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Stanton Glantz

When Public Health and Big Tobacco Align

Nobody trusts the tobacco industry, and it’s easy to understand why. For decades, industry executives knew that smoking caused cancer and heart disease yet publicly denied the dangers of cigarettes. It relentlessly attacked its critics. Documents that emerged in the 1990s showed that the industry targeted teenagers, knowing that the earlier someone became addicted to cigarettes, the more likely they would be lifelong smokers. And so on.

https://www.bloomberg.com/view/articles/2017-03-09/when-public-health-and-big-tobacco-align

In the 1980s and 1990s, the public health community went to war with the tobacco industry. Though the war largely ended in 1998 with Big Tobacco agreeing to a multi-billion-dollar settlement with the states, it remains a powerful memory for public health.

To this day, most tobacco-control advocates view the cigarette companies as being every bit as duplicitous and evil as they were in the bad old days. Some years ago, I asked Stanton Glantz, perhaps the leading anti-tobacco scientist in the U.S., what his ultimate goal was. He didn’t say it was to eliminate the scourge of smoking. He said: “To destroy the tobacco industry.”

What brings this to mind is an excellent cover story in the upcoming issue of Bloomberg Businessweek about the efforts of the tobacco industry to devise and market so-called reduced risk products like electronic cigarettes — products that give users their nicotine fix without most of the attendant carcinogens that come with combustible tobacco.

Although the tobacco companies have done decades of R&D on smokeless products, the business was dominated early on by startups like NJOY, which is today the largest independent e-cigarette company in America. From the start NJOY has said that a big part of its mission was “to end smoking-related death and disease.” And from the start, messages like that have been scorned by the public health community.

Ingesting nicotine in some smokeless fashion is vastly safer than smoking a combustible cigarette. (In the words of the late South African tobacco scientist Michael Russell, “People smoke for the nicotine but die from the tar.”) Last year, the Royal College of Medicine issued a report saying that e-cigarettes were some 95 percent safer than cigarettes.

Even so, the public health community in the U.S., led by the Centers for Disease Control and Prevention, has done everything it can to demonize smokeless products. Some of this has been with good reason: to try to keep kids from picking up an addictive habit. But this effort has also helped to create the impression that smokeless products are as dangerous as cigarettes. One result, sadly, is that many long time smokers have refused to try them, even though they could save their lives.

My sense in talking to tobacco-control officials over the years is that too many of them simply don’t believe in a reduced-harm approach. We give heroin addicts methadone not because methadone is good but because it is better than heroin. With cigarettes, however, the public health mindset appears to be all or nothing — that the only “right” thing for smokers to do is to go cold turkey.

But the lingering distrust of the tobacco industry has also had a lot to do with public health’s unwillingness to acknowledge the potential benefits of alternative products. Matt Myers, the president of the Campaign for Tobacco Free Kids, has often complained, for instance, about the marketing of e-cigarettes, saying that companies are using the same tactics to hook teenagers that Big Tobacco once used.

With the e-cigarette market clearly established, the four big tobacco companies — BAT, Reynolds American, Altria (formerly Philip Morris) and Philip Morris International (spun off from Altria) — have proclaimed themselves all in.

Philip Morris International is an especially interesting case: Not only does it have an array of e-cigarettes and other smokeless products, but as the Bloomberg Businessweek story points out, it has publicly proclaimed that its goal is to lead the world into “a smoke-free future.” The home page of its website asks, “How long will the world’s leading cigarette company be in the cigarette business?”

As astonishing as it is that a company with $26 billion in tobacco revenue last year would be calling for the end of cigarettes, I believe Philip Morris is sincere. It has spent around $3 billion in research. Its new flagship product, called IQOS, heats tobacco but doesn’t burn it — which the company believes will be more satisfying to smokers than vaping. IQOS already has 7 percent of the tobacco market in Japan, and is being rolled out in other countries.

Philip Morris recently asked the British government that tobacco products “be taxed according to their risk profile.” In other words, it wants the government to impose higher taxes on cigarettes to encourage smokers to move to reduced-risk products. What tobacco company has ever done that before?

In the U.S., Philip Morris has done something extraordinary: It has made a submission to the Food and Drug Administration to get the right to market IQOS as a reduced risk product. The expensive submission consumed 2.3 million pages and is backed by a great deal of research, including several clinical trials. So far, none of the U.S. e-cigarette companies have attempted to get such a designation, and it is a big problem. How do you sell a reduced risk product when you can’t tell anybody it reduces risk?

The business case for diving into this market is that it’s a product category that’s growing, while the cigarette market is shrinking. Philip Morris doesn’t want to be left behind. But there is no particular need for the company to set out such a transformative agenda, at least not yet. The small smokeless companies are not much of a threat. NJOY filed for bankruptcy last fall. And under a 2009 law, every company in the e-cigarette industry will have to file something called a premarket tobacco application with the FDA by August 2018. The submissions will cost, on average, over $450,000, and the companies will have to show that their products have some public health benefit. There is a legitimate chance that some small companies won’t be able to clear the hurdle.

