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October 5th, 2016:

Public health groups sue FDA on graphic cigarette warning labels

A group of anti-tobacco and public-health groups sued the Food and Drug Administration on Tuesday in an attempt to compel it to establish graphic warnings labels on cigarette packaging and marketing.

It’s been more than 3½ years since there’s been legal or regulatory movement on graphic warnings, particularly on what they will look like and when they will appear.

The 2009 federal Tobacco Control Act required graphic warnings covering the top half of the front and back of cigarette packs and on 20 percent of cigarette advertising.

The FDA was given until June 22, 2011, to issue a final rule requiring such warnings.

The governments of more than 90 countries require similar graphic warning labels. Australia, which was among the first to introduce the labels and has some of the most graphic images, is perhaps the most noteworthy.

The FDA chose nine labels in June 2011, which were scheduled to debut in September 2012. The labels included smoke coming out of a tracheal hole, diseased lungs and gums, and a man who appears deathly ill.

A group of tobacco manufacturers that include R.J. Reynolds Tobacco Co. and Lorillard Inc. filed a lawsuit in September 2011 against the FDA regarding the labels.

Two parallel legal cases with differing judicial opinions have put the initiative on hold.

The anti-tobacco and public health groups argue that the federal Administrative Procedure Act, which governs federal agencies, gives federal courts the power to “compel agency action unlawfully withheld or unreasonably delayed.”

“The FDA is in violation of its nondiscretionary statutory duty,” according to the plaintiffs’ lawsuit.

The plaintiffs contend that one of the legal tracks gives the FDA clearance to implement its final rule on the warning labels. Some plaintiffs argue that the lack of warning labels “makes it more difficult” for them “to educate and counsel members of the public not to smoke.”

In August 2012, a panel of the U.S. Court of Appeals for the D.C. Circuit voted 2-1 that the proposed specific warning labels violated the First Amendment. That ruling did not address the law’s underlying requirement.

The FDA said in March 2013 that it declined to further appeal the D.C. Circuit ruling and would create new warning labels.

In March 2012, the U.S. Court of Appeals for the Sixth Circuit upheld the law’s requirement for graphic warnings, finding that this provision did not violate the First Amendment. The U.S. Supreme Court declined in April 2013 to hear an appeal of the Sixth Circuit ruling.

“The FDA is undertaking research to support a new rulemaking consistent with (the Tobacco Control Act),” spokesman Michael Felberbaum said Wednesday.

While the industry and advocacy groups await the next FDA warning label proposals, several studies have been published that found mixed smoker reactions to the initial nine proposed labels.

In December 2010, an FDA study found putting graphicwarning labels on cigarette packs may stir emotions, but not lead to quitting.

UNC Chapel Hill researchers said in June that 40 percent of participants in their study said they were more likely to consider quitting after exposure to the graphic images, compared with 34 percent with the text warning.

A February 2016 study published by University of Illinois researchers at the journal Communication Research suggests graphic images strike some people as manipulative, a reaction that could backfire on the attempt to steer individuals away from smoking.

Lawsuit plaintiffs

The lawsuit was filed by the American Academy of Pediatrics, the Massachusetts Chapter of the American Academy of Pediatrics, the American Cancer Society, the American Cancer Society Cancer Action Network, the American Heart Association, the American Lung Association, the Campaign for Tobacco-Free Kids, Truth Initiative, and several individual pediatricians.

The Race to a Tobacco Endgame

Ruth E Malone

Correspondence to
Professor Ruth E Malone, Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, CA 94118, USA;

Accepted 5 October 2016

During the past month alone, I have had an opportunity to participate in four different meetings—in Utah, Sweden, Canada and the USA—where ideas about how to achieve an ‘endgame’ for the tobacco epidemic were being discussed. Other previous meetings—in India, Finland and the UK—have been held over the last few years, and I know of several other such discussions. Even before the US Surgeon General’s 50th Anniversary report on the health consequences of smoking1 called explicitly for achieving a tobacco endgame and suggested a combination of policy strategies to do so, other countries such as Ireland, New Zealand, Finland and Scotland were having conversations that led them to set hard target dates by which they intend to reduce tobacco use and/or smoking prevalence to <5%.

