Canada, and serves as the advisory committee chair for the university’s Centre for Health Law, Policy and Ethics.

“The key message should be to reinforce the importance of empowering people who would otherwise smoke cigarettes to move to low-risk alternatives. This means turning the FDA from a barrier to a facilitator in that transition, ensuring the public is told the truth about relative risks and using policy levers to make better choices for health easier choices to make.

There are literally millions of lives on the line, lives of people Biden cares about. Science and technology now allow us to send cigarettes to history’s ashtray, and that is a goal worth pursuing.”

Disclosures: Samrat Chowdhery, Lindsey Stroud and the author are previous recipients of THR scholarships from Knowlege-Action-Change, through a project independently administered by KAC and funded by a grant from the Foundation for a Smoke-Free World (FSFW). INNCO and CoEHAR have received grants from FSFW. The Influence Foundation (TIF), which operates Filter, has received scholarships from KAC to support tobacco harm reduction reporting, as well as unrestricted grants from FSFW. TIF has also previously received a restricted grant from the Drug Policy Alliance to support a Drug War Journalism Diversity Fellowship, and unrestricted grants from the American Vaping Association. Filter’s Editorial Independence Policy applies.

Photograph of Joe Biden at the 2019 Iowa Federation of Labor Convention by Gage Skidmore via Wikimedia Commons/Creative Commons 2.0.

The post Tobacco Harm Reduction’s Prospects Under the Biden Administration appeared first on Filter.

The CDC found that 19.6 percent of high school students and 4.7 percent of middle school students reported “current” e-cigarette use. But the large majority of use is not daily: Only 38.9 percent of high school vapers and 20 percent of middle school vapers reported vaping on at least 20 out of the previous 30 days.

According to CDC Director Robert Redfield, the decline in the number of youth who use e-cigarettes is an “achievement.” However, he quickly pivoted to a negative tone.

“Although the decline in e-cigarette use among our Nation’s youth is a notable public health achievement, our work is far from over,” said Redfield in a press statement. “Youth e-cigarette use remains an epidemic, and CDC is committed to supporting efforts to protect youth from this preventable health risk.”

David Sweanor, professor of law and chair of the Advisory Board of the Centre for Health Law, Policy and Ethics at the University of Ottawa, Canada, believes the CDC has misbehaved. “The CDC has become politicized in recent years, due to pressure from the administration but also by choice of CDC officials who have prioritized personal moralistic views in place of objectivity,” he told Filter.

Despite Redfield’s and the CDC’s official position on the recent data, a harm reduction perspective would note that frequent use and nicotine dependence remain rare among youth who have never smoked. And a focus on vaping in isolation ignores its potential relationship with a much more harmful form of nicotine consumption.

“Smoking—by far the more dangerous behavior—has been dropping rapidly during the era of vaping’s popularity among kids,” Kenneth Warner,  professor emeritus and dean emeritus at the University of Michigan’s School of Public Health, told Filter.

With David Mendez, Warner published a study in the journal Nicotine & Tobacco Research last year that compared the potential public health benefits of vaping with potential costs—and examined the claim that vaping among youth who have never smoked is a “gateway” to cigarettes. They concluded that “potential life-years gained as a result of vaping-induced smoking cessation are projected to exceed potential life-years lost due to vaping-induced smoking initiation.”

“Public messaging and policy should continue to strive to reduce young people’s exposure to all nicotine and tobacco products,” Mendez and Warner wrote. “But, they should not do so at the expense of limiting such products’ potential to help adult smokers to quit.”

“There is good evidence that the rise of youth vaping is associated with an accelerated decline in smoking. We don’t know that the reverse would be true, though it is certainly a risk that smoking may rise if vaping falls.”

Clive Bates, a consultant and former director of Action on Smoking and Health (UK), said the CDC had omitted a crucial area from its datasets.

“The key missing data is what happened to youth smoking,” he told Filter. “That data has been held back, so we don’t know if the decline in vaping was accompanied by a rise in smoking. Given smoking is likely to be at least 20 times as harmful as vaping, small rises in smoking can easily offset the large decline in vaping.”

To Bates, the youth vaping figures might represent bad news, but not for the reasons the CDC presented.

“There is good evidence that the rise of youth vaping is associated with an accelerated decline in smoking,” he said. “We don’t know that the reverse would be true, though it is certainly a risk that smoking may rise if vaping falls.”

In August, the CDC did also release the results of its most recent iteration of the Youth Risk Behavior Surveillance System survey, which serves as a significant source of information about the most common risky behaviors among youth.

It found that nearly one-third of surveyed high school students vaped. Meanwhile, only 6 percent smoked cigarettes, while a similar number smoked cigars. Given that vaping is about 95 percent safer than smoking, according to an oft-cited evidence review from Public Health England, the recent comparative prevalence of the former among young nicotine consumers is significant. It remains to be seen whether the US public health establishment’s concerted efforts to drive down youth vaping rates will have a nasty unintended consequence. 

The author has previously been supported by a scholarship from Knowledge-Action-Change. The Influence Foundation, which operates Filter, has also received scholarships from KAC to support tobacco harm reduction reporting.

Photo by Alexandra_Koch from Pixabay

The post Youth Vaping Declines, But the CDC Clings to Its “Epidemic” Narrative appeared first on Filter.

