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Tobacco/Smoking (13 posts)  RSS

E-Cigarettes – It’s Complicated

June 24, 2014

By Thomas J. Glynn, PhD

Editor's note: This blog is the last one frequent contributor Dr. Glynn will write before his upcoming retirement. We wanted to thank him for his expertise and ability to break down a topic and offer insight, as well as his excellent writing. We offer him best wishes for a long, happy retirement.

In May 2011, I had the opportunity to write the first Expert Voices blog on what was then a new, but growing, public health concern - the emergence of e-cigarettes.

At that time, I wrote that "e-cigarettes have been described both as a miracle answer to the devastating effects of cigarette smoking and as a grave danger to the public health;" that they "are a source of controversy;" and that we need "to put science to work (and) obtain, solid, independent data" regarding e-cigarettes.

Now, 3 years later, more than 1,000 research papers, commentaries, and opinion pieces have been published about e-cigarettes. There's been continuous public debate about and media attention paid to e-cigarettes, and there's a proposed FDA rule regarding e-cigarette regulation.

Now, it is finally possible, at long last, to say that... e-cigarettes continue to be described both as a miracle answer to the devastating effects of cigarette smoking and as a grave danger to the public health; that they remain a source of controversy; and that more independent, objective data are needed.

Consensus remains elusive

Yes, the old French adage - plus ca change, plus c'est  la meme chose  (the more things change, the more they remain the same)-- is an apt description for the state of affairs regarding e-cigarettes in June 2014. Despite the considerable research, debate, media attention, Congressional hearings, and, yes, blogs, over the past 3 years, the public health, advocacy, scientific, and medical communities are little closer to a consensus regarding e-cigarettes than they were in May 2011.

This is not to say that there has not been, as noted above, an enormous amount of activity surrounding e-cigarettes over the past several years. According to a recent study, awareness of e-cigarettes among the public - both cigarette smokers and non-smokers alike - has increased by more than 50%, with nearly 80% of Americans now reporting that they have heard of e-cigarettes. Tellingly, however, the public is split over whether they think that e-cigarettes are either safe or effective as a tool for quitting smoking, with just about 50% believing that they are safe and/or effective and an equal percentage believing the opposite.

Not surprisingly, the scientific community also remains split on the e-cigarette issue. A stark example of this divide occurred recently in reaction to a study regarding e-cigarette vapor and its effect on indoor air quality published in the International Journal of Hygiene and Environmental Health.

Dr. Stanton Glantz, a professor of medicine at the University of California at San Francisco and an e-cigarette opponent, highlighted the study on his web site with the headline "More Evidence That E-Cigarettes Cause Substantial Air Pollution. . .and Inflammatory Processes (in Users)." Several days later, Dr. Michael Siegel, a professor of medicine at Boston University and a proponent of e-cigarettes, highlighted the same study on his web site, with the headline "New Study of (E-Cigarette Vapor) Shows No Evidence of a Significant Public Health Hazard." One study, 2 experienced researchers, and 2 sharply divided opinions of the same material.

As another example of this scientific divide, the World Health Organization (WHO) recently published a comprehensive review of the science surrounding e-cigarettes, concluding that the data do not support either their safety or their effectiveness as quitting devices. Shortly after this review was published, however, an international consortium of 53 prominent scientists wrote to the WHO, asking that they reconsider their stance, since their reading of the WHO report caused them to reach a different conclusion, i.e. that e-cigarettes may have a role in reducing the horrific toll of death and disease from traditional, burned, cigarettes. And then, following this letter and further revealing the serious rift in the scientific and medical communities over this issue, a different group of 129 scientists wrote to the WHO and argued that the first letter underplayed the potential negative effects of e-cigarettes and WHO should maintain its original stance.

This lack of scientific consensus has, of course, been a challenge for policymakers as they are faced with immediate questions regarding e-cigarettes at the state and local levels, such as how to address e-cigarette use in public spaces, how to tax e-cigarettes, how to keep people from using both traditional combusted cigarettes and e-cigarettes, how to keep e-cigarettes out of the hands of children, etc.