Modelling studies suggest that current measures, even if they are greatly accelerated in countries that are tobacco control leaders, will not achieve these goals within the first half of this century.1 As the target dates move closer, will political leaders seize the opportunity to enact the bolder policy innovations that must be undertaken? Or, will they allow caution and inertia to shape another century of public health catastrophe?

The endgame requires consciously designing interventions to change permanently the structural, political and social dynamics that sustain the epidemic, in order to end it by a specific time.2 Thus, an endgame vision goes beyond ‘business as usual’ and calls for further policy innovations. No one knows how to do it yet, but the endgame conversation3–6 has become mainstream, and the first places that manage to achieve it will herald the beginning of the end of more than a century of industrially produced carnage. Which places will be first to cross the finish line?

Several factors will likely be decisive.

The first of these is whether the public health community can achieve some rough unity as to the goal and strategies to be employed. We do not have to agree on everything, and some places will do things differently than others, but within any locale, some consensus will be needed or we risk confusing the public and giving policymakers more excuses not to act. There is no doubt that the tobacco industry is eager to exploit and/or create such divisions,7 so compromises will be needed. The controversy over e-cigarettes, for example, has created multiple lines of division among public health proponents. This disunity does not serve well the advancement of new policy measures to end the epidemic.8 Yet, e-cigarettes and the burgeoning list of other non-combustible tobacco and nicotine products could represent potential leverage for accomplishing what once seemed unthinkable: phasing out combustible cigarettes, the single most deadly consumer product ever marketed. Yes, these other products may cause harm. Yes, there may be unintended and unanticipated negative consequences. But we do not require a single additional study to know with absolute certainty that the continued sale and use of cigarettes will reliably deliver more disease, death and suffering than any other product. And we do know that for at least some people who smoke, the use of these alternative tobacco and nicotine products is acceptable as a substitute or a transition to quitting. Let’s keep our eyes on the prize.

The second decisive factor is whether the ground has been sufficiently prepared in getting the public to believe in and support ending the tobacco epidemic. The incongruence of telling the public how bad cigarettes are, while simultaneously continuing to allow their widespread retail sale, contributes to confusion at best and cynicism at worst. In this regard, multiple studies from various countries suggest that the public—including smokers—may be further along the road to an endgame than we public health proponents have allowed ourselves to go. In Canada, for example, data from Wave 9 and preliminary analyses of Wave 10 of the ITC Survey, a nationally representative cohort study, show that more than half of smokers would support a complete ban on cigarettes within 10 years, if the government provided assistance to quit.9 These findings are consistent with several studies conducted in other countries, as well as internal data from tobacco company Philip Morris’s own public opinion surveys, which found that in the USA in 2004, 68% of those surveyed wished there was some way to get rid of cigarettes.10–12 However, such findings have never been used to develop effective campaign messaging to build a constituency for endgame measures.

A third element is whether policymakers in the location are courageous enough to tackle something new and politically risky, about which they will incur attacks from tobacco companies and their allies. Big Tobacco will raise every conceivable argument, arguing that protecting the public from these unreasonably dangerous and defective products infringes on rights, will create vast black markets, and will ruin economies. But governments have an obligation to act to protect public health, tobacco companies themselves have been implicated in black market trading, and to argue that we must keep killing people in order to sustain our economy seems to put the entire social enterprise in question. In addition, the places now closest to achieving a tobacco endgame are those where prevalence has dropped to historical lows, suggesting that the transition to new economic and business models is inevitable: policymakers should be anticipating and preparing for a different kind of economy.

