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September 8th, 2015:

How to dramatically reduce smoking without banning tobacco sales

Disclosure statement

Micah Berman receives funding from the US Food and Drug Administration and the National Institutes of Health. The work discussed in this article were not supported by any funding, and the views expressed are his own.

The Conversation is funded by CSIRO, Melbourne, Monash, RMIT, UTS, UWA, ACU, ANU, ASB, Baker IDI, Canberra, CDU, CQU, Curtin, Deakin, ECU, Flinders, Griffith, the Harry Perkins Institute, JCU, La Trobe, Massey, Murdoch, Newcastle, UQ, QUT, SAHMRI, Swinburne, Sydney, UNDA, UNE, UniSA, UNSW, USC, USQ, UTAS, UWS, VU and Wollongong.

Last November, the Board of Health for Westminster, a town in central Massachusetts, proposed prohibiting all tobacco sales – even e-cigarettes – in the town.

Westminster’s three-person Board of Health said that the proposal was meant to protect the next generation from tobacco and nicotine products. The board expressed frustration at its inability to keep up with the seemingly endless barrage of new tobacco products that appealed to minors. Ending all tobacco sales seemed like a clean and quick fix.

But in the face of intense opposition, Westminster’s Board of Health voted to drop the proposal. While banning tobacco sales might have protected children, many felt the proposal infringed on the “rights” and “freedoms” of adults. Some also suggested that people would simply go to other towns to buy tobacco products.

In proposing to ban all tobacco sales at once, Westminster’s Board of Health got ahead of itself. But there are plenty of other strategies that cities and towns can use to effectively reduce tobacco use – especially in young people – that don’t go as far as a total sales ban.

These measures, while aggressive, might help diffuse complaints of “prohibition” and instead keep the focus on dramatically reducing the 480,000 deaths caused each year by tobacco products. And, critically, these policies avoid the pitfalls that doomed the Westminster proposal.

To protect kids, make it harder for them to buy cigarettes

While tobacco sales to people under 18 are prohibited, most high school students report that they have little difficulty in gaining access to cigarettes.

There are two policy options that would make it a whole lot harder for kids to start smoking, while not preventing adults from buying tobacco products: raise the legal buying age to 21 and restrict cigarette sales to adult-only retailers.

Raising the age to 21 works because high school students get tobacco primarily from friends who can legally purchase tobacco. Ninety percent of those who supply cigarettes to minors are under 21. Raising the minimum sales age to 21 puts legal purchasers outside the social circle of most high school students.

A recent study found that raising the tobacco-buying age to 21 in the Boston suburb of Needham led to a nearly 50% decline in youth smoking, a much steeper decline than was seen in surrounding communities.

Already, more than 90 communities around the country, including New York City and the entire state of Hawaii, have looked at the evidence and decided to raise their tobacco sales age to 21.

Obviously this helps prevent sales to minors. But raising the tobacco buying age doesn’t shield minors from tobacco advertising. Since other avenues of tobacco advertising (TV, billboards, sports sponsorships) have been sharply limited or prohibited, tobacco companies have focused nearly all of their advertising dollars on retail stores where tobacco is sold.

In effect, the tobacco industry has used marketing contracts with retailers to transform the nearly 400,000 retail stores around the country that sell tobacco products into recruitment centers for new tobacco users. And numerous studies confirm that the more time youth spend in convenience stores (70% visit them at least once a week), the more likely they are to smoke.

Limiting tobacco sales to retail locations that only adults are permitted to enter would remove this barrage of tobacco advertising from the convenience stores where teens spend a significant amount of time. It would also make it easier to prevent minors from purchasing cigarettes.

This is not a radical strategy; it’s similar to how liquor sales are currently regulated in most states. Ideally, limiting cigarette sales to adult-only retail outlets would be done in conjunction with raising the minimum buying age for tobacco from 18 to 21.

These policies wouldn’t prevent adults from purchasing tobacco, but they would help keep youth from taking up smoking (while also making it easier for current smokers to quit).

Focus on the most dangerous tobacco products

Westminster’s Board of Health proposal to ban the sale of all tobacco products also included e-cigarettes, which contain nicotine derived from tobacco. This struck many as radical and unwarranted.

The vast majority of all tobacco related deaths result from the use of only one particular product: the cigarette.

