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The 2018 American Teen Vaping Epidemic, Recalculated



Former FDA Commissioner Scott Gottlieb and other government officials have repeatedly asserted that the U.S. is in the midst of a teen vaping epidemic (example here).  Their claim is based on last year’s National Youth Tobacco Survey, the full contents of which was finally released six weeks ago by the Centers for Disease Control and Prevention.  With that data in hand, I have confirmed some of the assertions made by anti-vapers but easily put the lie to others (here).Federal officials claim there were over three million high school vapers in 2018.  Let’s take a look at the actual numbers.  Each table below lists the number of high school students who used e-cigarettes 0, 1-5, 6-19 or 20-30 days in the past month, according to whether they were underage or of legal age (18+ years).   Table 1 shows that 3.13 million high schoolers vaped, with 877,500 using the products 20-30 days in the past month..nobr br { display: none } td { text-align: center} Table 1. Number of High School Students in 2018 Who Vaped in the Past Month, According to Age Days VapedLess than 18 years18+ yearsAll1-51,303,366200,2641,503,6306-19602,392150,841753,23320-30630,490247,000877,490All2,536,248598,1053,143,353Next, let’s remove any high school students who ever tried CIGARETTE SMOKING.  As shown in Table 2, that leaves 1.36 million, with 198,000 using the products 20-30 days in the past month..nobr br { display: none } td { text-align: center} Table 2. Number of High School Students in 2018 Who Vaped in the Past Month But Never Tried Cigarette Smoking, According to Age Days VapedLess than 18 years18+ yearsAll1-5762,02392,035854,0586-19259,45043,231302,68120-30151,17647,150198,326All1,172,649182,4161,355,065Removing students who ever tried CIGARS, the total drops to 978,000, with 132,500 using the products 20-30 days in the past month (Table 3)..nobr br { display: none } td { text-align: center} Table 3. Number of High School Students in 2018 Who Vaped in the Past Month But Never Tried Cigarette or Cigar Smoking, According to Age Days VapedLess than 18 years18+ yearsAll1-5607,89450,784658,6786-19163,69922,841186,54020-30109,12323,392132,515All880,71697,017977,703Finally, subtracting students who ever tried SMOKELESS TOBACCO, Table 4 reveals that the vaping epidemic consists of 897,000individuals, with 116,000 using the products 20-30 days in the past month.  Of those, 95,316 were underage..nobr br { display: none } td { text-align: center} Table 3. Number of High School Students in 2018 Who Vaped in the Past Month But Never Tried Cigarette or Cigar Smoking or Smokeless Tobacco, According to Age Days VapedLess than 18 years18+ yearsAll1-5572,09147,539619,6306-19139,88120,942160,82320-3095,31621,053116,369All807,28889,534896,822For comparison, I conducted the same analysis on the 2017 NYTS, which yielded 26,660 underage teens who vaped 20-30 days in the past month but never used other products.  That was less than 0.2% of all high school students.  It is true that frequent vaping among underage high school teens increased substantially from 26,660 in 2017 to 95,316 in 2018.  These numbers translate into an increase from less than 0.2 to 0.6% of all high school students.In summary, the oft-cited teen vaping epidemic involves not three million youths, but rather 95,000 underage teens who vaped frequently but never used other tobacco products – or 0.6% of the nation’s 14.8 million high school students.     Original author: Brad Rodu
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Rethinking tobacco and nicotine – a Twitter chat


May 15th, 2019

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About Sensationalist Science and Rhetoric on E-Cigarettes



Last week the Louisville Courier-Journal published my plea to stop confusing the public with sensationalist rhetoric on e-cigarettes.  Read it here or on the Courier-Journal website. The problem of misinformation is widespread. The public constantly receives alarmist misrepresentations about vaccinations, the food they eat, the household products they use, and now e-cigarettes and vaping. But hysterical rhetoric has consequences, because people act on what they are told. And health officials at all levels of government are misinforming Americans that e-cigarettes are as dangerous as cigarettes and pose an existential threat to their children. Unfortunately, this misinformation can be deadly. Production of tobacco misinformation follows a formula, originating in “user fees” (read: taxes) Congress established in 2009, giving the FDA regulatory authority over tobacco (here).  Every year tobacco manufacturers consumers pony up over $700 million dollars in user fees to the FDA, which then transfers a big chunk of that money to the National Institutes of Health, which distributes it to thousands of researchers at the nation’s universities to study tobacco products.  This system, which has been operating for several years, isn’t set up to discover the truth about tobacco.  Instead, it generates only what the NIH, and others in the federal government, wants: bad news about all tobacco products.  Including tobacco-free, smoke-free, and vastly safer e-cigarettes.    This bad news is then amplified by university media departments and our brave new world of social media, which makes it hard to see what’s true, and what’s exaggeration, distortion or pure fiction. Americans are exposed to a tsunami of fictitious “dangers” from vaping and of an e-cigarette “epidemic” that will put a generation of youth in danger. Of course, no policy measure is too strong when our kids are at risk. But the result of this misinformation cycle is significant. A study last month in JAMA Network Open found that the percentage of American adults who perceive e-cigarettes as equally harmful as cigarettes more than tripled from 11.5 percent in 2012 to more than 36 percent in 2017; those who perceive e-cigarettes as more harmful also tripled from 1.3 percent to over 4 percent. In short, Americans are listening to the alarmism about the “dangers” of e-cigarettes and the teen vaping “epidemic.”  They deserve better from our lawmakers and public health officials. The FDA knows that nicotine is the reason people smoke but it is not the reason that smokers die. Yet officials have not actively communicated this message to the public. Even worse, the FDA has exaggerated the teen vaping problem by manipulating data and incorrectly blaming retailers, in order to justify onerous regulations that will give consumers fewer healthier choices. Meanwhile, the real risks are forgotten. Smoking continues to prematurely kill 500,000 Americans every year, and smoking-related healthcare costs are nearly $300 billion. According to the CDC, more than 16 million people live with a smoking-attributable disease. In recent decades, anti-tobacco crusaders have tried everything to kill cigarettes, including litigation, legislation, taxation and regulation. But their crusade lost its direction when it started to target all tobacco products – even those that don’t contain tobacco.  Officials in international health organizations and national governments know that “tobacco” is not synonymous with “smoking,” yet they purposefullyconflate them.  In desperation, they have tried to kill e-cigarettes and vaping, an innovative, satisfying and vastly safer cigarette substitute. Ironically and tragically, their actions are sustaining and extending the cigarette market.  E-cigarettes contain nicotine – which is addictive – but they lack the toxins in smoke that cause lung cancer, heart disease and other maladies. This substantial difference is what led prestigious British medical organizations like the Royal College of Physicians and Public Health England to deem e-cigarettes at least 95 percent safer than combustible cigarettes.  In fact, the British government’s Department of Health helps smokers switch from combustibles to vapor. The good news is that even though misinformation is rampant, American smokers are still using e-cigarettes more frequently – and more successfully – than FDA-approved medicines to help them quit, according to a population-level studyusing the FDA’s national survey.  In February, British researchers reported in The New England Journal of Medicine that e-cigarettes are nearly twice as effective in helping smokers quit as FDA-approved nicotine medicines like patches and gum. Free and open conversation about truthful information is essential to a healthy democracy. But it’s also critical to establishing sound public health policy. It’s time for Americans to have all the facts about e-cigarettes, so they can make educated choices in order to enjoy longer and healthier lives. Original author: Brad Rodu
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CDC Quit-Smoking Ads Lack Real-World Solutions