E-cigarettes are evolving

Further complicating this landscape is the evolving nature of e-cigarettes themselves. Three years ago, the e-cigarette market was dominated by small manufacturers making devices that looked like cigarettes. Now, two major changes in this landscape are occurring.

First, the tobacco industry itself has seen an opportunity and begun to buy e-cigarette companies, as well as manufacture and market their own e-cigarettes. This entry of the tobacco industry into the e-cigarette space should raise all of the familiar warning signals in the public health community. And, second, new forms of e-cigarettes and related devices are emerging.

One such device is the so-called "vape tank," an inhaling device that allows consumers to customize their own nicotine delivery products. Another is the soon-to-be-released product from Philip Morris International called the Platform 1 device, which will heat, but not burn, tobacco (as opposed to most e-cigarettes, which heat nicotine alone). So when a ruling is made on one product, it may or may not apply to other or newer products.

Areas of potential agreement

Yet, despite the continuing controversy, legitimate scientific disagreements, and changes in the e-cigarette market, 3 additional years of data have allowed some principles or areas of general agreement (not necessarily consensus) to emerge within the public health community. These include:

  • E-cigarettes in any form should not be marketed to, sold to, or used by children and youth.
  • It is not possible to characterize e-cigarettes as a single entity, since more than 250 types are now sold in the U.S. and engineering changes are further blurring our ability to describe e-cigarettes in any one way.
  • E-cigarettes are less harmful than combusted cigarettes, at least for short-term use (They haven't been around long enough to know about the effects of long-term use). The secondhand vapor, or aerosol, from e-cigarettes is, in general, less harmful than secondhand cigarette smoke.
  • E-cigarettes are able to help an as-yet limited segment of regular cigarette smokers to stop, at a rate comparable to rates achieved by users of nicotine replacement medications. For this reason, e-cigarettes may have a role to play in reducing the use of combusted cigarettes, which are, by far, the primary source of death and disease from tobacco use.
  • The marketing of e-cigarettes and similar products must be carefully monitored and, where appropriate, regulated to eliminate unsubstantiated claims and advertising to children and youth.
  • Objective, independent scientific data regarding all aspects of e-cigarettes, including the emerging products, must continue to be collected and objectively evaluated.
  • The long-delayed proposed regulations from the FDA, issued in April, 2014, which would address e-cigarettes, among other products, are a step forward in providing objective advice to consumers, but need to be adjusted, pending comments from a wide range of constituent communities, including individuals, the public health community , and tobacco companies, and then implemented as soon as possible.

Of course, even the statements/principles above will be sources of controversy to many, which goes to show the breadth of disagreement regarding e-cigarettes in the public health field. Indeed, it's the most serious source of disagreement in the 50 years that public health has come together around the profound need to end cigarette smoking and the death and disease that tobacco causes.

The debate over 'harm reduction'

Controversies surrounding e-cigarettes will not be going away any time soon. This is especially true as the entire e-cigarette industry, which is only 10 years old, continues to morph into an even broader industry with a wider variety of products, and as the tobacco industry itself begins to play a much larger role in determining what e-cigarettes will look like and how they will be used and marketed. 

Also, while considerable progress in tobacco control has been made in the 50 years since the first Surgeon General's Report on Tobacco was published in 1964 - reducing cigarette smoking from 42% of the population in 1965 to 18% today - more than 42 million Americans continue to smoke and nearly 500,000 will die this year alone from the effects of cigarette smoke. Globally, the toll is even greater - 1.3 billion people smoke and more than 6 million people will die as a result this year.

The continued use of combusted cigarettes by such a large number of Americans  and global citizens will continue to exert pressure on the public health, advocacy, scientific, and medical communities to go beyond "business as usual" and what we know works to help people quit smoking and explore new solutions to the challenge of cigarette smoking. In this vein, the 2014 U.S. Surgeon General's Report on Smoking and Health raises the issue of whether ending the use of the most harmful tobacco product (i.e. combusted cigarettes), while reducing the potential harm from newer, innovative products such as e-cigarettes, may be a reasonable national goal.

