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Mountain Vapor Blog

Welcome to the blog area of our site where we hope to keep you updated on the trends of the e-cigarette industry as well as product reviews.

Detoxing the Heavy Metal Vape Scare


Jonathan Swift 300 years ago observed that “Falsehood flies, and the Truth comes limping after it; so that when Men come to be undeceiv’d, it is too late; the Jest is over, and the Tale has had its Effect.” (here)  That is the story of e-cigarettes and vaping today. 

Billions of dollars have been transferred from tobacco consumers to companies to the FDA in the form of user fees (here).  The FDA, via the NIH, has transferred hundreds of millions to fund university research on tobacco use and effects, in order to provide a “scientific basis” for FDA regulations (here).  With NIH making no attempt to hide our government’s objective – “a world free of tobacco use” (expressed here) – it is not surprising that much of the funded research and attendant publicity is biased to support the announced policy objective.

In March, anti-vaping researchers published a study claiming that metals in e-cigarette vapor are toxic when inhaled.  While the media headlined the findings “dangerous” and “alarming”, and termed vape products “brain-damaging,” I explained in this blog that the metal doses delivered by e-cigarette liquids in this study are trivial.  I estimated that an e-cigarette user could be exposed to excessive metal levels only by consuming high volumes of vape liquids.  For example, vapers would have to use 15.4 liters (nearly four gallons) of liquid per day to achieve exposure to 2 micrograms of cadmium. (here

I worked with Dr. Konstantinos Farsalinos, a prestigious vaping researcher at Greece’s Onassis Cardiac Surgery Center, the University of Patras and the National School of Public Health.  The findings of our risk assessment analysis of the metals study were just published in the journal Inhalation Toxicology (abstract here).

The original study referenced U.S. Environmental Protection Agency safety limits that apply to 24-hour air exposure, or to workers breathing factory air for 8 to 10 hours.  This standard is entirely invalid for e-cigarette analysis, as users do not inhale vapor continuously for such long periods of time. 

Dr. Farsalinos and I applied more realistic federal standards, such as established regulatory safety limits for inhaled medicines.  We calculated total daily exposure to metals by using an average daily vape liquid consumption of 3 to 5 milliliters (e.g., 3 to 5 grams, around 1 teaspoon).

The chart demonstrates that vapers would need to consume impossibly large volumes of liquid in order to exceed the safety limits for almost all metals.  The one exception is nickel, which requires only 17 grams of liquid, but even that is over three times normal daily consumption.

In this case, truth is limping in eight months after widespread false alarms flew about metals in e-cigarette vapor.  The Tale has had its Effect, but in the end, as Shakespeare assures us, truth will out.




Original author: Brad Rodu
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Will Marijuana Become the Next Juul?

Yesterday, the first recreational marijuana facility opened in Massachusetts. Out of curiosity, I decided to check out its menu of offerings. Although I thought that this ballot initiative was all about allowing adults to use marijuana for recreational purposes, I was surprised to find a menu that is certain to appeal to youth.

The Rest of the Story

Here are some menu items - tell me that they are not going to be appealing to teenagers:

Strawberry-flavored chewy bitesLarge, citrus gummy bearsDelectable Belgian dark chocolate bars Assorted fruit-flavored chewsAssorted fruit-flavored cubesRaspberry flavored confectionRaspberry flavored lozengesChewy, cocoa caramel bite-sized treats Raspberry & watermelon flavored lozenges Chocolate-chip brownies.”My point here is that we are in complete hysteria because youth are using flavored e-cigarettes and health agencies want to ban e-cigarettes because they attract youth with gummy bear and cotton candy flavors, yet we are practically encouraging youth to enjoy kid-friendly flavors and varieties of marijuana, doing nothing to address the access of youth to real cigarettes in retail stores, and allowing the unfettered sale and marketing of flavored alcohol products which are used by more high school students than use the Juul and other e-cigarettes combined.

I can drive to a store within 10 miles and get flavored alcoholic beverages, menthol cigarettes, and chewy, cocoa caramel marijuana, but I can't buy a Juul flavor multi-pack to help me quit smoking?