People regularly ask me why I’ve spent the last 25 years researching and advocating for tobacco harm reduction and related products.  While it’s difficult to provide a succinct answer, a powerful ad campaign from the Centers for Disease Control and Prevention illustrates why I am dedicated to helping smokers. The campaign is called “Tips from Former Smokers”. For the first 15 years of my career, I was on clinical staff at the Comprehensive Cancer Center of the University of Alabama at Birmingham.  As an oral pathologist I made microscopic diagnoses of hundreds of cancers.  But as a clinician and member of a multidisciplinary team treating countless patients with mouth, throat and lung cancer, leukemia and other serious smoking-related diseases, I was compelled to search for practical quitting options for smokers just like Terrie, the patient in the CDC public service ad above.  Click hereto watch the entire ad. Those smokers reminded me always of my maternal grandfather.  He had smoked for most of his 65 years, despite the onset of heart disease that led to his early retirement from operating a dragline excavatorin the coal strip mines of Western Pennsylvania.  I remember my great-grandfather, an underground coal miner who chewed tobacco until he passed away at age 99, pleading with him: “Worthy, every cigarette is another nail in your coffin.”  My grandfather never quit, and in 1965 he suffered a stroke that left him hospitalized for months before he died.  Every night, my parents drove us 25 miles to visit him. One memory from that sad period is still with me: my grandfather, on oxygen and barely able to move or talk, begging his nurse for a cigarette. For many tobacco opponents, patients like these are only an abstraction, numbers to be wielded in a fight for absolute prohibition.  Most extremists have never worked with smokers suffering from a devastating disease.  If they had, they would care enough to ensure that smokers are offered every option to quit before it’s too late. That’s the frustrating thing about the CDC advertising.  It doesn’t endorse the most frequently used, and most frequently successful quitting aids: e-cigarettes.  Instead, the CDC pitches telephone quit-lines and gives smokers trite advice: “keep your mouth busy…do something else…go for a walk or a jog…take slow deep breaths.”  These tips are worthless for most of those who are desperate for their next cigarette.  What about children?  After my lectures, I am often asked by parents, “What if my child learns about you and your ideas, then starts using smokeless tobacco or e-cigarettes?” My answer: “What if, despite all of your good intentions and nurturing, your child becomes a smoker?  And what if, after 10 or 15 years, they are unable or unwilling to quit?  As a parent, wouldn’t you want your child to know about safer tobacco products?” We have to keep tobacco out of the hands of children, but safer cigarette alternatives must not be regulated out of reach of their parents and grandparents, whose smoking habit leaves them desperate to avoid fatal illness.Original author: Brad Rodu
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The California Crusade Against Tobacco Flavors: From Foolish to Dangerous