One briefing from the Tobacco Control Legal Consortium estimated the available research to show that at least 70 to 80 percent of the US incarcerated population smokes or has previously smoked. Other research has explored how high incarceration rates impact overall smoking rates among Black Americans. Internationally, prison and jail systems across the world show far higher smoking rates than among the non-incarcerated population.

Vapes, of course, have been estimated by the UK’s Royal College of Physicians to be 95 percent less harmful than cigarettes, and described as “far less harmful” by the US National Academies of Sciences, Engineering and Medicine.

In the US, the Federal Bureau of Prisons (BOP) banned smoking in federal correctional facilities in 2015, having previously banned the sale of tobacco products in facility commissaries back in 2006. In addition, a 2019 briefing by the American Nonsmokers’ Rights Foundation showed that states including Colorado, Kansas, Michigan, Nevada, and Ohio have banned the use of all tobacco products by incarcerated people and staff in state facilities.

Like smoking bans in the outside world, the policy seemed tempting at a basic health level. Besides improving overall health, one of the supposed missions of prison bans is to promote detox environments. The Marshall Project, along with other criminal justice reform groups, posits that smoking bans in carceral environments aren’t all that bad. But in practice, bans without harm reduction alternatives pose a series of glaring problems.

One aspect is the potential benefits of nicotine and the harms of withdrawal to people in this setting. Nicotine has calming properties which help to explain, for example, very high smoking rates among people with mental health diagnoses—a population that heavily overlaps with the incarcerated population. Withdrawal, as Carrie Wade explained for Filter, brings symptoms like “irritability, anxiety, depressed mood, craving and malaise”—all of which would be greatly compounded for someone entering prison or jail.

Since incarceration is often physically and emotionally traumatic, smoking a cigarette can be a coping mechanism whose long-term risks understandably seem less important than immediate emotional needs. Unsurprisingly, incarcerated people have responded to bans by seeking contraband tobacco, which may lead to debts and power imbalances, or even violence, among the population.

“A lot of gangs run the business from inside, [from] sourcing the tobacco to smuggling it in, to selling it on the compound and collecting the money.”

“Tobacco comes in a bunch of different ways,” Seth Ferranti, a documentarian and writer who was incarcerated for over 20 years in the federal prison system for first-time drug-law violations, told Filter. “Through the guards, thrown over the fence, smuggled in through visiting rooms or through the warehouse, even mailed in.”

“A lot of gangs run the business from inside, [from] sourcing the tobacco to smuggling it in, to selling it on the compound in retail amounts and collecting the money,” he continued. “I think people should be able to smoke if they want, as long as they have smoking and nonsmoking units and areas.”

But what if prisons and jails promoted safer nicotine products as alternatives to smoking? This is the question a small vape manufacturer in Kentucky thought to ask. Crossbar was founded by former corrections officials. That sets off alarm bells, and the company and the model under which it cooperates with the carceral system, have understandably been criticized for profiteering from incarcerated people. To learn more, I reached out to its founder, Jamie Moseley.

“After much research, I determined that there was not an alternative nicotine product that was safe to be utilized in a correctional setting, so I began the process of developing my own,” said Moseley, who managed a jail in Laurel County, Kentucky, back in 2012. To meet safety regulations, Crossbar developed a product with a soft plastic casing and a low-voltage, non-rechargeable battery.

Mosley claimed, “My intention was to simply create a product that could impact our facility in a positive manner; there was no initial intent to offer the product commercially.” Nonetheless, Crossbar started selling its product through commissaries in Kentucky facilities. Vice estimated that the company stood to make $3.5 million in sales in 2018, and noted outrageous markups, supposedly imposed in part to support rehabilitation programs: “Mosley’s company sells the e-cigs to prisons and jails for about $2 to $3, and the facilities, in turn, sell them to inmates for between $10 and $15.”

“The impact was immediate,” Moseley said. “Tobacco contraband virtually disappeared, and we were generating a significant amount of revenue that would allow us to provide the inmate programming that we were seeking. To our surprise, there were many secondary benefits; we began to notice that inmate-on-inmates assaults declined significantly.”

Of the incarcerated people who use Crossbar’s products, Moseley said, “Many have indicated that upon release they do not intend to return to using combustible tobacco products.” He added that for people who are dependent on other drugs, “I have no question that the ability to utilize this product during incarceration helps to minimize the impact of the lack of drugs.”

This distribution of free or discounted vape starter kits seems highly promising.

It should be noted that there is no independent evidence to support Moseley’s specific claims. But despite the severe ethical problems surrounding this for-profit model to implement vaping in carceral settings, more study of the outcomes of tobacco harm reduction efforts here would certainly be welcome. It is possible that the findings would lend support to the provision of vapes to incarcerated people at the government’s expense—as has already happened elsewhere.

The United Kingdom’s Ministry of Justice supports the use of e-cigarettes in prisons, to allow them to remain smoke-free while giving nicotine-dependent people relief from cravings and other symptoms. In the UK, vaping products are typically provided in carceral medical environments, and supplied to prisoners either for free or at discounted cost. They are also available at full cost in commissaries. “Prisoners have been given support in quitting smoking if they need it,” a Prison Service spokesperson told Metro UK in 2018, “including vapes, e-cigarettes and nicotine replacement therapy.”

Similarly, the BBC reported in early 2019 that the Scottish Prison Service had spent £150,000 to fund a system-wide vaping kit scheme for incarcerated people. This distribution of free or discounted vape starter kits seems highly promising.