This concept of "harm reduction," is an approach to risky behavior that looks to lessen the damage rather than stopping the behavior. It has been used in other areas of public health  such as providing clean needles to intravenous drug users to avoid HIV rather than attempting the more herculean task of ending drug abuse altogether, or substituting methadone for heroin use.  

In tobacco control, however, "harm reduction" has traditionally been viewed as controversial, often pitting committed public health practitioners against one another. One side argues that the only path to eliminating the scourge of cigarette smoking is abstinence from all forms of tobacco, while another side argues that ". . . it is nonsensical to dismiss a (less harmful) alternative by demanding absolute safety."

Certainly, there is reason for concern on both sides of this issue - questions such as whether e-cigarettes could lead to the 'renormalization' of combusted cigarette use - that is, making such behavior a regular part of life, when smoking cigarettes no longer is; whether youth who might never have used nicotine might begin to do so through e-cigarette use; whether current cigarette smokers might continue smoking AND use e-cigarettes (rather than quitting altogether); and others remain unresolved.

This is the controversial context in which e-cigarettes - however broadly or narrowly defined - may play a larger role as tobacco control advocates continue to grapple with the need to consider additional measures to end the grip that the combusted cigarette has exerted on this country, and the world, for too many years. If we do not step forward and consider bold actions such as embracing the potential of e-cigarettes and other harm reduction agents then we, and the next generations, may have to confront the challenge laid down by former World Health Organization Director-General Dr. Gro Harlem Brundtland when she said:

"If we do not act decisively today, 100 years from now our grandchildren and their children will look back and seriously question how people claiming to be committed to public health and social justice allowed the tobacco epidemic to unfold unchecked."

Dr. Glynn is director of cancer science and trends and director of international cancer control for the American Cancer Society.

The Landmark Surgeon General Report on Smoking and Health, 50 Years Later

January 15, 2014

By Richard C. Wender, MD


Fifty years ago, on January 11, 1964, Luther Terry held a press conference to announce the results of the first Surgeon General's report on smoking and health, the most impactful public health document in history. The report laid to rest over a decade of debate about the health risks of smoking by definitively stating that smoking causes lung and laryngeal cancer in men, chronic bronchitis, and other diseases.

Research conducted by the American Cancer Society and other groups had already demonstrated the adverse health effects of smoking, but, until the Surgeon General's report, the tobacco industry had been successful in hiding the truth. The extraordinary methods used by the Surgeon General to ensure that the report was completely unbiased -- including allowing the tobacco industry to veto nominees to serve on the panel -- the thoroughness of the research, and the clarity of the conclusions, all led to one outcome: the end of the debate about the health risks of smoking and the launch of the true fight to end the use of tobacco products. The progress in the tobacco fight over the past 50 years represents one of the most successful, life-saving public health campaigns in our nation's history.

Learn more about the 50th anniversary of the Surgeon General's Report on Smoking and Health:

The Hammond/Horn study

The effects of tobacco control

Rates Drop for New Lung Cancer Cases in the US

Tobacco and Cancer

Guide to Quitting Smoking


The public health victories, and the challenges

Forty-three percent of Americans smoked prior to the Surgeon General's report; 18% smoke today. Smoking in airplanes, restaurants, and places of employment has largely disappeared.  We're now fully aware of the addictive nature of the nicotine in tobacco products, and the importance of preventing and treating that addiction. Tobacco executives were eventually forced to admit, before Congress and the country, that they were long aware of the addictive nature of their products as well as the harmful health effects. 