Today the California Globe published my oped on the foolish and dangerous legislative effort to ban flavored tobacco products.  Read it here or on the Globe website. “Crusades typically start out by being admirable, proceed to being foolish, and end by being dangerous.” Russell Baker used these words in a 1994 New York Times column describing the anti-tobacco crusade, noting that the holy war was entering the last stage. Now, 25 years later, California legislators are fighting their own crusade—against the so-called teen vaping “epidemic”—with a proposed ban on flavored tobacco products. First, let’s examine the “epidemic.” Authorities generously define “current use” of any drug by children as at least once in the past month. The FDA, using this definition in a national survey, reported that vaping among American high school students increased substantially in 2018. The FDA was only telling part of the story; about half of those kids had vaped five or fewer days, the equivalent of trying products at a party. And most frequent e-cigarette users are not virgins with respect to cigarette smoking; most of them have smoked in the past. Drug use by underage children is a serious matter. That makes it entirely baffling that California legislators ignore higher rates of alcohol and marijuana use among high schoolers, facts that have been known for decades. These behaviors have nothing to do with flavors, but instead demonstrate that kids are attracted to adult behaviors and products. The FDA promotes the myth that a teen vaping epidemic is caused by unscrupulous manufacturers and retailers. This isn’t true, especially in California, where the violation rate in FDA inspections was only 4% in 2018, one of the lowest in the country (here and here). Since retailers aren’t the problem in California, a ban on flavored tobacco products isn’t the solution. This is harassment without reason. Even advocates of alcohol prohibition 100 years ago didn’t try to ban flavors. A flavor ban is supposed to stop kids from using nicotine, but is that a worthwhile objective? Nicotine, while addictive, is not the cause of any diseases associated with smoking. It is as safe to consume as caffeine, another addictive drug used daily by millions of adults and teens. Because nicotine is so safe, prohibitionists fabricate hazards. One frequent claim is that nicotine can harm teenage brains. That may be a legitimate argument – for laboratory mice. If it was true for humans, then 40 million current smokers – and even more former smokers – who started as teens and smoked for decades would have demonstrable brain damage. There is no scientific evidence of such injury, nor to support the claim of youth brain risk. If California legislators want to protect children’s brains, they should ban football, as there is unequivocal evidence linking concussion-producing sports activities to chronic traumatic encephalopathy (here, for example). A flavor ban will not affect vapers who make their own vaping liquids. This segment of the market is already large and growing; a few examples can be found here, here and here. A ban might cause the current retail market to fracture in two: one segment selling concentrated, unflavored nicotine liquids, and another selling flavors. A high-tax jurisdiction like Chicago, where a prohibitively high per-milliliter tax is imposed on nicotine liquids, demonstrates what happens when the market is bifurcated.  Vape shops there sell 30 ml bottles of zero-nicotine e-liquids (no tax) and small concentrated bottles of high-strength nicotine that are taxed.  Flavor bans will simply encourage consumers to purchase flavorless e-liquids, and then buy flavoring that is widely available in grocery stores and online, such as here and here. Unintended Consequences A flavor ban would create unintended consequences. Flavors would no longer be supplied by legitimate companies. Instead, do-it-yourselfers would be adding flavors with unknown chemistry to concentrated nicotine solutions. It is worth noting that the only known death attributable to vapor products in the U.S. resulted from a young child accidentally ingesting pure nicotine. Politicians routinely ignore another basic economic fact: bans drive black markets. Economists and legal scholars use the terms “bootleggers” (black market retailers) and “Baptists” (legislators and other misguided do-gooders), calling them “unlikely allies from the tobacco wars [who] try to fight off a game-changer [e-cigarettes].” Two years ago, California was already the sixth biggest cigarette black-market state. Legislators should not create a bootlegger paradise for flavored tobacco, when they haven’t even solved the bootleg marijuana problem. The legislature legalized cannabis in 2016, but retained high taxes; the black market is now worth $3.7 billion, four times the legal market. The same rush to stigmatize vaping will doubtlessly create a black market in this category, as well. The California crusade to ban flavors isn’t just foolish, it’s dangerous. With the exception of menthol, the ban will have the least impact on sales of cigarettes, the deadliest tobacco products. But it will remove from retail shelves many more smoke-free products – including e-cigarette liquids, dip, chew and snus. These products are vastly less hazardous than cigarettes. Imagine if alcohol opponents had only banned flavors during Prohibition. Beer, wine and other flavored spirits would have been eliminated, leaving only pure alcohol on retail shelves. That policy would have been an abject failure, as would any similar ban on flavored tobacco products.Original author: Brad Rodu
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Broad Tobacco-Related Insurance Premiums Are Unjustified & Injurious



I recently received this email: “I am a 29 year old male from Upper Michigan, married with 3 kids.  My wife and I recently signed on with [company name redacted] as this was one of the only affordable health care options for our family and I like most all of their ‘principles’ or values. “Only 1 problem; they require that you don't use any drugs, drink, smoke, chew, nothing.  I consider myself a healthy individual as I'm 6'3", 200 lbs and fit. I haven't seen a doctor in years, frankly because I haven't a need.  I don't use drugs, drink, or smoke. However, I've chewed Copenhagen snuff for about 15 years and never had a problem with it. I was the one who had 2, maybe 3 small dips each day, a can would last me a week. It was never excessive and never a problem. “For the sake of [company] I quit chewing snuff a few months ago. Since I quit, I've noticed I'm short tempered with my wife and kids.  My performance at work has decreased, and I started gaining weight, and losing sleep. I think about it every day, and I feel no better without it. I feel like [company]'s penalty is harsh for dipping.  And they penalize the same for smoking or other hardcore drugs that I'd never do.  “I found you online, and I admire your courage to speak the truth about smoking and chewing.“Please let me know if you can help educate my health ‘insurance’ company on the truth about chewing tobacco. Any help is appreciated.”______________________________________________________________________________This narrative is not unusual; over the years, I have received numerous similar complaints.  Many smoke-free tobacco users are pioneers; my research group published a study about them in 1995, and I have also told their stories in this blog.   Unfortunately, smoke-free tobacco users continue to suffer from policies that consider all tobacco products – even medicinal nicotine – as equally dangerous, and all tobacco/nicotine users as high-risk.  This conflation of risks improperly raises premium costs, limits employment opportunities and degrades the quality of smoke-free tobacco users’ lives.  It also provides a financial windfall for insurers.  The federal government and health organizations often promote this conflation, and Obamacare legislation codified it, defining“smoking” as “using any tobacco producton average four or more times per week in the past six months.” (emphasis added)  It may be justifiable to charge smokers higher premiums, because they are at risk for many diseases that health insurance must cover and, on average, their lives will be shortened by 8-10 years, justifying higher life insurance premiums.  But use of smoke-free tobacco products which are associated with minimal or no added health risks should not incur such punitive premium treatment.  Many tobacco consumers avoid higher premiums by lying about their lifestyle choice.  Research shows that “tobacco users may be decreasingly likely to report their tobacco use status accurately to avoid surcharges” when enrolling in Healthcare.gov exchanges.  The problem for these individuals is that insurers and employers commonly require urine tests, which readily detect nicotine as long as three to four weeks after use. However, these tests do not distinguish how nicotine entered the body – via smoking or the use of smoke-free tobacco or medicinal nicotine.  As a health professional, I do not condone deliberate misreporting of tobacco use on insurance applications.  However, I do oppose the degradation of smoke-free tobacco users’ quality of life for no legitimate reason. Original author: Brad Rodu
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FDA Approves PMI’s IQOS Heat-Not-Burn Tobacco For U.S. Sales