No, Philip Morris is pushing as hard as it is, I believe, because it wants to get on the right side of the issue, finally — to be viewed as a good corporate citizen. When I spoke to Glantz the other day about the company’s new anti-smoking agenda, he said, “I don’t believe them.” (He added, “If they were serious, they would stop marketing cigarettes right now.”)

No doubt many others in the tobacco-control community feel the same way. They still loathe Big Tobacco, and view Philip Morris’s new strategy as just another deception. But the truth is, if there is ever going to be a serious move from cigarettes to less dangerous products, it will have to come from Big Tobacco. They have the R&D resources, they have the marketing apparatus — and, it appears, they have the will.

Public-health advocates don’t have to trust Philip Morris, or any other tobacco company. They don’t have to believe what I believe in order to arrive at the same conclusion: that the advocates should be rooting for the companies’ innovations — pushing them, double-checking their data, making sure regulations are in place to prevent their products from being marketed to kids. The advocates should also be spreading the word that there is an alternative to cigarettes. Who really cares whether it’s Big Tobacco or some other entity that reduces smoking deaths? What matters is that it happens.

The tobacco wars are long over. Continuing to fight the cigarette companies may bring a certain satisfaction to the veterans on the public-health side. But joining forces is the way to save lives.

This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.

To contact the author of this story:
Joe Nocera at jnocera3@bloomberg.net

To contact the editor responsible for this story:
Philip Gray at philipgray@bloomberg.net

Vapers beware: 10 things to know about e-cigarettes

With catchy names like Smurf Cake and Unicorn Puke and sweet flavors like bubble gum and strawberry, electronic cigarettes may have special appeal to young people, but that doesn’t mean they are safe.

https://www.universityofcalifornia.edu/news/vapers-beware-ten-things-know-about-e-cigarettes

Evidence is mounting that e-cigarettes are exposing a new generation to nicotine addiction and may be leading users toward a cigarette habit. As a result, the U.S. surgeon general last month issued a report declaring youth e-cigarette use “a major public health concern.”

“All Americans need to know that e-cigarettes are dangerous to youth and young adults,” said Surgeon General Vivek Murthy, in releasing the report. “Any tobacco use, including e-cigarettes, is a health threat, particularly to young people.”

The battery-powered devices heat a liquid typically containing nicotine mixed with the chemicals propylene glycol and glycerin as well as flavorings to deliver an aerosol inhaled by the user. While e-cigarettes deliver nicotine without the tar and smoke of traditional tobacco cigarettes, they still are considered tobacco products.

But their healthy halo has helped propel their popularity: E-cigarettes are now so popular that more American youth vape than smoke cigarettes. In just a decade, e-cigarettes have become a multibillion-dollar business led by multinational tobacco companies with outlets not just online but everywhere from vape shops to convenience stores and retail giants like Wal-Mart.

Ads tout them as a cool, harmless alternative to cigarettes. E-cigarette users, or vapers, have contests to see who can blow the largest cloud of vapor.

But there’s more to e-cigarettes than meets the eye. The surgeon general’s report aligns with increasing scrutiny of e-cigarettes, from new regulations to a growing body of research into health effects.

Here are 10 things to know about e-cigarettes:

E-cigarettes contain nicotine

E-cigarettes contain nicotine, which is addictive and can harm the developing adolescent brain, said UC San Francisco professor of medicine Stanton Glantz.

A lot of the kids who take up vaping are at low risk for smoking, but once they start using e-cigarettes, they are three to four times more likely to start using cigarettes, Glantz said.

“The biggest health concern with e-cigarettes is they are prolonging and expanding the tobacco industry,” Glantz said.

Glantz, director of UCSF’s Center for Tobacco Control Research and Education, said he was initially neutral on e-cigarettes, but now finds them concerning. Among other hazards, e-cigarettes produce ultrafine particles than can trigger inflammatory problems and lead to heart and lung disease.

“The data is just becoming overwhelming,” Glantz said.

E-cigarettes expose people to more than ‘harmless water vapor’

E-cigarettes are billed as producing “harmless water vapor,” but, strictly speaking, the vapor produced when users exhale is actually an aerosol that contains a mixture of nicotine, flavorings and other ingredients that can be toxic.

Stanford University pediatrics professor Bonnie Halpern-Felsher has studied young people’s perceptions of e-cigarettes. In September, she launched a free, downloadable youth tobacco prevention toolkit with an e-cigarette module, funded by the UC Tobacco-Related Disease Research Program (TRDRP) and the California Department of Education.