We've learned that raising the cost of a pack of cigarettes is the single most effective way to reduce the number of people who start using tobacco products and the most effective way to promote quitting. Tobacco tax increases have been implemented in many states.  As of 2009, the FDA was granted the authority to regulate tobacco products, although the tobacco industry has placed substantial roadblocks in the path of effective FDA action. The United States is not alone. Smoking rates in most high-resource ("Western") nations like England, Canada, and Australia have substantially declined, comparable to the progress that we've seen.  We've witnessed 50 years of amazing progress; we truly do have much to celebrate.  

And much to lament. More...

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What really works to help you quit and avoid tobacco?

November 17, 2013

By Thomas J. Glynn, PhD

The American Cancer Society's first Great American Smokeout was celebrated November 18, 1976. Gerald R. Ford was President of the United States, the "War on Cancer" had begun just a few years before, Barack Obama was 15 years old and, according to a Gallup Poll taken that year, 37% of American adults smoked cigarettes.

This year, the 37th anniversary of that first Great American Smokeout, the percentage of Americans who smoke has nearly been cut in half, to 19%. And, those who do smoke use far fewer cigarettes than in 1976, from about 4,000 cigarettes per year for every U.S. adult then, to about 1,200 now.

Certainly, we know that any cigarette smoking is dangerous to the smoker and non-smokers who inhale cigarette smoke. We also know that far too many Americans continue to smoke - 44 million, at last count. Still, astounding progress has been made in combatting what is the nation's largest cause of preventable death and disability.

How do we know what works?

How was such progress made? What actions were taken to achieve such significant changes in the face of the tobacco industry's relentless, illegal, and well-funded efforts to addict men, women, and children to their deadly products? There is no easy answer to that question. But we do know that, over the past 37 years, a wide range of interventions - in communications, education, policy change, and medicine - have been undertaken. Interventions in all of these areas have been effective, but some have been more effective than others. More...

Menthol cigarettes - what's the big deal ?

August 28, 2013

By Thomas J. Glynn, PhD

The discussion around whether the U.S. Food and Drug Administration (FDA) should keep or ban menthol-flavored cigarettes has produced a number of news headlines in recent weeks, because in July the agency released a report reviewing current science around these cigarettes. This science will inform many of the decisions the agency may make about menthol cigarettes, and the millions of current and potential smokers who will be affected by those decisions. But the menthol story goes back much further than just the past few weeks.

Menthol and cigarettes: a brief history

Menthol is an organic compound which can be made in a laboratory or derived from mint oils, and has a distinctive and, for most people, pleasant odor and taste. It is used to enhance the flavor, popularity, and ease-of-use of many food products, candies, and medications.

As a medication, it can be used as a mild local anesthetic, counter-irritant, and, more specifically, for the relief of minor throat irritation. That is why menthol was first introduced in cigarettes in the 1920's and gained broader popularity with the introduction of a filtered menthol brand, Salem, in the mid-1950's.

Over the years, largely because they mask the harsh taste and/or throat-irritating properties of inhaled tobacco smoke, mentholated cigarettes have gained a wide audience, such that about 30% of all 44 million smokers in the U.S. now identify menthols as their preferred cigarette. This is especially true among African American smokers, about 80% of whom are menthol users. More...

Light smoking as risky as a pack a day?

January 02, 2013

By J. Lee Westmaas, PhD

Do you occasionally have a cigarette, maybe not even every day? Although people resolve to quit smoking in the new year, you might think only heavy smokers need to quit. But that isn't the case.

Light or intermittent smoking has become a very common pattern for people of any age.  Many of these people do not feel addicted to tobacco and do not even call themselves "smokers." There are, however, some real risks associated with any level of smoking. Non-daily smoking, or smoking 1-5 cigarettes a day, was first noticed as far back as 1989 because it was a stark contrast to the more common pattern at that time -- 20 to 30 cigarettes a day. At that time, very light smokers were labeled "chippers" (a term that also referred to occasional users of opiates who appeared to not be addicted). Chippers didn't appear to smoke to relieve withdrawal, and sometimes didn't smoke for a day or more. More...