Neither the UK or Scottish prison services respond to Filter’s requests for comment. The US Bureau of Prisons also declined to comment, but pointed to its guidance issued in 2015, which makes no explicit mention of vaping.

Photo of Kingston Penitentiary in Canada by Larry Farr on Unsplash

The author has previously been supported by a scholarship from Knowledge-Action-Change. The Influence Foundation, which operates Filter, has also received scholarships from KAC to support tobacco harm reduction reporting.

The post The Potential and Pitfalls of Providing Vapes to Incarcerated People appeared first on Filter.

Last year, I reported on the UK National Health Service’s presentation of e-cigarettes as a measure to curtail smoking among at-risk people—including, for example, during pregnancy. Public-private partnerships have seen vape shops opening up inside several NHS facilities, as resources for patients and staff to better understand the products and potentially make the switch from smoking.

Preliminary reports now suggest encouraging outcomes. VPZ, an e-cigarette retailer in the UK, told Filter that there has been a significant rise in uptake for its health facility-based operations.

The company began working with University Hospital Lewisham in southeast London, providing vaping starter kits to patients in a mental health ward with high rates of nicotine dependence. This pilot program was a first for the whole country. Under the approach, patients were given vaping products as part of a broader rehabilitation plan. It was found that patients whose health and well-being improved through stopping smoking also saw other aspects of their mental health improve.

VPZ has now instituted support schemes for NHS staffers and practitioners, and is eyeing more.

In recent months, the company piloted a subsidized product scheme for NHS employees. According to VPZ Director Doug Mutter, this has seen record uptake in the past few weeks—he told Filter that 1,100 NHS staffers and providers used the discount scheme in the past month.

“We can certainly see that more NHS staff are beginning their quit journey.”

As healthcare workers worldwide are placed under extraordinary pressure, and the wider population struggles with the loneliness of isolation, there’s concern that for many, these stresses will result in increased smoking. According to a survey conducted in the first half of May, an estimated 2.2 million people in the UK are smoking more than usual in current circumstances. At the same time, however, another 1.9 million smokers are believed to have cut down.

“The COVID-19 pandemic has brought significant focus on lung health and the wider public is more educated on respiratory conditions,” Mutter said. “This has led to an increase in smokers looking to make the switch.”

“We can certainly see that more NHS staff are beginning their quit journey,” he continued, “but we probably will not know how many have managed to fully quit smoking until later in the year. As with all smokers, how long it takes to completely quit will vary hugely.”

An emerging hypothesis—arising from observation of the disproportionately low numbers of smokers identified to have COVID-19 in countries like the United States and France—posits that nicotine use may be a protective factor for the coronavirus. At the same time, those smokers who are hospitalized may experience faster progression of the disease. In this context, tobacco harm reduction products could be taking on a whole new significance.

“It has been good to see health organizations promote vaping.”

Doctors at the NHS hospital Royal Glamorgan, in South Wales, have noticed a similar trend of lower smoking rates among their coronavirus patients. While the evidence is still investigational, a team of doctors there is calling on health regulators to consider nicotine patches as a potential treatment option for coronavirus patients.

For all the favorable comparisons to be made with the US vaping landscape, the UK scene is not all positive, making the promising signs from VPZ’s projects all the more welcome.

“We have seen stop-smoking services in the UK hammered with budget cuts in recent years, and with stores closed, most smokers will not have been able to access the help needed to aid them in quitting,” Mutter said. “It has been good to see health organizations promote vaping.”

Photo via Wikimedia Commons/Vaping360.com

The post In the UK National Health Service, Staffers Benefit From Subsidized Vapes appeared first on Filter.

Amanda Wheeler, the owner of Jvapes, which has locations in Colorado, Oklahoma and Arizona, said she had to lay off employees at two shops in Colorado. “I’ve never had to close a store before,” she told Filter. “It felt like a sad preview of what is to come.”

Living in Colorado, I’ve found for myself how Wheeler’s staff are welcoming, kind and full of knowledge about the various intricacies of using a mod system or selecting a flavored e-liquid. They offer the kind of personalized guidance that can make all the difference for people trying to quit cigarettes.

Colorado Governor Jared Polis (D) declared a pandemic-related state of emergency on March 10. Like most of the country, Colorado established guidelines for social distancing, as well as what qualifies as an “essential” business.

Cigarettes remain widely available in businesses deemed essential.

A national and international debate revolves around whether specialty vape shops are essential. In Colorado, as in numerous other US jurisdictions, they were deemed non-essential, and are required to temporarily close all in-person operations.

It should be noted that cigarettes remain widely available in businesses deemed essential, such as gas stations and convenience stores. Liquor stores and marijuana dispensaries are also deemed essential and remain open.

It is true that some vaping products can also still be purchased at convenience stores. But since the Food and Drug Administration has effectively banned sales of flavored cartridges, the many vapers who prefer flavors can only find unflavored pod devices or single-use devices at these locations. For many people, these options don’t fit their needs.

Vape stores and vapers have been advocating against this situation. “We are hopeful that Governor Polis might make some kind of allowances to enable us to offer curbside [pick-ups], but the likelihood of that is very low,” Wheeler said.

Online vape sales are also permitted, but that still leaves many vapers at a disadvantage. Significant numbers of people, particularly the most marginalized, lack internet access. Older people, for example, may not be comfortable ordering online. And people who are relatively new to vaping will miss out on the personalized guidance and encouragement exemplified by Wheeler’s staff. It is easy to imagine some people returning to smoking in these circumstances.