Today the FDA approved Philip Morris International’s heat-not-burn tobacco system for sale in the U.S., saying in an agency press release: “Following a rigorous science-based review through the premarket tobacco product application (PMTA) pathway, the agency determined that authorizing these products for the U.S. market is appropriate for the protection of the public health because, among several key considerations, the products produce fewer or lower levels of some toxins than combustible cigarettes. The products authorized for sale include the IQOS device, Marlboro Heatsticks, Marlboro Smooth Menthol Heatsticks and Marlboro Fresh Menthol Heatsticks.” The FDA approval was issued two years (alternatively, 1 million smoker deaths) after PMI’s application, which is about a year and a half past the agency’s own deadline.  IQOS is only the second product approved under the PMTA pathway.  The first was in 2015 for eight General snus products from Swedish Match.  The FDA action is both good and bad news for e-cigarette and vapor manufacturers and retailers.  The good news is that the PMTA process works.  The bad news is that it took years, and hundreds of millions of research dollars, for PMI to obtain this approval.  By 2022 manufacturers and retailers, who already sell tens of thousands of e-cigarettes and vapor products but don’t have the resources of PMI, will be required to submit PMTAs to the FDA, or risk having them ordered off the market.  Original author: Brad Rodu
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FDA Holds IQOS Heat-Not-Burn Hostage, As Market Forces & Smoke-Free Products Slash Japan Cigarette Sales




The media has been silent about an unprecedented decline in cigarette consumption.  Japan Tobacco International reports (here) that cigarette sales in Japan declined 12% in 2018, largely due to sales of reduced-risk products.  The dominant reduced-risk product in Japan is Philip Morris International’s IQOS heat-not-burn HeatStick. David Sweanor, a veteran tobacco harm reduction advocate in Canada, observed: “Japan provides a great lesson in how tobacco control groups ‘doing nothing’ and ‘staying out of the way’ has led to outperformance in reducing cigarette smoking.  A key question is what could be accomplished if these groups actively facilitated transitions away from combustibles.  Japan has reduced cigarette sales dramatically in just three years, Iceland reduced prevalence of cigarette smoking by 40% in three years, Norway reduced the cigarette market by half in a decade, Sweden achieved by far the lowest rates of smoking in Europe, and the U.S. appears to have tripled the rate of decline in cigarettes sales. All this largely despite, not because, of, actions by mainstream tobacco control. That should be a wake-up call.” Clive Bates, another veteran THR advocate from the U.K., remarked: “The only mystery is why the skies over Tokyo are not dark with chartered planes bringing officials from WHO, FDA, Truth Initiative, the Campaign for Tobacco-Free Kids, the European Commission and others on an emergency mission to learn about this most extraordinary shift.  What is the secret they would find? ‘Do nothing, stay out of the way....’  There was very little involvement from tobacco control – the demise of cigarettes in Japan has been driven by the market and consumer preference.”  Meanwhile, in the U.S., smokers can’t buy IQOS because the FDA has not approved PMI’s marketing application (known as an PMTA), which was submitted in March 2017.  Approval requires the company to demonstrate “that the new tobacco product is beneficial to the population as a whole.”  Nothing benefits a population more than the rapid deterioration of cigarette sales, as seen in Japan. An FDA official recently indicated that a decision on IQOS will be issued by the end of this year.  That would mark the passing of 2.75 years from submission, and the untimely deaths of 1.3 million American smokers. The FDA took eight months (335,000 dead smokers) to grant Swedish Match a PMTA for eight snus products in 2015 (here).  What will happen in 2022, when the FDA receives thousands of PMTAs from vapor manufacturers and retailers? Original author: Brad Rodu
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Bizarre FDA vaping retail restrictions more likely to do harm than good


Caught in its auto-induced moral panic about the teen vaping epidemic, the FDA has decided that it would be better if certain vaping products were harder to get hold of than cigarettes, and the ones that were easiest to get hold of should be the ones most like cigarettes – tobacco and menthol flavour. This seems entirely mad to me and riddled with the potential for unintended consequences that would increase smoking in both adults and adolescents.

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Premium Cigars Threatened by Pending FDA Regulations, with Negligible Public Health Benefit