This is public health in 2018?
Original author: Michael Siegel
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FDA to Announce Ban on Sale of Most Cigarettes in Convenience Stores Due to Addiction of Hundreds of Thousands of Youth to Cigarettes

Tomorrow, the FDA is expected to announce the strictest regulation of cigarettes sales in decades. Spurred by the data showing that nearly 8% of high school students are current cigarette smokers, the FDA will announce that from now on, with just a few exceptions, cigarettes may not be sold in any convenience store or gas station. Online sales of cigarettes will still be allowed, but it will be subject to advanced age verification procedures. The only stores that will be allowed to sell cigarettes without restriction will be those which are only open to adults (or which establish an area that is only open to adults).

The FDA said it was forced to take this drastic action because it has evidence that: "a new generation is being addicted to nicotine, and we can’t tolerate that."

The tobacco companies intentionally make cigarettes more addictive by adding ammonia to the product, which enhances nicotine absorption. Cigarettes are the most effective known product to deliver nicotine in a pattern that is capable of quickly initiating and then sustaining addiction.

According to the CDC, every day more than 3,200 youth smoke their first cigarette. It has been estimated that it only takes four to five cigarettes for a youth to become addicted to smoking. One out of every two long-term addicted smokers will die prematurely, primarily from lung cancer, lung disease, heart disease, stroke, or other cancers. 

The Rest of the Story

Actually, I got it wrong.

The FDA is not banning the sale of most cigarettes at convenience stores; it is banning the sale of most fake (electronic) cigarettes at convenience stores.

Convenience stores and gas stations can continue to sell real cigarettes - which, despite lower smoking rates, continue to addict a new generation to nicotine - but they will no longer be able to sell electronic cigarettes (with only minor exceptions).

Somehow, we have completely lost all sense of public health perspective. Every argument that the FDA is making in justifying a ban on the sale of electronic cigarettes in convenience stores and gas stations applies even more strongly for real tobacco cigarettes: you know, the ones that kill hundreds of thousands of Americans each year. Something is terribly wrong with our sense of perspective when we take the fake cigarettes off the shelf but allow the real ones to remain.

So let me attempt to correct this skewed perspective.

First, we need to recognize that the problem of youth addiction to electronic cigarettes is not a broad problem of youth becoming addicted to e-cigarettes; it is a very specific and narrow problem of youth becoming addicted to Juul. It is one specific product that is causing the problem.

Other than Juul, all other closed system electronic cigarettes do not have high addiction potential because they are actually quite poor at delivering nicotine. Specifically, there is no nicotine spike in the blood, and the nicotine level drops off quite slowly. In contrast, the Juul uses a specially formulated nicotine salt that is absorbed much more rapidly into the bloodstream, and the pattern of blood nicotine levels from Juuling mimics that of a real cigarette. Youth are becoming addicted to nicotine not because they are vaping generally, but because there is an epidemic of Juul use occurring in middle schools and high schools across the nation.

However, just four days ago, Juul announced that it would voluntarily stop selling flavored Juul products in all convenience stores and gas stations. In fact, Juul has agreed to stop selling flavored Juul products in any brick-and-mortar establishment. These products will only be available online and with age verification procedures.

So this sweeping action by the FDA is not necessary. It will not result in the elimination of flavored Juul sales from convenience stores because that is already occurring.

So the rest of the story is that what the FDA's action is doing is to make it much more difficult for adults who have quit smoking to continue to stay smoke-free using their favorite brands of electronic cigarettes, which will be taken off the shelves. Youth will not be able to purchase flavored Juul products from stores, but that was going to happen anyway. The other e-cigarettes that are being sold at these stores (i.e., products other than Juul) have low nicotine addiction potential. It makes no sense to take them off the shelves but to allow real cigarettes, which have extremely high addiction potential, to remain available for sale and distribution to the 3,200 youth who try these products every day.

I believe this action will have a net negative impact on the public's health because it will almost certainly result in many ex-smokers returning to smoking as their products disappear from convenience store shelves.

What the FDA should have done is to deal directly with Juul and demand that they voluntarily remove their flavored products from the shelf and bolster their age verification procedures for online purchases. But since Juul has already agreed to this, there is no need for this drastic regulation, especially because cigarette sales are being left unencumbered.