Being restricted to online sales—with a shortfall in overall business and facing competition from larger online vendors—also harms the small shops on which customers would hope to rely long-term. Wheeler told Filter that her business’s total sales have declined 30 percent since the lockdown.

“Despite going through chemo and radiation, I still smoked for 10 years after that. I couldn’t quit any other way than vaping.”

Wheeler has a background in clinical addiction counseling, and entered the vaping industry with her husband just over five years ago. She was previously, at the age of 19, diagnosed with Hodgkin’s lymphoma, but stayed a consistent smoker for a decade.

“The vaping industry has impacted every part of my life, very personally,” she said. “Despite going through chemo and radiation, I still smoked for 10 years after that. I literally couldn’t quit any other way than vaping. My husband was a two-pack-a-day smoker and he quit with vaping. Everything about vaping made our lives better. That’s why we have a business selling these products to others.”

I asked her how she sees the future of her business and the wider vaping industry. “I wish I had the crystal ball that contained the answer to that question, ” she replied. “Our challenges are myriad and exist at every level of government.”

Part of the problem may be that vaping, as a relatively new innovation, doesn’t yet enjoy the same level of mobilization, in terms of activism and lobbying, as more established forms of drug use.

Marijuana advocates like the National Organization for the Reform of Marijuana Laws (NORML) have rightfully and responsibly recommended that governors of states with legal medicinal marijuana should classify dispensaries as essential for patients. Adult-use dispensaries have also been included in numerous jurisdictions, including Colorado for curbside pick-up.

In the case of alcohol, Denver Mayor Michael B. Hancock implemented a citywide ban on non-essential business—and he included liquor stores, a move with the potential to jeopardize the health of dependent drinkers. Hearing of this plan, people swamped the city’s liquor stores hours before the closures took effect, buying up remaining stock. Under pressure from the public as well as lobbying from the city’s liquor retail industry, Mayor Hancock then relented, expanding the definition of essential businesses to include liquor stores.

Wheeler feels these differences keenly. “We feel that we are more essential than liquor or recreational cannabis, as people depend on our products to stay off of combustible tobacco,” she said. “It is particularly poignant that cigarettes remain freely available, and yet open vapor products are not as accessible.”

“Vapers deprived of their vaping products are at risk of restarting smoking to cope with heightened levels of stress and anxiety,” Dr. Riccardo Polosa*, a researcher on vaping and tobacco harm reduction, said in an email discussing the essential status of vaping in his home country of Italy. “They have the right of a less harmful alternative to cigarettes. There is no doubt to my mind that vape shops, being ‘essential health facilities,’ should stay open.”

Filter recently profiled Polosa following his successful efforts to convince the Italian government to deem vape shops as essential. He also noted that “Vape shops have quickly adopted government recommendations about complying with social distancing.” Wheeler mentioned that her stores in Oklahoma and Arizona are doing the same, for example by strictly limiting the number of people allowed inside at a time.

“A tragic blow to harm reduction.”

Situations similar to that in Colorado are unfolding around the US. Danish Iqbal, the CEO of e-cigarette wholesaler Medusa Distribution and the president of the New Jersey Vapor Rights Coalition, also has a fight on his hands.

“Most states that have stay-at-home orders have deemed vape shops to be “non-essential” businesses,” Iqbal wrote in an email to Filter. “Nicotine vaping is, by the admission of the FDA, a safer alternative to combustible tobacco cigarettes.”

“While convenience stores and gas stations are still selling those, millions of people who switched to vaping now have no access to products,” he continued. “It is essential to keep people who switched from cigarettes off of them.”

Like Iqbal, Wheeler—who is also vice president of the Rocky Mountain Smoke-Free Alliance and executive director of the Arizona Smoke-Free Business Alliance—emphasized the harms already done to the industry by recent events, and the knock-on impact on vapers.

“We are at a David and Goliath moment, ” she said, “except we are fighting at least three Goliaths at once. We have several states now that have completely fallen for the vape industry, which is really a tragic blow to harm reduction. We must find a way to overcome the rampant misinformation about vaping, and rapidly become as politically savvy as our more well-funded opponents.”

* Dr. Polosa’s Center of Excellence for the Acceleration of Harm Reduction has received grants from the Foundation for a Smoke-Free World (FSFW). Michael McGrady is a recipient of Tobacco Harm Reduction Scholarship from Knowledge-Action-Change (KAC), independently administered by KAC and supported by a grant from FSFW. The Influence Foundation, which operates Filter, has received restricted and unrestricted grants, respectively, from KAC and FSFW. Filter’s Editorial Independence Policy applies.

Photographs of empty store, and of Amanda Wheeler and her husband, courtesy of Wheeler.

The post The Damage to Vape Shops Deemed “Non-Essential”—And Their Customers appeared first on Filter.

Like the previous viral outbreaks MERS or SARS, COVID-19 attacks the lungs and other parts of the respiratory system. No vaccine or pharmacological therapy is currently available.

A working theory links the harms of COVID-19 to the damage done to the lungs from smoking cigarettes. Michael Ryan, executive director of the WHO’s Health Emergencies Program, said on February 14 that higher rates of cigarette smoking are “an excellent hypothesis” for why men seem to be more heavily impacted by COVID-19 than women.

A study published by the Chinese government on February 17 found that of 45,000  confirmed cases at the time, the gender split was roughly equal, but that the fatality rate then recorded was 2.8 percent for men, compared with 1.7 percent for women.