People use tobacco products primarily because nicotine is addictive. Nicotine itself is not benign, but on its own it’s much less harmful than the smoke and tar produced by burning tobacco. E-cigarettes and other vaporized nicotine products are almost certainly less toxic and less harmful when used instead of conventional cigarettes.

A bold yet more incremental step would be to allow the sale of potentially less harmful products, like e-cigarettes, while sharply limiting sales of conventional cigarettes and other combusted products. This might take the form of exempting e-cigarettes from the adult-only retailer policies described. Or, potentially, a community might consider prohibiting all cigarette sales, while allowing sales of non-combustible products.

If cigarettes were harder to come by, the “harm reduction” potential of e-cigarettes would be much more likely realized. As summarized by the Surgeon General:

The impact of noncombustible [e-cigarettes] on population health is much more likely to be beneficial in an environment where the appeal, accessibility, promotion, and use of cigarettes and other combusted tobacco products are being rapidly reduced, especially among youth and young adults.

But the evidence to date indicates that e-cigarettes are primarily being used along with cigarettes, rather than instead of them. In addition, use of e-cigarettes by youth, which is rapidly expanding, puts these youth in danger of “graduating” to cigarette use.

A recently published study found that adolescents who had used e-cigarettes were more than twice as likely as their peers to subsequently start smoking. Making it harder for adolescents to obtain cigarettes would help reduce the likelihood that minors using e-cigarettes move on to smoking.

Get community support before acting

The most important lesson of Westminster’s experience may be that policymakers cannot get too far ahead of their communities. As public health law scholar Wendy Parmet recently wrote:

Public health laws that are strongly rooted in, and indeed arise from, the public, may face a quite different fate than those that derive from the good intentions of public health policymakers alone.

Rather than announce a plan to ban the sale of all tobacco products, the Westminster board of health could have instead started a series of community discussions about the problem of tobacco use – and youth tobacco use in particular.

It is likely that such discussions would have quickly produced broad consensus about the need to better protect youth from tobacco, which could have then led to a discussion about potential policy solutions (such as those discussed above).

It is also notable that some of the loudest critics of the proposed Westminster law were proponents (and users of) e-cigarettes, many of whom struggled for years to quit cigarettes. Including this community in early discussions could have led to a shared vision about how to minimize the dangers of e-cigarettes while focusing on the much more significant harms caused by cigarettes.

Making sustainable public health policy requires the slow but important processes of community engagement, education, compromise, and consensus building. With deliberate and incremental steps to reduce the prevalence of tobacco in our communities, we can save countless lives.

E-Cigarettes Are a Gateway to Tobacco, Study Says

A new study looks at how smoking and vaping habits change over time

Young people who use e-cigarettes are significantly more likely to try conventional cigarettes later on, a new study suggests.

Whether e-cigarettes serve as a “gateway” to traditional tobacco products is hotly debated. But the new study, published in JAMA Pediatrics, finds that young people who use e-cigarettes are much more likely to start using conventional cigarettes within a year compared to peers who do not use e-cigarettes.

Researchers at the University of Pittsburgh Center for Research on Media, Technology, and Health (CRMTH) and the Dartmouth-Hitchcock Norris Cotton Cancer Center looked at about 700 people from ages 16 to 26 who did not smoke cigarettes. At the study’s start, the men and women were asked if they would try a cigarette if a friend offered them one, or if they thought they would smoke a cigarette within the next year. Those who answered “definitely no” were found to be “non-susceptible” to cigarette smoking. The group was surveyed in 2012 and again in 2013.

During that year, things changed—especially for those who used e-cigarettes. When the young men and women were surveyed again, more people who said they used e-cigarettes at the start of the study had started using regular cigarettes, compared to people who did not use e-cigarettes.

Notably, the number of young people who used e-cigarettes at the start of the study was small. Out of the 694 people in the study, only 16 were e-cigarette users at the start. Six of those 16 people, or 37.5%, used cigarettes a year later. Just 65 out of the 678 people who did not use e-cigarettes progressed to smoking cigarettes, or 9.6%.

The authors say that because the number of e-cigarette users at the start of the study was so small, it could be inferred by others that the public health risk with smoking e-cigarettes may not be “substantial”. But other data, they note, suggest that increasingly more young people are starting to use e-cigarettes, and as many as half of them do not use traditional cigarettes. Any overlap in use should be monitored, they say.