Mind the (Smoking) Gap: Those Who Want to Quit and Those Who Actually Do

November 14, 2012

By Thomas J. Glynn, PhD

For those who have traveled London's Underground, or Tube, the term "Mind the Gap" will be familiar. It's the warning for riders to be aware that there is a gap of several inches between the station platform and the train cars. In the public health community, we also have a gap: the gap between the number of smokers who want to quit and those who actually succeed. The American Cancer Society Great American Smokeout, held this year on November 15, is an opportunity to remind us that we also need to "mind the gap."

In the United States, this gap is very wide. Nearly 70% of the country's 43.8 million smokers say they would like to quit smoking; 52% report making at least one serious attempt to quit each year; but a disappointingly low 4% are actually successful in doing so. More...

The FDA and Tobacco Regulation Three Years Later

October 29, 2012

By Thomas J. Glynn, PhD


As the official sponsor of birthdays, the American Cancer Society has every reason to be proud of a "toddler" celebrating its third birthday this year. The Family Smoking Prevention and Tobacco Control Act - aka the Tobacco Control Act - was strongly supported by ACS and ACS CAN and signed into law by President Barack Obama on June 22, 2009.

For the first time and after nearly 2 decades of debate, this historic legislation gave the U.S. Food and Drug Administration (FDA) the authority to regulate tobacco products. In doing so, Congress enabled the FDA to establish the Center for Tobacco Products (CTP), which is charged with regulating the manufacture, marketing, and distribution of tobacco products in order to reduce tobacco use by children under 18 and protect public health.

More specifically, the Tobacco Control Act authorizes the FDA to act in a number of ways, including:

  • Restricting tobacco sales, distribution, and marketing
  • Requiring stronger health warnings on packaging and in advertisements
  • Requiring disclosure of tobacco product ingredients
  • Reducing (but not eliminating) the amount of nicotine in tobacco products
  • Creating standards for tobacco products
  • Regulating "modified risk" (i.e. potentially harm reducing) tobacco products, such as e-cigarettes, snus, dissolvables, etc.

So, with the authority to take these types of action, how is the Tobacco Control Act doing 3 years later? Is it having its intended effects? Are Americans - tobacco users and non-users alike - beginning to see its hoped-for health benefits? To best address these questions, it will help to take a small step back and consider the history of the Tobacco Control Act, take a brief look at the Act's accomplishments to date, and then look a bit into the future. More...

Hookahs are trendy, but are they safe?

May 29, 2012

By Tom Glynn, PhD



Hookah smoking is no safer than cigarette smoking. If you read no further, that is the take-home message for this blog -- no matter what you may have heard or read, the scientific evidence is clear that hookah smoking is not a safe alternative to smoking cigarettes.


Countering the widely-held, although mistaken, belief that hookah smoking is safer than cigarette smoking is important, so let's take a step back and consider what hookah is, learn about its history and current popularity, and then look at the facts about the scientific evidence regarding its effects on health. More...

Here Come the Dissolvables

November 16, 2011

By Thomas J. Glynn, PhD


No, "The Dissolvables" are not a Saturday morning TV cartoon show - they are the tobacco industry's latest attempt to maintain, and even expand, the number of tobacco users in the U.S., at a time when fewer people are smoking cigarettes.

"Dissolvables," as they have become collectively known, are products made of compressed tobacco and are available in a variety of forms, including sticks, pellets, and strips (think the Listerine breath strip). They dissolve in the user's mouth, delivering nicotine, as well as thousands of other chemicals and substances. Examples of these products are below.  More...

Ewwww, that's gross! A New Era in U.S. Cigarette Labeling

June 22, 2011

By Thomas J. Glynn, PhD

OK, admit it - you have no idea what current cigarette packs in the U.S. have to say about the dangers of tobacco use. I've been working in this field for nearly 30 years and I'm not really sure, either. And we're not alone - very few of us remember that they say things like "Quitting Smoking Now Greatly Reduces Serious Risks to Your Health" in very tiny letters and are virtually hidden on one side of the pack. More...

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