China has the world’s largest population of smokers, at well over 300 million. But a study published in 2019 found that in 2015, there was a huge gender divide within an overall smoking rate of 28 percent—with 52 percent of Chinese men smoking, compared with under 3 percent of women.

The general rate of infection from respiratory viruses is higher among smokers. And while smoking hasn’t been definitively linked to exacerbating COVID-19, for MERS—the respiratory syndrome coronavirus first identified in the Middle East in 2014—increased risk of infection has been linked to smoking by a multinational research team.

Then-acting US Surgeon General Boris D. Lushniak released a report in 2014 stating that smoking greatly reduces someone’s ability to fight against ailments like respiratory infection. It specifically noted that there is “conclusive evidence that smoking is associated with an increased risk of respiratory viral infection.”

According to a briefing on coronaviruses from the American Lung Association, the severity of symptoms will vary depending on numerous factors. “For the milder strains, respiratory symptoms like a runny nose, headache, cough, sore throat, fever and fatigue are common,” it states. “If an infection progresses to something more severe, it can cause pneumonia, bronchitis, kidney failure and even death. This is more likely to happen in children, the elderly and people with weakened immune systems.”

It is plausible—though unproven—that large-scale switching would significantly mitigate against future respiratory viruses.

While switching smokers to risk-reduced nicotine products like vapes would likely come too late to slow the current spread of COVID-19, it is therefore plausible—though unproven—that large-scale switching would significantly mitigate against future respiratory viruses. A 2019 study—notably authored by Dharma N. Bhatta and the controversial anti-vaping researcher Stanton Glantz—found that e-cigarettes could reduce the impact of respiratory infections in smokers if they made the switch.

“Current use of e-cigarettes appears to be an independent risk factor for respiratory disease in addition to all combustible tobacco smoking,” they said. “Although switching from combustible tobacco, including cigarettes, to e-cigarettes theoretically could reduce the risk of developing respiratory disease, current evidence indicates a high prevalence of dual use, which is associated with increased risk beyond combustible tobacco use.”

Despite Bhatta and Glantz’s opposition to e-cigarettes as a way to reduce the risks of respiratory illness among smokers, they still found an empirical probability that risk-reduced products could assist in immune system recovery.

Dr. Alex Wodak, an addiction medicine physician, prominent drug policy reform advocate and board member of the Australian Tobacco Harm Reduction Association, raised this question in a February 27 email to colleagues.

Wodak merely asked this question in hypothetical terms, and noted that we are in “uncharted territory” when it comes to determining any efficacy of tobacco harm reduction in curtailing COVID-19.

The purported—also unproven—additional risk for vapers sees harm reduction products included in such messaging.

He pointed out that public health authorities in a number of countries are recommending that people refrain from smoking to reduce their risks of infection, “Although of course that’s not proven yet.” Such messaging is understandable—and of course, it is always better for one’s health not to smoke—yet in an environment where panic-fueled misinformation abounds, there is also a risk of overemphasis blaming an already-stigmatized population for hastening the spread of COVID-19 without sufficient evidence.

The purported—also unproven—additional risk for vapers compared with people who don’t use nicotine sees harm reduction products included in such messaging.

“If you are a smoker or a vaper, that does make you more vulnerable,” New York Mayor Bill de Blasio said at a March 8 press conference. “If you are a smoker or a vaper this is a very good time to stop that habit and we will help you.”

“If you smoke or vape, stop,” recommended John Silvernail, director of the Pitt County public health department in North Carolina. “Smoking or vaping doesn’t make you a bad person, but it is bad for you. Furthermore, smoking and vaping irritate your respiratory system, potentially making it easier for infections to invade your body.”

Questions should be asked of such declarations, especially in light of the potential for people who quit smoking through vaping to return to smoking.

Marewa Glover, a behavioral scientist and director of the New Zealand-based Centre of Research Excellence: Indigenous Sovereignty and Smoking, believes such messaging to be harmful.“This is typical tobacco control exploiting what is a tragic unexpected outbreak,” she told Filter. 

“The behavioral changes we may be asked to make will not all be as easy as washing our hands,” Glover continued. “This is where I should plug the importance of involving behavioural scientists like myself and other behaviour change experts. Motivating people to change, to adhere to a prescribed course of action—this is our thing! Will we be called upon for advice? I’d guess not.”

The fast-developing situation with COVID-19 requires public health authorities to make decisions without the benefit of substantial evidence, but balanced communications are essential. The far more predictable health harms of smoking continue to contrast with the substantial relative benefits of switching to risk-reduced nicotine products (of which some, such as oral snus, have no known respiratory impact).

If that key message—already denied by the WHO and many others—were to be further obscured by stop-vaping calls amid the COVID-19 crisis, there’s every likelihood that it will further exacerbate the harms of this outbreak.

*The author is a recipient of Tobacco Harm Reduction Scholarship from Knowledge-Action-Change (KAC), independently administered by KAC and supported by a grant from the Foundation for a Smoke-Free World (FSFW). Dr. Marewa Glover’s Centre of Research Excellence: Indigenous Sovereignty & Smoking,has also received grants from FSFW. The Influence Foundation which operates Filter, has received restricted and unrestricted grants, respectively, from KAC and FSFW.

Photo by VapeClubMY on Unsplash

The post COVID-19 and Tobacco Harm Reduction: What’s the Relationship? appeared first on Filter.