One of the public health issues surrounding e-cigarettes is the fact that the U.S. Food and Drug Administration (FDA) currently does not regulate e-cigarettes as it does other tobacco products, though it proposed an expansion of its jurisdiction to do so in 2014. E-cigarettes are still subject to regulation by other entities like states or counties or cities. As the study authors note in their report, this still means that in some cases e-cigarettes are not subject to restrictions like age limits. The study authors also add that e-cigarettes come in flavors like bubble gum and chocolate which could be attractive to younger consumers.

E-cigarettes are still not fully studied, the FDA says. “It is not known whether e-cigarettes may lead young people to try other tobacco products, including conventional cigarettes, which are known to cause disease and lead to premature death,” the group says on its website. However, study author Dr. Brian A. Primack, director of CRMTH, disagrees with the notion that there’s not enough information to determine the public health risk of e-cigarettes. “I do think that things have changed,” he says in an email to TIME. “This study, in combination with other recent findings, raises more concerns about some potential harms to the public health.”

The researchers conclude that their findings support regulation that limits e-cigarette sales and lowers their appeal to young adults. The FDA plans to restrict sales, though the proposed rules by the FDA are not yet enforced.

CTA SAYS: Here is our prediction on the new revolution of vaping

Worldwide authorities will either ban or regulate E-cigarettes as medicinal products

Only systems with enclosed canisters will pass required testing (to prevent people adding MDMA or other drugs and accidental poisoning of children attracted to the colours)

The cost and timing of certification and testing each product, its electrical charging system and battery safety, contents of the canister and accuracy of nicotine / other ingredients will be extreme

Only the largest e-cig companies and Big Tobacco will be able to afford such testing- their own scientists will already know what is required to achieve FDA or equivalent testing

The smaller e-cig companies will fall by the wayside or survive on mail order and a huge black market will appear for fillable tank tape inhalers

More inhaler type products like VOKE will appear on the market and Big-T will issue patent suits against copycats

Big-T will start a ‘General Cargo’ aka smuggling, network via its supply chain to avoid payment of Excise tax on approved cartridges and to keep people addicted to nicotine

Black market cartridge copies containing higher nicotine content will appear – canisters containing flavorings and synthetic drugs like MDMA will appear – police in a quandary how to deal with situation

Big-T will use its paid bent senators and front groups to push for a seat at the Govt Health tables, since they are now part of the harm prevention ‘solution’ and Govt / NHS Health Services are now their major clients

Meanwhile youth will experiment with vaping , normalise usage, add drugs to the tank, – move on to combustibles = who knows? – all in all , a mess;- meanwhile Big-T gets richer and more powerful, sues Governments to prevent adoption of health measures like plain packaging, Governments add massive excise increases in retaliation, ‘General Cargo’ surges to fill the demand, the death cycle continues

India’s soft stand on tobacco draws fire

DILI (TIMOR LESTE): Delay by India to implement larger pictorial warnings on packs of tobacco products came up for criticism at the World Health Organisation’s regional meet here as delegates assessed tobacco-control measures by countries in the region.

“We are going to emphasise on it (delay by India) at the roundtable. Even Indonesia which is not signatory to WHO’s framework convention on tobacco control (FCTC) has implemented 40% pictorial warning on both sides of packs. India, being an important member and such a large country, has only 40% on one side,” WHO Regional Director (South East Asia) Poonam Khetrapal Singh said.

India’s health minister J P Nadda Nadda was absent at 68th South East Asia Regional Committee meeting which is being attended by health ministers from nine countries of the region. Health ministry officials cited domestic engagements as reasons for Nadda’s absence. India was represented by a senior official of the ministry at the meeting of the highest decision-making body of WHO for the region. Thailand’s health minister also couldn’t attend the meeting.

Nadda though has maintained that the health ministry is determined to implement stricter tobacco control measures, including larger pictorial warnings on packets of tobacco products.

The health ministry had earlier notified to implement 80% pictorial warnings on packs of all tobacco products from April 1. However, the government deferred the move following an interim report by a parliamentary sub-committee asking the ministry to put the decision on hold till it consults all stakeholders and submits a final report.

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The government’s decision to defer implementation of larger pictorial warnings had upset several public health groups.