Finally, achieving a tobacco endgame will reflect how well public health proponents work alongside and with the communities that are now most affected by the tobacco epidemic. ‘Nothing about us without us’ is an important principle as smoking and tobacco use become more concentrated among certain population groups, each of which has different resources, needs and priorities. The tobacco industry’s targeting and exploitation is one part of how these disparities in tobacco use came to be, but the whole story is much more complex, especially for indigenous peoples. Now Big Tobacco hides behind these groups, claiming, for example, that tax increases hurt the poor—despite evidence that such increases actually benefit poor people more (because they quit in greater numbers) than wealthier groups.13 But those alliances are beginning to fray. For example, activists in the US African-American community, concerned with the consequences of high menthol cigarette use, are providing aggressive leadership on efforts to pressure government to get menthol out of tobacco products.14 New Zealand Maori leaders’ report in 2010 led to establishment of that country’s Smokefree 2025 goal.15

While for many countries, combustible tobacco products are the biggest issue to be addressed, in others like India, dangerous oral tobacco products proliferate. Some countries already have robust regulatory infrastructures that are trusted by the public; others are only beginning to build the capacity that would allow more radical measures such as limiting sales outlets for cigarettes or setting a timetable for a phaseout. This is why ‘there is no single endgame’, as Arnott16 pointed out several years ago. But even tobacco companies are beginning to realise that the endgame is in sight.

I recently received in the mail a heavy envelope from overseas, containing a ‘Global Compact Report’ from Philip Morris International, along with a personalised letter encouraging me to review it and engage in dialogue. One line jumped out at the end of the first paragraph, which focused largely on spin about the company’s latest reinvention of itself as a responsible, transparent seller of death and disease: a reference to ‘acknowledging and addressing the social harms caused by our products, including the phase out of combustible cigarettes’. This oddly written sentence would be cause for genuine excitement if the report actually said anything specific about phasing out cigarettes, but it did not appear to do that. Nowhere could I find any plan or timetable for such a phaseout, despite the company’s touting of new ‘heat-not-burn’ products and reference to leading an effort to ‘replace’ cigarettes with them. Elsewhere, such products are also reassuringly reported as not ‘cannibalising’ existing cigarette brands in test markets,17 suggesting they are not really seen as substitutes for them any time in the near future. Meanwhile, the industry keeps marketing the same old deadly stuff all over the world. So, we simply cannot count on the tobacco companies to make the endgame happen.

They are getting ready for us to tell them they have to stop. But we have to make them do it. Let’s tell them when this epidemic has to end.

Which country will go first?

Competing interests None declared.

Provenance and peer review Not commissioned; internally peer reviewed.

↵ US Department of Health and Human Services. The health consequences of smoking: 50 years of progress: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.
↵ Malone RE, McDaniel PA, Smith EA. Tobacco control endgames: global initiatives and implications for the UK. Cancer Research UK, 2014. http://wwwcancerresearchukorg/sites/default/files/policy_july2014_fullendgame_reportpdf
↵ Malone RE. Imagining things otherwise: new endgame ideas for tobacco control. Tob Control 2010;19:349–50. doi:10.1136/tc.2010.039727 [FREE Full text]
↵ Smith EA. Questions for a tobacco-free future. Tob Control 2013;22(Supp1 1):i1–2. doi:10.1136/tobaccocontrol-2013-051066 [FREE Full text]
↵ Warner KE. An endgame for tobacco? Tob Control 2013;22(Supp1 1):i3–5. doi:10.1136/tobaccocontrol-2013-050989 [Abstract/FREE Full text]
↵ McDaniel PA, Smith EA, Malone RE. The tobacco endgame: a qualitative review and synthesis. Tob Control 2016;25:594–604. doi:10.1136/tobaccocontrol-2015-052356 [Abstract/FREE Full text]
↵ McDaniel PA, Smith EA, Malone RE. Philip Morris’s Project Sunrise: weakening tobacco control by working with it. Tob Control 2006;15:215–23. doi:10.1136/tc.2005.014977 [Abstract/FREE Full text]
↵ Gartner C, Malone RE. Duelling letters: which one would you sign? Tob Control 2014;25:369–70. Google Scholar
↵ Chung-Hall J, Craig L, Driezen P, et al. Canadian smokers’ support for tobacco endgame strategies: findings from the ITC Canada Survey. Ontario, Canada: ITC Project University of Waterloo, 2016. Google Scholar
↵ Edwards R, Wilson N, Peace J, et al. Support for a tobacco endgame and increased regulation of the tobacco industry among New Zealand smokers: results from a National Survey. Tob Control 2013;22:e86–93. doi:10.1136/tobaccocontrol-2011-050324 [Abstract/FREE Full text]
↵ Wang MP, Wang X, Lam TH, et al. The tobacco endgame in Hong Kong: public support for a total ban on tobacco sales. Tob Control 2015;24: 162–7. doi:10.1136/tobaccocontrol-2013-051092 [Abstract/FREE Full text]
↵ Altria [Parrish S]. Corporate affairs societal alignment/regulation update. 2004. https://wwwindustrydocumentslibraryucsfedu/tobacco/docs/znyv0024
↵ Furman J. Six lessons from the US experience with tobacco taxes. World Bank Conference paper: winning the tax wars: global solutions for developing countries. 2016.
↵ Tavernise S. Black health experts renew fight against menthol cigarettes. New York Times. 13 September 2016. Google Scholar
↵ Maori Affairs Committee. Inquiry into the tobacco industry in Aotearoa and the consequences of tobacco use for Maori. 49th Parliament, New Zealand. 2010.
↵ Arnott D. There’s no single endgame. Tob Control 2013;22(Suppl 1):i38–i9. doi:10.1136/tobaccocontrol-2012-050823 [Abstract/FREE Full text]
↵ Caplinger D. Philip Morris International, Inc’s best move so far this year. The Motley Fool. 2016. http://wwwfoolcom/investing/2016/08/26/philip-morris-international-incs-best-move-in-2016aspx