Are anti-vaping advertisements inadvertently promoting product recognition and uptake among youth?

In a December report for the Competitive Enterprise Institute, Senior Fellow Michelle Minton argued that anti-vaping campaigns portraying e-cigarettes as a deadly youth epidemic have the opposite effect to that intended. She noted that after an early surge in youth vaping, there was a decline from around 2015-2017—but that a 78 percent increase in high schoolers who tried vaping in 2018 followed a proliferation of anti-vaping media campaigns.

“You don’t need a degree in child psychology to realize that message was doomed to backfire,” she wrote, citing the concept of “psychological reactance”—as well as evidence that media content warnings may entice youth, for example, and that some groups of students showed an increase in drug use after participating in the abstinence-only DARE program.

Minton is not the only person to suggest this. My conversations with tobacco harm reduction experts in the past several months have pointed in a similar direction.

“It encourages the behavior. Like telling a three-year-old not to stick peas up his nose.”

David Sweanor, a professor of law at the University of Ottawa, Canada and industry expert, told me last fall that stigma-focused advertisements could drastically backfire in the long run. Regarding “moralists” who are “yelling about young people,” Sweanor said, “It encourages the behavior. Like telling a three-year-old not to stick peas up his nose.”

One noteworthy example of the kind of messaging to youth that we’re talking about is provided by the US Food and Drug Administration’s “The Real Cost” campaign. Last summer marked the beginning of a new series of advertisements under that moniker, showing street magician Julius Dein performing magic tricks for random teens who say they vape. The ads depict youth surrounding Dein in various settings where he “magically” turns their vapes into cigarettes and warns, “Vaping can lead to trying cigarettes.”

As critics have pointed out, even if the likelihood of trying vapes and trying cigarettes may be correlated, that does not demonstrate that the former causes the latter.

Just like other anti-vaping advertisements pushed by public health organizations around the world, the slick presentation of The Real Cost generates a predicament of inadvertent product recognition among the youth these campaigns are designed to warn. The props used resemble closed-system devices like those made by Juul* or NJOY.

“We now have the absurd situation where anti-vaping activists blame Juul for glamorizing vaping with youth-appealing ads,” Clive Bates, a tobacco harm reduction expert and former director of Action on Smoking and Health (ASH UK), told Filter. “Yet the most likely place you will see these ads today is on anti-vaping campaign websites—they are long gone from Juul’s marketing, which is now boring to a fault.”

A lawsuit against Juul brought this month by Massachusetts Attorney General Maura Healey is one of many that accuses the company of the “glamorizing” that Bates referenced. It addresses a series of digital marketing campaigns that reportedly used models and influencers on social media to draw in new youth customers. Healey also cites the vape manufacturer’s purchase of advertisements on websites focused on youth entertainment.

The lawsuit will take its course. But for our purposes, the media coverage of the lawsuit is interesting. The lawsuit’s evidentiary exhibits feature the marketing samples that Healey says are illegal. In turn, news organizations’ reporters and editors have used the images as headline photos, examples in articles, and clips in local and national news broadcasts.

Youth are thereby further exposed to the marketing that has ceased to be published in its original contexts—and the media’s negative framing of such marketing is unlikely to dampen its effects.

“What do these anti-vaping groups expect to happen when they inform every kid in the land that vaping is something they absolutely must not do because other kids are finding it awesome and upsetting to adults?” asked Bates.

“Anti-vaping campaigners are stimulating curiosity by making vaping the most widely discussed youth issue in the US.”

“We know vaping is driven by curiosity and the wider social environment,” he continued. “But that is exactly what the anti-vaping campaigners like the Truth Initiative and the Campaign for Tobacco-Free Kids are doing: stimulating curiosity by making vaping the most widely discussed youth issue in the US, even though there are many more pressing youth concerns such as opioid use, drink-driving, bullying, guns and mental health.”

The Truth Initiative is a major player in US anti-vaping messaging. It conducted a 2019 study, published in the journal Tobacco Control, which found that “Juul-related” content on Instagram had proliferated.

The study focused on keyword research to determine the popularity of hashtags related to Juul, other products and vaping in general, analyzing thousands of posts from March to May 2018. The researchers found that out of 14,838 Juul-related Instagram posts made by 5,201 users, about one-third were promotional in nature; only 11 percent contained nicotine and addiction information, and over half reportedly appealed to a definition of what they consider “youth culture.”

Keyword hashtags like #juulbuzz and #nichead were used more often in anti-vaping content than in promotional content. One “spoof” account called @nicheadnation accounted for hundreds of posts found under the #nichead hashtag. The posts all promoted negative messages about vaping—alongside images depicting cartoon characters and children using Juul products.

No sensible harm reduction advocate would support the promotion of nicotine products to youth who do not smoke, and a continuing crackdown reflects this. The FDA recently ordered, for example, that the manufacturer Eonsmoke cease deploying social media influencers to promote its pod systems. Adult film star Mia Khalifa and reality television star Scott Disick had promoted Juul-compatible Eonsmoke pods and other products, the FDA determined.

Yet while the justified reduction of promotional materials available to youth continues, the anti-vaping content that has flooded social media to compete with the pro-vaping content remains.

It is important to note that the case I’m making is not proven. It is, however, highly plausible that widespread depictions of the behavior of vaping, regardless of their anti-vaping intentions, could normalize vape brands, devices and flavors for minors who consume these media.