Chairman Marco Rubio convened a field hearing of the Senate Committee on Small Business & Entrepreneurship on April 5 in Tampa, Florida.  The focus was on proposed FDA regulations’ likely effect on premium cigar production and marketing.  I was invited to testify on the health effects of cigar smoking.  In addition to submitting formal testimony, available here, I made the following remarks at the hearing. As an oral pathologist at a major cancer center 25 years ago, I discovered that Americans, including doctors, are grossly misinformed about the high health risks of cigarettes versus the vastly lower risks of dip and chew.  This launched my tobacco research program that has produced 70 publications in the peer-reviewed medical literature. My research established that smokeless tobacco use is 98% less hazardous than smoking, and that extends to the risk for mouth cancer.   This was confirmed by a large recent study from federal and federally-funded investigators; they found that men who dipped or chewed tobacco had no excess risk for mouth cancer. Zero.   Differences in health effects are also well documented for combustible products.  First, some basic principles.  When you burn tobacco, you release nicotine and about 7,000 other chemicals.  Twenty to 30 years of 10 deep puffs on 20 to 30 cigarettes per day builds high risks for cancers, circulatory diseases and emphysema… leading to a high death toll.  Cigars also involve burning tobacco, but patterns of use are completely different.  The FDA knows that the cigar category encompasses a wide spectrum of products.  On one end are premium cigars; the rest of the category largely consists of machine-made, mass-produced cigarillos, little cigars and filtered cigars. I will reference the latter group as “little cigars”.  In 2014 FDA staff estimated that less than one percent of Americans smoked premium cigars; most light up infrequently.  Consumers of little cigars smoke a lot more often, and they also tend to smoke cigarettes. Premium cigar smokers fit another FDA label, primary (they never smoked cigarettes), as opposed to former smokers and dual users of both products.  This is important because adding cigarettes adds risk.  In my submitted testimony I present detailed information from a published FDA analysis of 22 epidemiologic studies of the causes of death among cigar smokers, most of whom are men.    The FDA study listed many diseases associated with cigarette smoking; the biggest killers are cancers, heart diseases, strokes and emphysema.  Consumption of one or two cigars per day was not associated with significantly increased deaths from any of these.  To be clear, puffing or inhaling the smoke of burning tobacco is not a healthy activity.  But the FDA researchers misstated the facts when they concluded that “…cigar smoking carries many of the same health risks as cigarette smoking.” All tobacco consumers deserve truthful information and guidance.  The sweeping FDA indictment ignores scientific evidence and misleads cigar smokers.  The following facts are indisputable: (1) in the U.S. the prevalence of cigar use, especially premium cigars, is very low; (2) premium products are used infrequently and in small numbers; and (3) they are puffed, not inhaled.  Low prevalence, infrequent use and reduced exposure translates into minimal harm at the population level.  Conflation of cigarette smoking with dip and chew, vaping, cigar and pipe smoking falsely informs consumers that all tobacco products are equally dangerous.  When Congress gave the FDA regulation of tobacco products 10 years ago, it did not direct the agency to treat all tobacco products as equally hazardous.  Unfortunately, the FDA’s regulatory actions have done just that. The FDA’s current posture wastes government resources, undermines public health and does nothing to address the 500,000 annual deaths caused by cigarette smoking. Original author: Brad Rodu
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Some FDA Claims About Teen Vaping Confirmed, Others Evaporate




The Centers for Disease Control and Prevention just released the 2018 data for the National Youth Tobacco Survey (NYTS).  My analysis confirms the FDA claim of a substantial increase in vaping among high school students.  However, I also discovered some information that challenges the FDA commissioner’s narrative (here) that this “threatens to hook an entire generation of kids into a lifetime of addiction.” As seen in the chart at left, current (past 30 days) dual use of combustible and electronic cigarettes rose from 4.2% the year before to 5.7% in 2018.  Exclusive e-cigarette use almost doubled, from 7.6% to 15.1%.  The only good news is that exclusive cigarette use declined from 3.6% to 2.6%.  Frequency of use is seen in the table below, which displays the percentages of the estimated 14.4 million high school students in 2018 who were currently using cigarettes and/or e-cigarettes, by number of days in the past month.  For example, 76.6% of students used neither product (bold text, upper left), an 8 point decline from the year before.  Current users of e-cigarettes are in the red-bordered boxes.  In 2017, 60% of current vapers used the products 5 or fewer days (green text) – the equivalent of trying products at a party.  But in 2018, that percentage dropped to 49%.  In contrast, in 2017 only 20% of current high school vapers used the products 20-30 days (red text), i.e frequent users, which is suggestive of dependence.  That number grew to 28% in 2018.  Slightly over half of those were not currently using cigarettes (bold red text). These worrisome numbers fuel the government’s dire warning that e-cigarettes are creating a new generation of nicotine addicts.  However, these claims require context, which the newly available NYTS data provides.  For example, the FDA emphasized that 28% of high school vapers were frequent users in 2018.  However, only 25% of underage vapers were frequent users, compared with 41% of legal vapers.  Further analysis of frequent vapers according to their underage or legal status shows the following: .nobr br { display: none } td { text-align: center}Table 2. Lifetime Cigarette Consumption of Frequent High School E-Cigarette Users, NYTS 2018Lifetime Cigarette ConsumptionUnderageLegalNot Current SmokersNever smoked43.1%28.2%1 puff to 5 cigarettes35.730.3Half to 1 pack9.417.31-5 packs6.412.65+ packs5.511.6All100%100%Current SmokersNever smoked0%2.8%1 puff to 5 cigarettes16.15.6Half to 1 pack19.725.01-5 packs20.015.85+ packs44.150.8All100%100%The table shows that most frequent e-cigarette users were not virgins with respect to cigarette smoking.  In the underage nonsmoking group, 57% of frequent vapers had smoked in the past.  The percentages were even higher among legal-age and current smokers.  These percentages will likely increase if cigars, smokeless tobacco and other tobacco products are included (as I explained years ago here).  These youths had already smoked, which counters Dr. Gottlieb’s assertion that “e-cigarette use…threatens to hook an entire generation of kids into a lifetime of addiction.”  Simply put, kids who use or try stuff, use or try other stuff.I have noted previously that the FDA’s campaign to eliminate teen vaping has improperly focused on tobacco retailers (hereand here).  The following table from the 2018 NYTS confirms that the dominant sources of e-cigarettes for underage high school users are friends, family and other individuals (71%), while the primary source for legal high school vapers are retailers (64%).  Raising the legal purchase age – Tobacco 21 – remains a viable way to curb underage use. (here).nobr br { display: none } td { text-align: center} .nobr br { display: none } td { text-align: center}Table 3. Source of E-Cigarettes for High School Vapers,* NYTS 2018 UnderageLegalFriend58.0%24.9%Family6.83.2Other person6.68.0Vape shop12.946.8Gas, convenience store6.69.7Internet3.92.0Other store2.31.4Drug store1.12.7Grocery0.90.6Mall kiosk0.90.7All100%100%* Reporting a single source (81% of all)(weighted).I previously said that “The FDA’s Teen E-Cigarette-Addiction Epidemic Doesn’t Add Up” for 2017.  There is no question that e-cigarette use among high school students increased substantially in 2018.  However, analysis of NYTS data documents that the FDA claim that e-cigarettes from retailers are singlehandedly hooking an “entire generation of kids into a lifetime of addiction” is exaggerated and inaccurate.  Original author: Brad Rodu
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Tobacco Sales to Kids Is a Problem For States, Not Retailers