Toxins Remain in Home Long After Smokers Quit

Toxins from tobacco smoke persists in smokers’ homes for at least six months after they quit and remain a threat to nonsmoking residents, according to researchers.

The team studied 65 smokers who were quit smoking and discovered that tiny particles from burning tobacco get into surfaces such as carpets, wallpaper, ceiling tiles upholstery, clothes, blankets and pillows and were still present long after a smoker quit, The New York Times reported.

There were large immediate declines in nicotine on surfaces and in dust, which then leveled off and remained the same, but still detectable, by the end of the study period, according to the study in the journal Tobacco Control.

And even six months after smokers quit, nonsmokers still in the same home still had detectable levels of a marker of tobacco exposure in their urine after six months, The Times reported.

Hungary regulates cigarette market further

Regulation of electronic cigarettes will further strengthen in Hungary as e-cigarettes and related products are expected to be treated the same as regular tobacco products in Hungary, under a bill Cabinet Chief János Lázár submitted to Parliament Tuesday, according to Hungarian news agency MTI.

If the bill is approved by Parliament, e-cigarettes could only be sold in licensed tobacco shops, the text of the bill says, according to MTI, which apparently means that only national tobacco shops will be eligible to sell such products.

The text of the bill says the regulatory changes aim to reduce smoking in Hungary, especially among the younger generation, while the country is required to comply with certain European Union directives.

The bill Lázár submitted would also abolish a progressive healthcare contribution tobacco companies must pay, after the European Commission expressed concerns in July related to the discriminatory nature of the contribution.

Hungary will soon introduce plain and uniform cigarette packaging and ban the distribution of flavored tobacco products. Under a decree published earlier this week, retailers of e-cigarettes will be required to pay additional fees.

Exposure to e-cigarette vapour induces negligible or no oxidative damage to lung epithelial cells

E-cigarette vapour is much less harmful to lung cells than cigarette smoke. Lab tests show that, unlike tobacco smoke, which causes oxidative stress and cell death, e-cigarette vapour does not. Oxidative stress and cell death are driving factors in the development of many smoking-related diseases such as COPD and lung cancer.

Vapour from e-cigarettes has been found to contain significantly lower levels of the toxicants found in cigarette smoke (Chemical Research in Toxicology DOI: 10.1021/acs.chemrestox.6b00188), but suitable lab tests and clinical studies are necessary to understand whether this translates into reductions in biological responses and disease.

Researchers at British American Tobacco have developed a standardized way of measuring and comparing the potential of conventional cigarette smoke and e-cigarette vapour to cause oxidative stress in an in vitro model of lung epithelium.