Using fear, misinformation and stigmatization to promote public health messages is fundamentally disempowering. But how strangely helpful it would be for anti-vaping groups if these tactics were to be fueling the very youth uptake that supports their own, well funded existence. 

*In 2020, Juul provided an unrestricted grant to The Influence Foundation, which operates Filter. Knowledge Action Change, from which the author received a scholarship, also provided a restricted grant to The Influence Foundation through a scholarship in 2018. Filter’s editorial independence policy applies. 

Photo by Priscilla Du Preez on Unsplash

The post Do Anti-Vaping Ads and Media Actually Encourage Youth Vaping? appeared first on Filter.

What some critics quoted in these reports missed was that these stores were established in order to encourage patients who struggle to quit smoking to switch to vaping. The stores had a secondary purpose of enabling hospital employees to benefit from store associates’ vaping knowledge.

It should be no surprise that these hospitals were able to create such partnerships. The United Kingdom is a world leader in regulating vaping products. Its government, unlike much of the world, has developed a permissive vapes market within a strict, age-controlled regulatory framework.

And unlike in the United States, the UK’s public health community has been sending a risk-proportionate message to the people it serves. Public Health England (PHE) commissioned the seminal independent 2015 evidence review that found e-cigarettes to be about 95 percent safer than combustibles. The agency and its Tobacco Control lead, Martin Dockrell, endorsed vaping for smoking cessation based on this evidence.

NHS pregnancy advice: “If using an e-cigarette helps you to stop smoking, it is much safer for you and your baby than continuing to smoke.”

Since then, UK vaping has developed in a pro-harm reduction environment, with products regulated by the equivalent to the US Food and Drug Administration: the Medicines and Healthcare Products Regulatory Agency (MHRA).

The National Health Service has now wholly adopted a smoke-free policy position that encourages vaping for smokers. It sensibly states in its pregnancy advice, for example, “If using an e-cigarette helps you to stop smoking, it is much safer for you and your baby than continuing to smoke.”

Members of Parliament have even called for e-cigarettes to be prescribed for smokers in pharmacies. (While the NHS promotes vaping for smoking cessation, it has yet to prescribe them as an alternative to traditional nicotine replacement therapies.)

Amid all this risk-proportionate messaging, what’s happening on the ground? 

Well over 3 million Brits now vape—with an estimated 10 percent rise from 2017-2018. Just over half are now ex-smokers, and almost all of the rest are engaging in dual use—which may mean they’re transitioning to vaping-only, or that they’re just reducing their smoking. Smoking rates continue to decline, particularly among young people—for whom the rise of vaping has not “normalized” smoking. Regular vaping among youth who have never smoked remains rare.

Opposite Approaches to a Lung Disease Outbreak

A comparison between UK and US public health authorities’ messaging, in the context of the US outbreak of lung injuries that began this summer, is instructive. 

The US Centers for Disease Control (CDC) quickly branded “e-cigarettes” as responsible, without clarifying its uniquely all-encompassing use of the term, and waited well over a month before conceding that “THC products may play a role.” We now know that vaping of contaminated and unregulated THC oils, containing, for example, vitamin E acetate, was the primary factor. Yet the CDC continues to advise against all vaping.

“These cases are worrying and need investigating but it is always preferable to vape than to smoke.”

But despite the drug panic across the pond, Public Health England officials reassured vapers that they shouldn’t be alarmed. “Unlike the US, all e-cigarette products in the UK are tightly regulated for quality and safety by the [MHRA] and they operate the yellow card scheme, encouraging vapers to report any bad experiences,” Dockrell told the Guardian in early September. 

“These cases are worrying and need investigating but advice from all official bodies in the UK is that it is always preferable to vape than to smoke,” added Paul Aveyard, a professor of Behavioural Medicine at Oxford University. “These reports should not change that advice.”

Even if we were to set aside the overwhelming culpability of adulterated THC, rather than nicotine products, for the recent outbreak—and without minimizing dozens of tragic deaths—the US response would still have been disproportionate. 

At publication time there were 2,290 reported cases and 47 confirmed deaths from the outbreak, in the context of many millions of Americans vaping THC or nicotine. In comparison, one in five deaths in the United States is tied to smoking cigarettes or second-hand smoke. There is an average of 1,300 smoking deaths per day, and more than 480,000 Americans die from smoking per annum.

Vaping as a Tool for Health Equity

Public Health England has adopted a patient-oriented, pragmatic approach by supporting the concept (bolstered by an important study earlier this year) that vaping can help people quit smoking. It follows that vaping should be supported in medical and social service settings.

The demographics of health inequalities are similar in the US and UK. Communities of color, LGBTQ communities, older people, lower-income people, people with mental health diagnoses, veterans, homeless populations and people who use illicit drugs all smoke at high rates.

Unencumbered by vaping outcries and crackdowns, the UK is in a position to respond rationally to the question of how best to reduce smoking-related harms for these at-risk groups.

Amid high smoking rates among mental health patients, tailored programs are becoming increasingly common, though not all hospitals have them.

For example, the Daily Telegraph reported last month that an NHS system in London will be providing mental health patients with free e-cigarette starter kits. The South London and Maudsley (SLaM) NHS Foundation trust healthcare system has partnered with vape retailer VPZ to provide products to mental health patients at its Lewisham Hospital psychiatric facility who struggle with quitting smoking. Each kit features instructions for first use, plus e-liquids of various flavors. Patients will be permitted to vape in designated areas.