One might argue that the reason that Juul agreed to remove their flavored products from the shelf is that they anticipated this FDA regulation. If that is the case, then perhaps the threat of regulation was successful in achieving this result. But now that Juul has agreed to take most of their products off the shelves, the FDA should not proceed with the regulation. Unless it is sincerely concerned about youth becoming addicted to nicotine, in which case it should ban all cigarette sales in brick-and-mortar establishments that are not restricted to adults.
Original author: Michael Siegel
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Tobacco Control Special Issue Yields Smoke But No Hazard for IQOS Aerosol


Recently a special issue of the journal Tobacco Control offered 22 articles on Philip Morris International’s (PMI) IQOS heat-not-burn tobacco product (here), aiming to dissuade the FDA from allowing IQOS sales as reduced risk products for smokers.  In the words of editor Stanton Glantz: “Policy makers should give greater weight to the advice provided by public health scientists than to submissions from industry when it comes to regulating tobacco products such as heated tobacco products.”



Dr. Glantz’s advice has been inaccurate in the past. A year ago, when he argued that “PMI’s own data fails to support a modified risk claim in people who are actually using [IQOS],”  I detailed the errors in his analysis (here).  This new collection of anti-IQOS articles deserves the same scrutiny.



One treatise, by UCSF’s Gideon St. Helen and colleagues, acknowledges that “All substances in PMI’s list of 58 constituents (PMI-58) were lower in IQOS emissions compared with mainstream smoke of reference cigarettes.”  That accurate statement is followed by the suggestion that PMI ignored that “levels of 56 other constituents, which are not included in the PMI-58 list or FDA’s list of [harmful and potentially harmful constituents], were higher in IQOS emissions.”  The authors criticize PMI for not undertaking “non-targeted chemical analysis” to identify these compounds.



Dr. St. Helen et al. are mistaken.  The chart above, taken from PMI’s presentation to the FDA advisory committee last January (here), documents that the company performed that analysis.  PMI’s extensive investigation of “other” substances is confirmed on the FDA website, where a chart labeled “non-targeted screening” appears in a document submitted by PMI on December 8, 2017, and published by FDA on January 12, 2018 (here). 



The December filing acknowledged that “80 compounds were found to be of higher concentration or new in [IQOS] aerosols…compared to cigarette smoke.  A toxicological assessment was performed and identified 68 of those that do not present specific toxicological concern. 8 compounds present potential genotoxic concerns based on structure-activity computational alerts and 4 compounds are classified mutagens/carcinogens.” 



PMI scientists did not dismiss the findings: “Although a minor subset of compounds identified in this study show intrinsic (potential) toxicological hazards, overall toxicity of the THS generated aerosol was lower compared to cigarette [smoke]. In vitro studies demonstrated a marked decreased biological activity of [IQOS] aerosol compared to smoke. An in vivo 90 days inhalation study showed in general a lower biological activity of the mainstream aerosol from [IQOS] when compared to mainstream smoke.”



Importantly, PMI is undertaking more research: “Additional investigations are ongoing to further characterize the impact of the [mutagens/carcinogens] on the overall toxicity of [IQOS] products.”        

Original author: Brad Rodu
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Truth Initiative Stumbles in JUUL Study


It’s surprising how many fundamentally flawed e-cigarette studies are aggressively promoted by their authors and allied organizations as grounds for FDA regulatory action.  It is also concerning when authors refuse to acknowledge or respond to honest scientific inquiries about their research.  Here is a representative case involving researchers associated with Truth Initiative, a non-profit anti-tobacco organization.

Researchers led by Donna Vallone, Ph.D., recently published a study in Tobacco Control on the “prevalence and correlates of JUUL [e-cigarette] use among a national sample of youth and young adults (here).”  While they reported that the overall prevalence of ever and current (past 30-day) JUUL use was 6.0% and 3.3% respectively, they failed to disclose information about the most important correlate of JUUL use – other e-cigarette use.

The authors noted that among underage children (15-17 years), current JUUL use was 6% and current use of combustible tobacco was 7%.  They connected these, finding that children who were currently smoking were five times more likely to use JUUL than non-smokers.  However, 11% of children in that age group currently used e-cigarettes.  They ignored this important correlate in their analyses.  Instead, they inexplicably included e-cig use among other members of the youths’ households.

There are other significant problems with this study.  First, youths and young adults were asked: “…on how many days did you smoke a Juul vape?” (emphasis added)  That wording likely confused participants. 

Second, the authors didn’t define current use of e-cigarettes, nor did they even give any description of the question in their survey. 

Third, the survey flow for JUUL and e-cigarette questions was not provided.  Were separate questions about these products asked of all participants, or did researchers ask first about e-cigarettes, and then only ask current e-cig users if they used JUULs? 