“Youth are definitely using e-cigarettes because they think they are cool,” Halpern-Felsher said. “Adolescents and young adults don’t know a lot about e-cigarettes. They think it’s just water or water vapor. They don’t understand it’s an aerosol. They don’t understand that e-cigarettes can have nicotine. They don’t understand that flavorants themselves can be harmful.”

The flavors can be toxic

More than 7,000 varieties of flavored e-cigarettes are on the market.

UC Riverside professor of cell biology Prue Talbot screened the cytotoxicity (quality of being toxic to cells) of 36 refill fluids and found that some were highly toxic. The most cytotoxic flavor, Cinnamon Ceylon, contained a chemical called cinnamaldehyde, which gives cinnamon its flavor and whose side effects may include coughing and sore throats. Talbot has been studying more flavors and is building a database to help determine the most dangerous ones.

“Flavors are something that could be potentially regulated,” Talbot said.

Vaping has secondhand and thirdhand effects

Unlike cigarettes, which emit smoke from the lit end, e-cigarettes don’t produce sidestream emissions between puffs, but they still generate secondhand and thirdhand effects when users exhale the mainstream vapor.

In a TRDRP-funded study, Berkeley Lab researcher Hugo Destaillats led a team that found 31 chemicals that include several toxicants at significant levels in e-cigarette vapor. The most toxic chemicals included acrolein, a severe eye and respiratory irritant; and formaldehyde, an irritant and probable carcinogen.

Emissions varied by type of device and voltage.

“The way you heat the liquid drastically determines if you produce a lot of compounds or just a few,” Destaillats said. “As you increase the voltage, toxic byproduct concentrations increase exponentially.”

The batteries can explode

There were 134 reports of e-cigarette batteries overheating, catching fire or exploding between 2009 and January 2016, according to the Food and Drug Administration, which will host a public workshop in April to gather information about e-cigarette battery safety concerns.

E-cigarette batteries “can explode without notice,” Talbot said. “People can be quite severely injured.”

E-liquids are poisonous if swallowed

Calls to poison control centers about e-cigarette exposure in young children have skyrocketed nationally in recent years. In California, the number of calls involving e-cigarettes increased from 19 in 2012 to 243 in 2014, according to the UC-administered California Poison Control System. More than 60 percent of those e-cigarette calls were related to nicotine poisoning in children 5 and under.

E-cigarettes show mixed results in helping smokers quit

While some people have quit smoking with e-cigarettes, on average, adult smokers who use e-cigarettes are about 30 percent less likely to stop smoking cigarettes, Glantz said. Also, e-cigarettes are associated with more, not less, cigarette smoking among adolescents.

“If you are a middle-aged person who has been smoking for 20 years, maybe it is good to switch to e-cigarettes,” Destaillats said. “But if you are a teenager and never have smoked, then it is not a good idea to use e-cigarettes.”

The minimum age has risen

In June, California became the nation’s second state, following Hawaii, to raise the minimum age for tobacco sales to 21, and for the first time added e-cigarettes to the definition of tobacco products. In August, the FDA extended its tobacco oversight to e-cigarettes, banning sales to those under 18.

“It sends a message to youth that e-cigarettes are in the same category of all tobacco products,” Halpern-Felsher said.

E-cigarettes will be taxed

Under Proposition 56, the tobacco tax passed by California voters in November, the state will tax e-cigarettes for the first time, starting April 1. It’s estimated that the price of a typical 30-milliliter bottle of e-liquid could increase to about $30 from $20.

“Anytime you increase the price, people buy less,” Glantz said.

The tax revenue will enhance education efforts by boosting funding for the state Tobacco Control Program. The surgeon general’s report also will make it easier for states to integrate e-cigarettes into tobacco education campaigns and could lead to more regulations, Glantz said.

E-cigarettes may be safer than cigarettes, but unknown risks remain

Expect more information to emerge about e-cigarettes as studies examine long-term effects.

“It’s often assumed that e-cigarettes are safer than cigarettes, but that could be an incorrect assumption,” Talbot said. “We don’t yet know the long-term health effects of e-cigarettes.”

Decades of research have helped scientists determine that cigarette smoke creates more than 7,000 chemicals, at least 69 of which are known to cause cancer and many of which are poisonous.

So, while e-cigarettes deliver fewer cancer-causing chemicals than cigarettes, research has yet to reveal how e-cigarettes fully impact heart and lung health and their cancer-causing potential, Glantz said.

He estimates that e-cigarettes are about one-third to one-half as dangerous as cigarettes.

In other words, they are still plenty dangerous.

“Regular cigarettes are super unhealthy,” Destaillats said. “E-cigarettes are just unhealthy.”