FDA Commissioner Scott Gottlieb recently threatened that “some flavored e-cigarette products will no longer be sold at all…other flavored e-cigarette products that continue to be sold will be sold only in a manner that prevents youth access…” (here) Dr. Gottlieb blames the so-called youth vaping “epidemic” on illegal retail sales and “kid-friendly marketing.” (here)  Focusing so heavily on retailers, he ignores the fact that underage sales rates are extremely low in many states – Georgia (2.2%), Montana (2.7%), Hawaii (3.0%) and California (4.2%) for example, according to 2018 FDA inspection data – while violation rates in others is extremely high -- North Dakota, Michigan, Ohio and Nevada are close to 23% (here). In order to explore the connection between retailers’ violations and state enforcement efforts, I downloaded FDA information on 26,000 inspections conducted in 2018 at national retail chain stores – Walgreens, Walmart, Rite Aid, Shell, Family Dollar, Dollar General, Circle K and 7-Eleven.  I calculated the rate of violations for these chains’ stores in each state (excluding Nevada and North Dakota, with very low numbers of inspections).    The chart shows the combined results for these retailers.  Note that the x axis is the state rate, based on 146,000 inspections, and the y axis is the retailers’ rate, based on 26,000 inspections.  There is a strong correlation between violations in these chain stores and the state in which they were located (correlation coefficient, CC = +0.77).  The correlation is also seen with individual companies.  For example, Walgreens’ violation rate was 2.2% in Georgia (based on 46 inspections) and 17% in Ohio (with 229 inspections).  Note that nearly all of the retailers’ rates are below the green diagonal line, showing that they were lower than the state rates in all jurisdictions except DC, Connecticut, Oregon, Minnesota, Alaska and Hawaii. The FDA blames retailers for selling tobacco products to children, but it ignores the significant differences in violation rates among states.  Youths in Georgia, Montana, Hawaii and California can seldom buy tobacco products, suggesting that those states’ enforcement efforts are far more effective than the other 46 states. The simplest route to obtaining age restriction compliance seems to be FDA pressure for stronger state enforcement, rather than agency action against retailers or product categories. Original author: Brad Rodu
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FDA’s Campaign Against Tobacco Retailers Doesn’t Hold Up to Inspection



Today Dr. Scott Gottlieb announced a draft compliance policy predicting that ““some flavored e-cigarette products will no longer be sold at all…other flavored e-cigarette products that continue to be sold will be sold only in a manner that prevents youth access…” (here)Gottlieb has blamed a so-called youth vaping “epidemic” on illegal retail sales and “kid-friendly marketing.” (here)  Last week he spotlighted Walgreens, saying that 22% of its stores had illegal sales of tobacco products to minors “since the inception of the FDA’s retailer compliance check inspection program in 2010.”  He also listed 14 other national retail chains that had violation rates of 15% to 44%.  These shocking numbers are, in fact, inflated through the use of cumulative math covering a nine-year period. I reported on public FDA inspection data just after the program started (here) and again in 2016 (here).  In response to current FDA news, I have now analyzed the data from 2018 (available here), the year Dr. Gottlieb said youth vaping skyrocketed, based on still unpublished data from the National Youth Tobacco survey.  My findings on the 2018 FDA inspection data are illuminating.FDA contractors conducted over 146,000 retailer inspections in 2018, resulting in a national average violation rate of 12%, just one percent higher than in 2015-16 (here).  The following table contrasts the cumulative violation rate (range) reported by Dr. Gottlieb with the actual rate in 2018..nobr br { display: none } td { text-align: center} National Retailers’ Tobacco Sales Violations: “Cumulative” Versus 2018 RatesRetailerGottlieb “Cumulative” Rate (%)Actual 2018 Rate (%)Walmart15-246Walgreens15-249Family Dollar15-2411Circle K15-2412Kroger15-2413Casey’s General Stores25-34117-Eleven25-3414Shell25-3419Chevron25-3419Marathon35-4426Citgo35-4419Exxon35-4420Mobil35-4420Sunoco35-4421BP35-4424Dr. Gottlieb did not need to use inflated cumulative numbers to demonstrate that national retail chains, especially those with gas stations, are still selling tobacco products to underage youth.  Additionally, his focus on Walgreens, with a 2018 violation rate of 9%, three points lower than the national average, seems inappropriate.  Other key data points were omitted from Dr. Gottlieb’s remarks.  First, there is a large variation in state violation rates, from Georgia (2.2%), Montana (2.7%), Hawaii (3.0%) and California (4.2%) all the way to North Dakota and Michigan at 22.5%; Ohio and Nevada at 22.9%.  Retailers’ state rates were similarly diverse. For example, Walgreens and Walmarts in Georgia had much lower rates than those in Ohio.  This doesn’t absolve retailers of responsibility.  Rather, it indicates that state policies and attitudes may be contributing as significantly to underage sales as retailers.While Dr. Gottlieb’s regulatory effort is aimed ostensibly at combatting youth access to e-cigarettes, only 19% of the cited 17,500 violations in 2018 involved those products.  Cigars were the most frequent culprit (44%), followed by cigarettes (33%), with smokeless tobacco at a mere 4%.There is no excuse for a national tobacco sales violation rate of 12%; retailers everywhere must stop selling to underage youth.  Still, the federal government’s own survey data shows that more than 90% of teens who use tobacco products obtain them from social sources, such as friends or family.  Only 10% of current teen vapers buy their own e-cigs (here).  Given these facts, the FDA can’t hold retailers entirely responsible for teen e-cigarette use.Original author: Brad Rodu
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Federally Funded Authors Promote Misperceptions of Smoke-Free Tobacco Products