To do this they bubbled matched amounts of smoke (from a reference cigarette) or vapour (from Vype ePen or Vype eStick) through cell-growth medium to produce a stock that could be diluted into various concentrations. They then exposed lung epithelial cells to the same concentrations of either smoke or vapour extract and, following exposure, used a panel of commercially available assays to measure and compare the stress responses of the cells.

Lung cells exposed to any of the concentrations of cigarette smoke showed signs of oxidative stress and, at higher doses, cytotoxicity. In stark contrast, vapour from e-cigarettes tested had no such effects, even at the highest concentration.

The research is published in a special edition on e-cigarettes of Toxicology Mechanisms and Methods DOI: 10.1080/15376516.2016.1222473.

Azerbaijan subsidizes tobacco manufacturers

President of Azerbaijan Ilham Aliyev has issued an order on providing state support to development of tobacco-growing.

APA reports that AZN 0.05 will be paid in subsidy to the tobacco manufacturers for each 1 kg of dry tobacco and 10 kg of wet tobacco sold to the processing enterprises.

The subsidy also concern dry and wet tobacco sold to the processing enterprises in 2016.

The Cabinet of Ministers is to approve the rules on paying subsidies to the manufacturers by agreeing with the Azerbaijani President within two months, and the Ministry of Finance is to provide the funding.

Transparency, Yes. Interference, No.

Vera Luiza da Costa e Silva Head of the Secretariat of the WHO FCTC

There was a time when public health discussions on tobacco were an extraordinarily open process. Government officials met a wide range of people and listened to their concerns and ideas as they formulated policy.

Among the “contributors” were representatives of the tobacco industry, which offered assurances about its earnest intentions. The tobacco industry had access to policy-makers and infiltrated public health forums and because everyone involved was open the industry gained access to internal government documents listing a wide range of ways of regulating the industry.

All that changed when courts, particularly in North America, began considering cases from tobacco victims. Judges ordered – as is normal in such matters – that the tobacco industry discloses internal documents to plaintiffs. It became clear that the industry lied when denying the harms caused by their products, disputing scientific findings, and luring millions, including the world’s youth, into addiction, in a drive to build its business.

The publication of this mountain of paperwork (the documents are now numbered in the millions) from the late 20th and early 21st centuries was a watershed moment, providing incontrovertible evidence that the tobacco industry could not be trusted. There was no sign of the earnest partner the industry claimed to be.

Documents show how the industry worked behind the scenes successfully lobbying policy makers to discontinue or water down tobacco control measures. The documents mapped efforts to delay and confound policy initiatives and to create vast new markets in the developing world. They also show how the tobacco industry created or co-opted front groups to defend their interests and used tobacco farmers to prevent governments pushing on with public health policies.

As British American Tobacco’s (BAT) chairman noted in an internal memo in 1990: “We should not be depressed simply because the total free world market appears to be declining… There are areas of strong growth, particularly in Asia and Africa… it is an exciting prospect.”

The revelations kept on coming, including the disclosure that industry research was suppressed or secretly moved to other countries to put material beyond the reach of the courts. Other documents showed how the industry conspired in attempts to raise the proportion of women smokers to the levels of men.

The tobacco industry documents had a significant effect – firstly on the court cases to which they related, but just as importantly in creating a resolution among policy-makers. If the tobacco industry was now a global industry seeking to expand to new markets, the response must be equally global.

The UN Tobacco Control treaty itself, the WHO Framework Convention on Tobacco Control (WHO FCTC), was a response to the transnational nature of the business and the need for a global response to curb the epidemic. It entered into force in 2005 becoming the first global health treaty, an attempt to strongly regulate the trade in this noxious product.

The Convention brought together various government sectors with public health experts, researchers and others in the certainty that unified action was required to counteract the industry’s behaviour. This, we fervently hoped would save millions of lives.

We have been successful in doing so, even as we recognise that the tobacco industry is expanding its markets, placing many more people at risk of premature death.