Fourth, Vallone et. al. defined JUUL “regular use” as 10-30 days in the past month, and they reported that 25% of youth fell into this category.  That percentage is grossly inflated.  The CDC and other authorities use a more credible “frequent” category of 20+ days (hereand here), which would generate a lower percentage of users at risk.    

In summary, Vallone et. al. produced an error-ridden study focused on JUUL “smoking,” while ignoring the effect of other e-cigarette use.  The obvious problems ought to have been resolved in peer review.  Additional questions remain, owing to the fact that the authors used a private dataset.  When Truth Initiative posted the study on the Society for Nicotine and Tobacco Research listserv, I asked the authors to resolve some of these problems; they did not acknowledge my listserv post.


Original author: Brad Rodu
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Peer review of: Linda Johnson et al. (Washington U med school), E-cigarette Usage Is Associated with Increased Past 12 Month Quit Attempts and Successful Smoking Cessation in Two U.S. Population-based Surveys, NTR 2018.

by Carl V Phillips

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CDC Data Reveal Many Far More Dangerous Teen Behaviors Than Vaping


In the hierarchy of teenage risk behaviors, government data shows that vaping pales compared to drinking-, driving- and weapon-related activities. It is remarkable that public health officials and the media focus so greatly on the former, to the detriment of teen safety and health.

A report from the CDC earlier this year (here), based on the 2017 Youth Risk Behavior Survey (YRBS), allows us to put the data in context.

The prevalence of past-month e-cigarette use in the 2017 YRBS was 13%.  That rate is higher than those for cigarettes (8.8%), cigars (8.0%) and smokeless tobacco (5.5%).  However, as I discussed recently (here), the vaping rate pales next to those for marijuana (19.8%) and alcohol (29.8%).  In fact, the e-cigarette rate is nearly identical to the rate for binge drinking (4 or 5 drinks within a couple hours).

These rates of drug use are troubling, but there is much worse in the federal report for parents and policymakers to be concerned about.  Following is a list of other risky behaviors by high school students in the past 30 days.


.nobr br { display: none } td { text-align: center}
Prevalence (%) of Risky Behaviors Among American High School Students (YRBS, 2017)


Past 30 Days


Rarely/never wore a seatbelt (as an occupant)5.9%
Rode with driver who had been drinking16.5%
Drove after drinking5.5%
Drove after marijuana use13.0%
Texted or emailed while driving39.2%
Carried a weapon (e.g. gun, knife, club)15.7%


Past 90 Days
Had sexual intercourse28.7%
..…and used condom, 53.8% of previous


Past Year


Involved in physical fight23.6%
Physically bullied on school property19.0%
Electronically bullied14.9%


Felt sad or hopeless31.5%
Considered suicide17.2%
Made suicide plan13.6%
Attempted suicide7.4%



Media coverage of the CDC YRBS report (here) was largely confined to the sensational -- “Fewer teens having sex and using drugs, CDC says.”

The absence of focus on the more prevalent and dangerous behaviors in part reflects the FDA-led public health community fixation on vaping.  This may stem from the fact that, of the many greater-risk categories outlined by the CDC, the FDA’s regulatory authority only extends to tobacco. To a federal agency with a hammer, everything is a nail.

Original author: Brad Rodu
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Do vapers have an obligation?

by Carl V Phillips

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The Answers to FDA’s Tobacco Questions Are Obvious, But Perhaps Unwanted


In his recent Nicotine & Tobacco Research commentary, “The Future of Nicotine Regulation,” FDA Center for Tobacco Products director Mitch Zeller listed five “challenging questions.”  I offer the following answers.

1. How comfortable are we with long-term, or possibly permanent, use of less harmful nicotine delivery mechanisms by adults, if they help keep currently addicted smokers from relapsing to combustible tobacco products?

If addicted smokers stay smoke-free by using less harmful smoke-free alternatives, everyone who is not a tobacco prohibitionist is probably comfortable with long-term use.  The harm of permanent nicotine use is of the same magnitude as that of permanent caffeine consumption.  Most are comfortable with chronic consumption of caffeinated drinks, by adults and teens.

While the FDA does now acknowledge tobacco harm reduction, the agency still does not adequately distinguish the harm differential between smoke and smoke-free products, nor does it promote smokers’ transition to vastly safer products that have been on the market during the nine years of FDA regulation. 