Vaping’s Long-Term Effects: Here’s what the experts say

The debate over electronic cigarettes rages on, despite the vaping industry’s best efforts to promote its value in decreasing the use of tobacco cigarettes. Proponents of e-cigs argue that the technology is safer than traditional cigarettes and can be used to quit smoking altogether. The scientific community is beginning to see things differently, however. Its consensus: vaping is a scam.

https://mic.com/articles/161221/vaping-s-long-term-effects-here-s-what-the-experts-say#.oZe252gbh

The myth of e-cigarettes as a safe alternative

“The evidence consistently shows that, while some people successfully quit smoking with e-cigarettes, most people using e-cigarettes have their chances of quitting conventional cigarettes reduced by about 30%,” Dr. Stanton Glantz, Professor of Medicine at the University of California, San Francisco’s Center of Tobacco Control Research and Education, told Mic. “The most dangerous thing about e-cigarettes is that they keep people smoking cigarettes.”

Dr. Glantz conceded the possibility of e-cigs as a way to transition from tobacco cigarettes, but argued that the bulk of e-cig users are what are referred to as “dual users” — consumers who smoke both e-cigs and traditional cigarettes.

That notion is backed by a 2012 study published in the American Journal of Public Health, in which researchers found that e-cig utilization was highest among current tobacco cigarette smokers at a rate of 11.4%, compared to 3.4% of the total population surveyed, 2% of former smokers and 0.8% of those who never smoked a traditional cigarette. Furthermore, a study in scientific journal Tobacco Control found that 75% of dual use smokers do not even believe vaping will help them quit cigarettes and “reported planning to quit within the next 6 months less often than adults who smoke cigarettes exclusively.” A substantial 42.3% said they never plan to quit smoking whatsoever.

That continued use means that e-cigarettes will have long-term health effects on users, but it’s still too early to tell exactly what they will be (the first e-cigarette was invented in 2003). Dr. Glantz suggests another 5-10 years are required to conduct definitive research, but his research has led him to develop an understanding of the short-term epidemiological impact, and how it relates to potential long-term risks.

Vaping’s damaging effect on the cardiovascular system

“My current thinking is that e-cigarettes are going to cause less damage than conventional cigarettes in terms of cancer, but they’re probably just as dangerous – if not more – when it comes to heart disease and non-cancer lung disease and asthma,” Glantz said.

According to the Center for Disease Control and Prevention, approximately 610,000 people die of heart disease in the United States every year — that equates to one in every four deaths. In fact, heart disease is the leading cause of death for both men and women in the United States. The spreading popularity of e-cigarettes are likely to increase those numbers.

“One of the main things about smoking that causes heart disease is the ultrafine particles that are delivered through the smoke, which trigger inflammatory processes and damage the cardiovascular system,” Glantz said. “E-cigarettes deliver as much or more ultrafine particles as the ones found in cigarettes. That’s something you can’t get rid of because of the way cigarettes work — you generate an aerosol of ultrafine particles that carry the nicotine down into your lungs where it’s absorbed. You do that by burning the tobacco.

“The way e-cigarettes work is by heating up a liquid solution — propylene, glycol, glycerol, nicotine and flavorants – and that generates the ultrafine particles that go into your lungs,” Glantz continued. “The e-cigarettes that work the best in terms of delivering nicotine generate more and smaller particles than a conventional cigarette, and the smaller these particles are, the more dangerous they are. They have immediate effects on your blood and blood vessels, which we have already been able to measure and quantify.”

“The similarities between e-cigarettes and conventional cigarettes in terms of vascular effects are extremely troubling,” Glantz said, bluntly, as he concluded his explanation.

Vaping’s influence on teenage smoking

Perhaps most troubling aspect is the e-cigarette industry’s hold on adolescents. A July 2016 study published by the American Academy of Pediatrics examined prevalence rates in Southern California and concluded that “the high prevalence of combined e-cigarette or cigarette use in 2014, compared with historical Southern California smoking prevalence, suggests that e-cigarettes are not merely substituting for cigarettes and indicates that e-cigarette use is occurring in adolescents who would not otherwise have used tobacco products.”

Dr. Glantz partially attributes this phenomenon to marketing techniques utilized by the vaping industry, as well as a plethora of enticing “flavors” which attract younger users. This is highly irresponsible because, even if these teenagers aren’t converting to tobacco cigarettes, “Nicotine is still really bad for the developing brain,” according to Glantz.

Between early use among adolescents and adults’ insistence on dual use smoking, e-cigarettes are bound to have long-term effects — both physiologically and culturally. What exactly they will be cannot yet be definitively quantified, but one thing’s for sure: they won’t be good.

**PART 2** | POLITICIZING SCIENCE | SIEGEL ON GLANTZ & E-CIGS

PART 2 | GLANTZ ON E-CIGS | PROMOTING THE TOBACCO EPIDEMIC

PROMOTING THE TOBACCO EPIDEMIC | GLANTZ ON E-CIGS | PART 1