The tobacco industry is targeting Parties’ delegations attending the world’s largest intergovernmental meeting solely dedicated to tobacco control. At the last Conference of the Parties in 2014, letters were sent representing tobacco industry interests petitioning finance officials on taxation.

We cannot sit at the negotiating table with the people who caused this global disaster because one thing is crystal clear – this industry lies. Publicly it speaks in a mild voice, while behind the scenes it executes policies in absolute opposition to its public statements, ultimately killing one in every two regular users of its products.

So when we meet in Delhi in November for the WHO FCTC’s seventh session of the Conference of the Parties (COP), we will be making documents available, we will be briefing journalists and we will publicize our decisions.

We will also guard against tobacco industry interference, this most untrustworthy of businesses. It would be a dereliction of our duty to do otherwise.

That means some sessions will be held in public and some behind closed doors, normal in international meetings and as provided by the rules of the FCTC Conference of the Parties. We will be as open as possible, but we are not naive. We have learned a critical lesson – this industry can never be trusted and will try to disrupt and confound the tobacco control process.

COP7 will, I believe, send an unequivocal message to the tobacco peddlers. The world understands who you are and what you do, and is determined to stamp out the global plague which you do so much to spread.

Follow Vera Luiza da Costa e Silva on Twitter:

The Real Reason Why E-Cigarettes Can’t Help More American Smokers

Dr. Amy Fairchild Professor of Sociomedical Sciences, Columbia University’s Mailman School of Public Health

Co-Authored by Amy L. Fairchild, Ronald Bayer, and Sharon H. Green

Over the past few years, the chances are high that you have seen fewer smokers and more vapers—that is, people using e-cigarettes. These devices have become ever more popular, but they also have ignited a bitter battle. Remarkably, this dispute has not pitted public health professionals against Big Tobacco flacks, as in decades past. Rather, the fight is playing out among scientists committed to drastically reducing if not eliminating the prevalence of smoking. Traditional cigarettes kill 480,000 Americans each year and will take one billion lives worldwide this century. Scientists around the world are actively debating: What can be done to stop them?

Given the anti-e-cigarette messaging of some influential anti-tobacco groups, many may be surprised to learn that it is increasingly difficult to make a scientific case against e-cigarettes. Last month, a second Cochrane Review—the gold standard when it comes to assessing the state of the evidence on hot topics from salt to fat to smoking—concluded that e-cigarettes may help smokers quit without serious health consequences. The review concluded that of all 24 studies included, not a single one reported serious health risks to vapers from up to two years of e-cigarette use. Like the first review in 2014, this update is guarded, but it also gives an approving nod to 15 currently ongoing randomized trials that are underway.

As the evidence moves in favor of e-cigarettes, this latest report is sure to add fuel to a raging firestorm. This debate highlights two key tensions. First, what do we do in the absence of scientific certainty about all possible harms? This question was at the heart of a furious exchange of letters between scientists over the course of 2014. This feud over e-cigarettes can’t be understood absent the values that animate it.

Framing the position of those who favor e-cigarettes is Michael Russell, a pioneer of smoking cessation methods who famously wrote, “People smoke for nicotine but they die from the tar.” By extension, many scientists argue that e-cigarettes can satisfy nicotine addictions without causing harmful exposures to tar and combustion. They believe e-cigarettes could drastically reduce if not eliminate cigarettes.

This “harm reduction” perspective acknowledges that many smokers cannot or will not quit. Even if e-cigarettes carry some risks, those risks are far less serious than those of smoking. Thus, weighing the risks of e-cigarettes requires a comparison to the well-documented harms of smoking.

On the other side of the debate are those who preach precaution. Until the uncertainty about e-cigarettes is resolved, these devices have no place in a public health anti-tobacco arsenal. And there is uncertainty regarding the harms smokeless products may pose, particularly in the face of unknowns about how the FDA’s new regulatory regime may impact quality control. But even if e-cigarettes may be a better option for any individual smoker who wants to quit but cannot, how might they change the pattern of disease in the long run? The fundamental question, in other words, isn’t how e-cigarettes might help or harm individuals, but whether they will change population-level smoking patterns.