2. How much weight should be placed on diminished interest in quitting nicotine altogether?

None.

3. Given the potential health impacts of dual use of tobacco, how acceptable is a short period of dual use while transitioning to less harmful nicotine-containing products? What if many current smokers engage in dual use on a long-term or permanent basis?

For smokers trying to quit, dual use of cigarettes and smoke-free products is a common practice which can occur over varying periods of time. 

Currently, owing to nonstop campaigning by federal authorities and health organizations, most American smokers believe incorrectly that smokeless tobacco and e-cigarettes are as dangerous as cigarettes (hereand here).  Nine years ago I wrote in this blog: “In 2005, there were 1.4 million American men who were dual users of both cigarettes and ST [smokeless tobacco] products. These men consumed nicotine both from cigarettes and from ST, and the latter clearly resulted in lower consumption of the former. In both 2000 and 2005, every-day smokers who also used ST every day consumed significantly fewer cigarettes on average than exclusive smokers (13 cigarettes per day vs. 20 cigarettes). If these dual users knew that ST products were only 1% as hazardous as cigarettes, it is possible that many would have chosen to use only ST.” (here)

4. Can we revise labeling and indications for medicinal nicotine to increase quitting?

Of course, but this question is unrelated to tobacco harm reduction.  Medicinal nicotine is regulated by the FDA Center for Drug Evaluation and Research, not the Center for Tobacco Products, and the former has been futzing and diddling around with medicinal nicotine for decades (here).  In 1995, the Pittsburgh Tribune-Review published my open letter to FDA commissioner David Kessler, urging him to make medicinal nicotine products more available to smokers (here). The FDA did nothing to make them more effective or more affordable.

In February 2008, New York State Health Commissioner Richard Daines petitioned the FDA for revised package labeling and sales regulations for nicotine products – changes that would have greatly expanded product availability and consumer awareness. The petition was supported by numerous tobacco research and policy experts and organizations. The FDA failed to issue a response.

5. How might youth initiation be affected by the availability of different nicotine-containing products and how should we account for youth uptake of these products?

Teenagers have always been attracted to adult-oriented products and adult behaviors.  Teens are drawn to tobacco and alcohol, which are illegal for those under 21; many teens use marijuana, which is illegal for all or age-restricted in the various states (here).  It is not uncommon for teens to drive cars and have sex, two adult behaviors that can be high-risk.

Uniquely, tobacco use is regulated by a federal agency, the FDA, which now asserts that tobacco manufacturers are responsible for teen tobacco use. 

Everyone has a role to play in limiting teenage risk-taking, but focusing blame on manufacturers while ignoring other regulatory and information-sharing solutions ill serves the entire population.


October 24.  Clive Bates has just published his answers to Mr. Zeller's questions.  Please read them here.


Original author: Brad Rodu
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An overlooked lesson from Glantz harassment and fraud cases: tobacco is way out of FDA’s skill-set

by Carl V Phillips

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Peer review of: Michal Stoklosa (American Cancer Society), No surge in illicit cigarettes after implementation of menthol ban in Nova Scotia, Tobacco Control 2018

For an explanation of what this post is, please see this brief footnote post.

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Peer review of: Dunbar et al. (Rand Corp), Disentangling Within- and Between-Person Effects of Shared Risk Factors on E-cigarette and Cigarette Use Trajectories From Late Adolescence to Young Adulthood, Nicotine & Tobacco Research, 2018

by Carl V Phillips

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Footnote: Paper review posts

This is a prepositioned footnote to explain a series of posts I will be publishing.

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Not All Teen Smokers & Vapers Are Lawbreakers


Sixteen percent of high school exclusive vapers in the 2017 National Youth Tobacco Survey (NYTS), or 184,000 out of 1.15 million, were 18 years of age or older, meaning that they could buy tobacco products legally.  

Legal-age students also constituted one-quarter of high school smokers and 23% of dual users, according to the NYTS and shown on the chart at left.

Legal-age students are themselves the most common source for e-cigarettes among underage students, as the following table shows.  The majority of underage students (74%) obtained e-cigarettes from family members, friends and others.  The next biggest source was vape shops (12%).  The Internet, which was singled out by FDA Commissioner Gottlieb in his recent announcement, was the source for fewer than 5% of underage vapers.   