In their recent journal article, “U.S. adult perceptions of the harmfulness of tobacco products” (abstract here), a group of researchers from the FDA, other federal agencies, Canadian and American universities suppress important information about safer tobacco products.  G.T. Fong and 11 co-authors used federal funds to analyze the FDA Population Assessment of Tobacco and Health (PATH) Survey with respect to perceptions of eight non-cigarette tobacco products’ relative harms.  While their roughly 5,000-word treatise included three large tables, one figure, two supplemental tables, and 40 references, they included not a word about how these perceptions match up with reality.  The only time they used the word “misperception” was to suggest that Americans who view non-cigarette products as less harmful should be educated with “new information”. The authors found that “40.7% of adults believed that electronic cigarettes were less harmful than cigarettes.” In their view, “These results point to the potential value of enhancing knowledge, within the U.S. population, of the harm of tobacco products to prevent tobacco use and to encourage tobacco users to quit, through providing new information about the harms that may not be widely known and/or through countering misperceptions that may exist.” Readers of this blog know that numerous published studies document that smokeless tobacco use is vastly safer than smoking, and that the British Royal College of Physicians affirms that vaping is at least 95% less hazardous than smoking.  It is appalling that 12 government-funded researchers have published a lengthy screed without acknowledging that smoke-free products are less harmful.  Original author: Brad Rodu
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Vaping research priorities – my top ten


Following up on the guest post by Louise Ross: What are the vaping research priorities? Have your say… I have now had my say and wanted to share my top 10 priorities.

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Anti-vaping activists pitch unscientific fringe positions to a national newspaper





Some veterans of the tobacco control establishment have found the public health opportunity of vaping hard to come to terms with

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What are the vaping research priorities? Have your say…




Vaping: what do we need to know?

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The American Cancer Society: For and Against Tobacco 21



My op-ed about Virginia’s adoption of Tobacco 21 was published in the Richmond Times-Dispatch (available at Richmond.com hereand below).  As I have documented before (here), the American Cancer Society is out of touch with American smokers and their need for reasonable and rational ways to quit.  Further evidence is seen in the Society’s U-turn from supporting to opposing Tobacco 21 in Virginia (below) and Utah (here).  The Society complained in both states that “the devil’s in the details,” but there are no details: states simply want to move the legal age for tobacco sales from 18 to 21.  The Society should advocate for the health, and respect the rights, of American teens and smokers._______________________________________________________ Virginia has raised the minimum age for buying all nicotine products, including e-cigarettes, from 18 to 21. The bill had widespread support from state medical societies and Gov. Ralph Northam, a pediatric neurologist; and it is part of a national trend in which states are responding to the growing number of adolescents choosing to vape. But some in the public health community tried to make the perfect the enemy of the good by standing in the way of a sensible regulation that has the potential to curtail teen nicotine use, without making it harder for adult smokers to access healthier alternatives. It’s true there has been an increase in teen vaping — a problem exacerbated, in part, by older students legally buying tobacco products and selling them to their younger classmates. Raising the age from 18 to 21 will delegitimize tobacco sales to 18-year-olds and potentially disrupt high school “black markets.” Eighteen-year-olds make up 14 percent of all American high school students, but they account for one-quarter of high school smokers and smoker-vapers. Legal buyers — not manufacturers and retailers — are the primary source for tobacco products used by underage high schoolers. So Virginia’s Tobacco 21 law could make a big impact in limiting access to youth. The problem comes from the growing contingent of “anti-tobacco” activists who won’t be happy until there is simply no tobacco — or nicotine — for sale at all. Specifically, the American Cancer Society needs to start acknowledging scientific facts and abandon its “tobacco-prohibition” stance. The society opposed the sensible Tobacco 21 bill in the Virginia legislature, despite the fact that the ACS’s lobbying arm, the Cancer Action Network (CAN), endorses Tobacco 21 at the national level. CAN spokesman Brian Donohue insists, “the devil is in the details.” Similarly, the American Heart Association also supports Tobacco 21 in theory, but has been critical of the Virginia legislation. AHA spokesperson Ashley Bell said — somewhat incoherently — that youth access laws “may not be strong enough to support the current age … are not strong enough to support the enforcement of raising the age.” ACS-CAN’s Donohue added that Tobacco 21 “is a great goal, but it’s backwards.” The only thing backwards is the public health community’s flip-flopping on support for Tobacco 21. ACS-CAN is critical of the bill’s focus on youth — rather than retailers — and is insisting additional changes ought to be made such as the elimination of fines for teen buyers (currently $100 for the first violation, $250 after that), and increased fines for retailers (currently set at $500 for the first violation and up to $2,500 subsequently). But the reality is, they don’t intend to settle halfway because they want the complete elimination of nicotine and tobacco products. Efforts to stem the use of tobacco and vaping products through Tobacco 21 laws — like the one signed into law in Virginia — are growing. Hawaii, California, New Jersey, Oregon, Maine, and Massachusetts have already raised the purchase age to 21, and Alabama, Alaska, and Utah bumped it to 19. The leadership at organizations like ACS-CAN and the AHA know that the FDA punishes retailers who sell tobacco to anyone under 18. E-cigarette companies have implemented stringent age verification systems online to support these measures. No tobacco product is perfectly safe, but vaping is considered 95 percent safer than smoking. E-cigarettes not only provide a safer alternative for adult smokers; but, as the New England Journal of Medicine just confirmed, they are used more often by smokers, and they are more effective than medicinal nicotine in helping smokers quit. Each year more than 16 million Americans live with, and almost half a million die from, smoking-attributable illnesses; the total economic cost is more than $300 billion. We can’t afford to let politics interfere with sensible policies. Kudos to Governor Northam for ignoring tobacco policy u-turners in order to remove legal tobacco consumers from Virginia high schools. Original author: Brad Rodu
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Teen Smoking-to-Vaping Is More Frequent Than Vaping-to-Smoking, Says Data in New Study