“It requires political will. All other countries in the region have set example by prescribing warnings up to 90% on both sides. India being an important player in the region has shown poor performance,” said a senior WHO official advocating for stronger provisions to control advertising and marketing of tobacco products.

Emphasising that India is a signatory to FCTC which mandates tobacco control measures, Khetrapal Singh said, “We advise countries on what they should be doing for good health of their people and then leave it to them to either follow our advice or if they choose not to. These are countries which are signatories to a resolution that was adopted in the World Health Assembly. Respecting their sovereign right, we leave it to them to now implement whatever they themselves have adopted.”

She said tobacco use is an important “risk factor for non communicable diseases” and hence high on WHO’s agenda.

Dili, the capital of the host country, has the highest percentage of tobacco consumers in the region. Though the country, which earned its independence from Indonesia just about a decade back, has implemented several tobacco control measures, it proposed WHO to focus on the issue to be able to share experiences from other member countries, Khetrapal said.

Experts said delaying larger pictorial warnings is likely to have a serious impact on the health of those who are less educated and poor. Recently, a study by National Council of Applied Economic Research (NCAER) and University of Maryland revealed about 46% of illiterate men smoke, while only 16% of college graduates are hooked to tobacco. For the uneducated, larger pictorial warnings could be a way to create awareness about the dangers of tobacco use.

Southeast Asian Health Ministers Sign Anti-Tobacco Declaration

According to a statement issued by the World Health Organisation (WHO), health ministers from 11 countries of the WHO South-East Asia region have signed a declaration pledging to accelerate hard-hitting measures to reduce tobacco use. The ministers gathered in Timor-Leste, capital of Dili, for the inaugural session of the 68th Regional Committee Meeting of the WHO South-East Asia region. With tobacco killing 150 people every hour in the region, they expressed their concern over high tobacco consumption “Tobacco use in South-East Asia is alarmingly high, triggering major health and economic consequences. Tougher actions are needed for tobacco control and prevention,” said Poonam Khetrapal Singh, regional director of WHO South-East Asia region. “Countries must equally tax all tobacco products, ban tobacco advertisements, enforce pictorial warning on cigarette packs and implement ban on public smoking,” she added.

The Dili Declaration called on governments, United Nations agencies and partners to accelerate tobacco control in the region which accounts for over one-third of the world’s tobacco use. “Tobacco kills 1.3 million people in the region every year, including people who were exposed to second-hand and third-hand tobacco effects. It is also home to 25 percent of the world’s smokers and 90 percent of the world’s smokeless tobacco users,” the statement said.Tobacco use has been identified as one of the major risk factors for serious diseases of the lung, heart, and cancer. In 2012, an estimated 62 percent deaths in the region were attributed to non-communicable diseases; of these 48 percent were below 70 years. Highlighting the fact that premature deaths were not only a loss to the families, but also have a huge economic impact on the country, Singh said there was an urgent need to “enforce stringent policies and measures to help people reduce and eventually quit tobacco”.

“WHO recommends enhancing awareness on the ill-effects of all types of tobacco products; effective control measures to reduce tobacco consumption and counter-interference of tobacco industry; strengthening taxation systems on tobacco products to reduce consumption, and enhancing surveillance, research and cessation of tobacco use,” she said.

Electronic Cigarettes Are Another Route to Nicotine Addiction for Youth

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23-Year-Old Severely Injured When E-Cigarette Exploded in His Mouth

James Lauria, a 23-year-old from Destin, Florida, left work on July 29 to smoke an e-cigarette when the e-cig exploded inside of his mouth, according to FOX 5. “Next thing I know, it exploded and I was on my way to a hospital in an ambulance,” Lauria said. “That is the last thing I remember.”

Lauria was a frequent e-cigarette smoker leading up to the accident and had never experienced anything like this before. The explosion burned his cornea and hand, and fractured his neck and his finger. It also blew a hole through his palate while flames simultaneously “went down and he got first-degree burns on his chest and up on his face. It forced his front tooth up into his gum and chipped the other one and damaged a few other lower teeth,” Lauria’s father told FOX.

The injuries were so severe that he was airlifted to the University of Alabama’s Burn Unit, where he spent a week in the ICU. More than six weeks after the explosion, Lauria is still on a liquid diet and will soon be fitted for a prosthetic to close the hole that remains on the roof of his mouth. He is living at home with his parents until he is strong enough to be on his own.