.nobr br { display: none } td { text-align: center}
E-Cigarettes Sources for Underage High School Users, 2017


Source
Friend64.0%
Family member5.8%
Other person4.0%


Vape shop11.8%
Internet4.7%
Other retail3.6%
Gas station/convenience store3.4%
Mall kiosk1.4%
Drugstore1.2%
Grocery storeUnder 1%




Retailers must stop selling e-cigarettes to underage youths, and the FDA is responsible for enforcing that rule.  However, it is critical that regulators and the public address the fact that friends and family are the biggest contributors to underage use.



N.B.  Thanks to Bill Godshall for suggesting this assessment.




Original author: Brad Rodu
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Glantz settles academic fraud and sexual harassment lawsuit

by Carl V Phillips

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Public health publishing is fundamentally unserious: evidence from a single measure of area

by Carl V Phillips

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The FDA’s Teen E-Cigarette-Addiction Epidemic Doesn’t Add Up



Commissioner Scott Gottlieb on September 12 announced an agency initiative to “address [the] epidemic of youth e-cigarette use” (here) and a teen-vaping-related “epidemic of addiction.”  He promised to use the FDA’s “civil and criminal enforcement tools” to reign in e-cigarette marketers.

Dr. Gottlieb based his assessment on non-public data, but publicly available data from the 2017 National Youth Tobacco Survey (NYTS) does not show an epidemic. 

The table at left displays the percentages of the estimated 14.9 million high school students who were “currently” using cigarettes and e-cigarettes, by number of days in the past month.  The numbers in each box represent the percentages of all high school students.  For example, 84.3% of students used neither product (boldtext, upper left). 

Current users of e-cigarettes are in the red-bordered boxes.  The majority (60%) of current vapers used the products 5 or fewer days (green text) – the equivalent of trying products at a party.  In contrast, a minority (20%) of vapers used them 20-30 days (red text), which is suggestive of dependence.  Half of those were not using cigarettes (bold red text).  This means that in 2017, only 184,000 high schoolers (1.24% of 14.9 million) constituted the FDA’s e-cigarette-addiction epidemic.

Original author: Brad Rodu
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Over 70 experts call on WHO to embrace technology innovation in the fight against diseases caused by smoking

October 1st, 2018

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Sunday Science Lesson: Calling vaping/tobacco use an “epidemic”: it’s even stupider than you might think

by Carl V Phillips

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FDA’s New Anti-Vaping Campaign Is a Misguided Clone of “Reefer Madness”


FDA Commissioner Scott Gottlieb on September 12 announced an FDA initiative to “address [the] epidemic of youth e-cigarette use.” (here)  Dr. Gottlieb misbranded teen vaping an “epidemic of addiction.” 

The commissioner asked manufacturers of JUUL, Vuse, MarkTen, blu and Logic e-cigarettes to respond “to the FDA in 60 days with robust plans on how they’ll convincingly address the widespread use of their products by minors, or we’ll revisit the FDA’s exercise of enforcement discretion for products currently on the market.”

Dr. Gottlieb added: “Let me be clear: Everything is on the table. This includes the resources of our civil and criminal enforcement tools.”

The commissioner’s rationale and targeting for the threatened enforcement action appear to be grossly flawed.

Dr. Gottlieb said he used “the word epidemic with great care,” but his statement that teen e-cigarette use is “almost ubiquitous” is simply wrong.  The chart at left, based on University of Michigan Monitoring the Future data, shows that e-cigarette use among high school seniors is only marginally higher than cigarette use, which has been declining for decades.  E-cigarette use pales in comparison with marijuana and alcohol, which are far more dangerous (hereand here).

In his remarks, the commissioner used the word “danger” three times to describe teen nicotine and e-cigarette use.  This characterization is reminiscent of the “reefer madness” propaganda of the 1930s and beyond, which is well-chronicled in Mark Hay’s article, “A Brief, Paranoid History of Anti-Weed PSAs” (here). 

Dr. Gottlieb’s attack on the four e-cigarette marketers may be misdirected, as FDA data show that only 10% of current teen users purchased e-cigarettes for themselves; the vast majority obtained them from social sources (here) – older siblings, friends and parents.  While elimination of underage tobacco use is an important objective, focusing the full force of the agency’s civil and criminal enforcement tools on manufacturers and retailers misses the target almost entirely.


Original author: Brad Rodu
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