FDA Commissioner Gottlieb on February 10 tweeted, “Now, a new study, published in the Journal of the American Medical Association (JAMA), further demonstrates what we’ve seen from other data: Teens who vape are more likely to start smoking cigarettes.” (Tweet here)  The study (here), by Kaitlyn Berry at Boston University and colleagues there and at the Universities of Louisville and Southern California, appeared in JAMA Network Open.Berry et al. examined the FDA Population Assessment of Tobacco and Health (PATH) survey involving youth, which started in 2013-14 and had two follow-ups, one and two years later.  The researchers identified 6,123 youths age 12-15 years who had not used a tobacco product at enrollment.  Some of the participants first tried a tobacco product over the next two years.  Berry et al. assessed whether first use of a particular product resulted in youth ever or current (past 30 days) cigarette smoking.  They concluded that “e-cigarette use is associated with increased risk for cigarette initiation and use.”Taking a closer look at the study, New York University professors David Abrams and Ray Niaura and I produced a comment, which has been published in the journal, making the following important observations.While Berry et al., and Commissioner Gottlieb, emphasized the 4.0% probability of current smoking among e-cigarette first users, we found a reverse result buried in a supplemental table: The probability of current e-cigarette use at follow up among cigarette first users was 8.3%.  This means that twice as many first-smoking teens currently used e-cigarettes at follow-up than first-vaping teens who currently used cigarettes.  We also noted that 527 teens first used e-cigarettes during follow-up, 202 used cigarettes first, and 306 used other products.  The table shows that out of 130 current smokers at follow-up, the relative impact is 25% for first e-cigarette use and 75% for all others. .nobr br { display: none } td { text-align: center} First Use of Tobacco Products By Teens in the PATH Survey and Current Smoking at Follow-upFirst Product Used (n)Percentage Currently Smoking at Follow-up (n)E-cigarette (527)5.9% (31)Other Tobacco (306)8.2% (25)Cigarette* (202)None* (5,088)1.4% (74)All (6,123)2.1% (130)*First cigarette users were combined with nonusers by Berry et al.This is entirely relevant to the FDA public health standard.  The absolute population impact (API) can be calculated using the full denominator of 6,123 teens. This reveals that e-cigarette first use resulted in 31/6,123 or about 0.5% API, contrasted with 25+74 = 99 /6123 or 1.6 % for teens without any first e-cigarette use.  In short, the API for teens without e-cigarette first use was triple that for teens with first e-cigarette use.Drs. Abrams, Niaura and I concluded:“Even with this small impact [0.5% API], e-cigarette first use cannot be causally linked to current smoking two years later, because plausible shared liability factors have not been ruled out. As a result of the issues we raise, scientists, journalists, regulators, policymakers and the public may be misled into thinking that e-cigarette first use is a unidirectional gateway into smoking. When information about API and the opposite gateway to smoking cessation are included, a much more complete picture emerges.”We look forward to a response from Ms. Berry and her colleagues.Original author: Brad Rodu
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Twitter Caught Up In This Year’s Annual Through With Chew Misinformation Orgy



Smokeless tobacco users are in for harassment this week, the 30th iteration of the annual Through With Chew orgy of smokeless tobacco misinformation.  Dippers and chewers will be demonized and the real science about the relative safety of their favored products will be twisted into fear-inspiring untruths. Consider this Tweet, for example, from the U.S. Department of Defense @ucanquit2 account on February 11: “Smokeless tobacco users are 50x more likely to get cheek, gum & mouth cancer than nonusers.”  The DoD made the same bogus claim two years ago (here).  I responded to this blatant fabrication with a Tweet of my own on February 15: “Your 50 claim is a complete fabrication by a staffer @theNCI. Here is the explanation: https://tinyurl.com/yxjsnugd . Furthermore, a large federally-funded study documented that men who dip/chew had ZERO excess risk for mouth cancer. ZERO. http://tinyurl.com/hd8nd49” After my Tweet was liked by 24 people and retweeted by 13, a strange chain of events occurred.  The Twitter accounts of many of the above were suspended.  The affected individuals pleaded with @TwitterSupport to make amends.  On February 16, I also asked for a correction: “To @TwitterSupport, Pls restore me/others. I am a scientist, 25 years published in this field. My tweet was professional and credible. In 2010 @CarlBialik at @WSJ investigated ‘50’ number and reported it was a fabrication used by @AmericanCancer, others http://tinyurl.com/y6a7ox8a.” That’s right.  Carl Bialik, “The Numbers Guy”, published a weekly column in the Wall Street Journal.  When Carl exposed the “50” myth (here) the American Cancer Society promised to stop using it: “Dr. Thomas Glynn, director of cancer science and trends for the American Cancer Society, said this week that his organization will no longer use the statistic citing a 50-fold increase in risk.” Yet still today, the Cancer Society and other tobacco prohibitionists tout the 50 number.       This week’s Twitter account suspensions likely resulted from a complaint by an authoritative anti-tobacco figure or agency.  While I understand that Twitter aims to protect the integrity of the information on its platform, in this case they sanctioned the wrong party. Note: As I post this on February 19, the suspended accounts have not been restored.   February 22: Today Jacob Sullum authored an article on the Reason Hit and Run Blog, "Did Twitter Punish Criticism of Government Propaganda About Smokeless Tobacco. (here).  A few hours later affected users reported that their accounts were returned to normal functioning. Original author: Brad Rodu
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