According to FEMA, more than 25 separate incidents of e-cigarette explosions and fires were reported in the U.S. between 2009 and 2014. Thankfully, none of those explosions led to deaths, but two of them resulted in serious burns.

Electronic Cigarettes Are Another Route to Nicotine Addiction for Youth

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Dangerous Trend: Some Teens Using E-Cigs To Smoke Cannabis

New York (ABC News) – Electronic cigarettes (E-cigs)…their use among high school students has been growing exponentially over the last couple of years. So, it’s no wonder that these trendy devices have many parents worried.

Now, new research may give these parents even more to be concerned about. The research suggests high school students may be getting creative with the substances they “vaporize” in these e-cig devices. Namely, cannabis.

Researchers at Yale University and Oberlin College surveyed roughly 4,000 high school students in Connecticut and they found that nearly six percent of these students admitted using e-cigs to smoke cannabis. The rate at which these students used e-cigs for this purpose is twenty-seven times the rate found in adults.

The practice is potentially dangerous since the hash oils and waxes used in e-cigs can be much more potent than other forms of the drug, and the vaping technology effectively masks the drug’s smell, making detection more difficult. Of course, this study doesn’t necessarily reflect what’s going on in the rest of the nation, but it does suggest that parents and teachers should be on the lookout for this new smoking technology.

E-cigarettes make teenagers four times more likely to move on to real smoking, health experts warn

Teenagers who use e-cigarettes are four times more likely to end up smoking ‘real’ cigarettes, according to new research. American researchers said unregulated electronic cigarettes which are advertised on TV and in magazines serve as a gateway to smoking for teens and young adults. Results showed 38 per cent of e-cigarette users had started smoking traditional cigarettes within a year compared to just ten per cent who had not used an e-cig. Smoking an electronic cigarette makes the user more likely to start using real tobacco (pic posed by model) Recent research suggested that vaping could be a way of breaking the habit and could save the NHS millions.

But the latest study indicates that because e-cigs deliver nicotine more slowly than traditional cigarettes, it allows users to advance to cigarette smoking as they become tolerant of nicotine side effects.

They are also designed to mimic the behavioural and sensory act of cigarette smoking, allowing the user to become accustomed to the act of smoking. Because they are not banned from public spaces, e-cigs may be seen as potentially renormalising smoking after decades of public health efforts to demonise it. And the flavoured smokes may simply appeal to teenagers. Dr Brian Primack of the University of Pittsburgh said: ‘E-cigarettes are not subject to many of the laws that regulate traditional cigarettes, such as age limits on sales, taxation and labeling requirements. ‘They also come in youth-oriented flavourings that laws have limited in traditional cigarettes, such as apple bubble gum and chocolate candy cane.’ Professor of pediatrics Dr James Sargent at the Geisel School of Medicine at Dartmouth added: ‘It also is notable that electronic cigarettes are marketed on television. ‘This represents the first time in more than 40 years that a smoking-related device has been advertised on this medium, which has tremendous reach and could drive appeal of these products among youth.’

The study published in JAMA Pediatrics was the first to assess this relation in a national US sample of youngster, and to include people older than 18 among its participants. It analysed data on a national sample of nearly 700 nonsmokers aged 16 to 26 surveyed in 2012 and again in 2013 through the Dartmouth Media, Advertising, and Health Study. All participants were considered ‘non-susceptible’ to initiating traditional cigarette smoking at the beginning of the study, because they had responded ‘definitely no’ when asked if they would try a cigarette offered by a friend or believed they would smoke a cigarette within the next year.

By the next year, 38 per cent of the baseline e-cigarette users had initiated traditional cigarette smoking.

In comparison, only 10 per cent of the youths who were not baseline e-cigarette users started smoking traditional cigarettes which Dr Primack said ‘these differences remained statistically significant.’ Dr Sargent said: ‘However, recent data suggest that more youth than ever are using e-cigarettes and that as many half of these adolescents are not smoking traditional cigarettes ‘Therefore, it is important to continue surveillance of both e-cigarettes and tobacco products among young people so policymakers can establish research-informed regulations to help prevent e-cigarettes from becoming gateway products on the road to youth smoking.’