This tension between harm reduction and precaution, then, highlights a second vital question: Whose risk matters?

In 2015, Public Health England, the United Kingdom’s equivalent to the CDC, roiled the waters when it endorsed e-cigarettes for harm reduction. Remarkably, while they drew fire from the Lancet and the British Medical Journal, they received the backing of ASH, a major anti-tobacco NGO with an unimpeachable record of opposition to cigarettes. In 2016, they were also joined by the Royal College of Physicians, which advocated for a harm reduction approach that included not only e-cigarettes but also other forms of smokeless tobacco.

The positions of British organizations that embraced e-cigarettes reflected a long history of support for harm reduction. Also, the UK organizations have focused on populations in immediate, certain danger: smokers themselves.

In the US, in sharp contrast, federal agencies have remained staunchly opposed, not only because of precaution, but also because of a focus on a different population: vulnerable youth and non-smokers. Former FDA commissioner David Kessler and Campaign for Tobacco-Free Kids president Matthew Myers wrote in an op-ed in the New York Times, “we cannot afford to waste more time while the tobacco industry addicts another generation of kids.” For advocates of precaution, protecting populations that haven’t yet been seduced by tobacco has remained paramount. For the non-smoker, an e-cigarette does nothing but increase risk.

Data alone cannot tell us what to do. Interpreting the emerging evidence on e-cigarettes relies on values and priorities: harm reduction or precaution, immediate peril or potential risks. While there can be no question that the public health community must look for emerging scientific data regarding risks and benefits, we must acknowledge the values that animate the controversy. Only then will we be able to reduce the enormous health burden of tobacco.

‘E-cigarettes can reduce burden of smoking-related deaths in India’

Electronic-cigarettes, popularly known as e-cigarettes, provide a third line of option to stay away from harmful effects of tobacco, and can significantly reduce the burden of smoking-related deaths in India, a renowned expert on vaping has said.

“The first line option to shield yourself from the toxicity of tobacco products is to quit smoking altogether and the second line of option is to quit with the help of medication,” Konstantinos Farsalinos, from the University of Patras in Greece, told reporters at an event here.

Farsalinos, who is a research fellow at Onassis Cardiac Surgery Centre, is on a visit to India to interact with Indian medical fraternity and government authorities to share his latest findings on how e-cigarettes have helped millions of Europeans to quit smoking.

“Just as medicines offer a harm reduction technique for diseases or helmets provide bikers harm reduction in case of accidents, e-cigarettes adds a harm reduction option for smokers,” said Farsalinos.

He called upon Indian public health officials and anti-tobacco activists to maintain an open-minded and evidence-based approach, and provide proper education to the society concerning these products.

Use of electronic cigarettes has helped 6.1 million smokers in the European Union to quit smoking, according to a 2014 study that analysed data involving a representative sample of nearly 28,000 Europeans, Farsalinos pointed out.

“India is a country where smoking and harmful tobacco use is thriving. The WHO Global Adult Tobacco Survey (GATS) study found that 34.6 per cent of adults use some form of tobacco, while about one million Indians die annually from smoking-associated disease (2010 data),” Farsalinos said.

“For countries with high prevalence of smoking and harmful smokeless tobacco use (unfortunately snus is virtually non-existent in India), e-cigarettes should be considered a golden opportunity to reduce harm in a cost-effective manner,” he explained.

In November India will be the host to the Seventh Conference of Parties (COP-7) of the Framework Convention on Tobacco Control (FCTC) where public health officials from 180 countries will participate in discussions on Electronic Nicotine Delivery Systems and potentially agree on guidelines for policy and regulation.

The focus of tobacco control community and anti-smoking activists have been on nicotine, which, according to Farsalinos, is misleading because in reality none has ever died from nicotine dependence.

“Disease and death is associated with the vehicle used to deliver nicotine and is caused by the combustion of tobacco,” he noted, adding that e-cigarettes, on the other hand, involves evaporation of a liquid that contains nicotine, thereby reducing the harm associated with conventional cigarettes.

Association between use of flavoured tobacco products and quit behaviours

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