“Patients may be unhappy about being on a ward where they are not allowed to smoke, but they are likely to be willing to use a vape as an alternative.”

“Knowing that people with poor mental health are more likely to smoke than in the general population, there is an increasing drive to use [vapes] to support smoke-free policies,” Louise Ross, a smoking cessation consultant for the National Centre for Smoking Cessation and Training, told Filter. “This is a popular move among patients. They may be quite unhappy about being on a ward where they are not allowed to smoke, but they are likely to be willing to use a vape as an alternative.”

“Many patients reject the offer of nicotine replacement therapy, having tried it before and found it lacking,” she noted. “The added benefit is that they may stick with the vape on discharge instead of going back to smoking.”

Filter previously interviewed Ross in a video about her work to protect vulnerable people from smoking harms. As manager of the Leicester Stop Smoking Services, she assisted thousands of people in quitting smoking. She worked to make the Leicester service one of the UK’s first smoking cessation programs to adopt a harm reduction model by promoting e-cigarettes for mental health patients and other vulnerable smokers.

Providers like SLaM are simply following the logic espoused by British public health institutions. For example, the Royal College of Psychiatrists, in a 2018 position statement, argues that both the prescription of drugs like Chantix and e-cigarettes can be viable smoking cessation solutions for people who suffer from severe mental illness (SMI).

“Smoking rates among people with SMI are much higher than in the general population, contributing to increased morbidity and premature mortality among this group,” it stated. “Psychiatrists are well placed to help them stop smoking … While we do not fully understand the long-term risks, psychiatrists should advise their patients that [e-cigarettes] are an effective option for some people to give up smoking and are substantially safer than continued tobacco use. All mental health providers should have policies in place that facilitate the safe and effective [vaping].”

Similarly, the Royal College of Physicians has recommended that general health practitioners advise patients to quit smoking through vaping. The list of UK public health supporters of vaping goes on. The Royal Society for Public Health noted in 2015 that nicotine is no more harmful than caffeine. The Smokefree Action Coalition, of which the NHS, along with 300 other UK health organizations is a member, also endorses vaping and recommends use of MHRA-regulated e-liquids.

“Bans on smoking in mental health service facilities are particularly lacking in compassion.”

Dr. Marewa Glover, a smoking cessation expert from Auckland, New Zealand who heads the Centre of Research Excellence: Indigenous Sovereignty and Smoking (she has also written for Filter), told me that when it comes to vaping in healthcare and mental healthcare contexts, the UK offers a compassionate framework that health leaders around the world would do well to emulate.

“Bans on smoking in mental health service facilities are particularly lacking in compassion,” she said, noting that prohibitions in mental health wards have contributed to “avoidable” suicides of some patients and erect barriers to care.

“If mental health facilities ban smoking on the premises then they should have to supply a satisfying nicotine alternative,” Glover said. “Otherwise … some people won’t go to these facilities for treatment.”

Remaining Room for Improvement

Despite its relatively enlightened approaches, the UK still has much room for improvement. A recent letter to the Guardian from a group of pediatricians demonstrated that anti-vaping voices and “think of the children” arguments against harm reduction are not uniquely American. And vaping uptake among marginalized smokers is still not what it could be.

The many intersecting factors that make smoking more likely include poverty.

Accordingly, some public health advocates in England are focusing on potential economic incentives to switch to vaping. Jessica Harding, administrator of the New Nicotine Alliance charity (she has also written for Filter), believes that social services should be an important conduit for this.

“Vaping is affordable in the UK for many but it is still prohibitively expensive for some smokers,” she told Filter. “So initiatives which offer free or heavily discounted devices to people without much money help by overcoming the barrier of cost.”

“Most UK authorities are open-minded about e-cigarettes and look at the evidence. In the US, the situation is very different.” 

Mary Yates, a nurse consultant for Health Promotion & Wellbeing at SLaM, describes her organization’s free e-cigarette program in these terms. “Smoking traps vulnerable people in poverty because it is so expensive,” Yates told the Telegraph. “We are taking a very holistic approach where smoking is tackled along with mental health issues with the ultimate objective of improving our patients’ overall wellbeing.”

Programs offering free vape starter kits to low-income people are currently being tested by public support agencies, too. The county of Hertfordshire, near London, announced earlier this year that its community tobacco control strategy will include vaping education and a pilot program to provide clients of food banks with free and discounted starter kits.

Worldwide public-health and political approaches to vaping exist on a spectrum. The UK, while not perfect, stands out for its largely sensible and proportionate attitude. As we digest rapid policy and political developments here in the US, we should remember that the American approach also stands out—for the opposite reasons.

“There are deep ideological differences between health leadership, policymakers, regulators, and politicians when you look at the US compared with the UK,” noted Ross. “Most UK authorities are open-minded about e-cigarettes and look at the evidence. In the US, the situation is very different.” 

Long-term health outcomes will reflect this.

*The author is a recipient of a grant from the Knowledge Action Change Tobacco Harm Reduction Scholarship program. This independently administered program is supported by funding from the nonprofit Foundation for a Smoke-Free World. Dr. Marewa Glover’s organization is also a recipient of funding from the Foundation. 

The Influence Foundation, which operates Filter, previously received a KAC scholarship grant to support tobacco harm reduction reporting. Per Filter’s Editorial Independence Policy, no funding organization had editorial involvement in the creation of this article.

Photo by Sgt. Jeffrey Anderson, US Marine Corps.

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