May 25 Seminars

Regarding e-cigarettes, most US health organizations, media coverage, and policymakers focus on risks to youth. Due to their messaging, much of the public – including smokers – incorrectly consider vaping as dangerous as smoking. Policies intended to reduce adolescent vaping may also reduce adult smokers’ use of e-cigarettes in quit attempts. Because evidence indicates that e-cigarette use can increase the odds of quitting smoking, the health community, media, and policymakers should more carefully weigh vaping’s potential to reduce adult smoking-attributable mortality. This presentation provides an overview of the health risks of e-cigarette use, the likelihood that vaping increases smoking cessation, concerns about youth vaping, and the need to balance valid concerns about risks to youth with the potential benefits of increasing adult smoking cessation.

Prof Neal Benowitz will explore the current scientific evidence on the safety and health effects of e-cigarettes, including: 1) The nature of cigarette toxicity and health impact 2) Potential toxic exposures from E-cigarettes; comparison to cigarettes 3) The differences by e-cigarette device characteristics 4) long term safety of nicotine 5) Toxicity concerns with flavors. Alongside this summary of the e-cigarette health hazards to date, this session will explore the challenges and unmet needs in epidemiology studies including Animal vs human epidemiology and finally consider the Regulatory implications related to e-cigarette safety.

The evidence on the use of e-cigarettes to help adults who smoke quit combustible tobacco is growing year on year. Cochrane reviews are accepted as the gold-standard for investigating the evidence of potential harms and benefits of healthcare interventions. This talk will cover the most recent evidence from the Cochrane living systematic review of e-cigarettes for smoking cessation, highlighting gaps in the evidence as well as areas where certainty is growing. It will also cover other, non-Cochrane evidence, evaluating strengths and weaknesses of the different evidence available, and exploring where research might best serve to move the conversation forward.

2020 was a year like no other.  The COVID-19 pandemic affected everyone but especially challenged health care systems.  The social unrest of the “Black Lives Matter” movement led health care systems to increase focus on reducing causes of health disparities and addressing institutional racism.  New research on e-cigarettes and clinical guidelines on tobacco treatment continued to appear but may have been overlooked by distracted clinicians.  After a year like no other, what might a typical U.S. clinician caring for adults be thinking about smoking cessation and e-cigarette use?  Health care systems remain a key conduit for delivering the tobacco cessation and harm reduction treatments needed to reduce tobacco-related morbidity and mortality. This presentation will consider the unprecedented events of 2020—and clinicians’ and health care systems’ responses to them – in order to reflect on opportunities and challenges that might affect the delivery of tobacco cessation treatment to U.S. adults.

Session Responder:  Dr Jasjit S. Ahluwalia, Professor, Behavioural and Social Sciences & Internal Medicine, Brown University, School of Public Health & Alpert School of Medicine

• Does current US Policy and discourse reflect the evidence on safety and current prevalence of e-cigarette use
• Are smokers inappropriately discouraged from trying e-cigarettes
• Have we achieved a point where we can accurately say “E-cigarettes are less harmful than combustible tobacco and are effective for smoking cessation”?
  

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Globally, tobacco control researchers, policy makers, advocates etc are passionate and often united in working towards ending the smoking epidemic,  though we choose to take different paths to achieve this ambition. The UK has taken a compassionate approach to vaping, including for groups for whom there is a very high smoking prevalence, such as people who experience mental health problems, misuse substances and those who experience homelessness. However this approach is also evidence based as e-cigarettes have been shown to be beneficial at an overall population level, particularly if youth uptake is constrained. This presentation will discuss why it has been appropriate for England to take a population level approach, as well as a focus on high risk groups at an individual level, to reducing smoking and hence to vaping regulation. It will also give a more personal reflection on responses to nicotine use in society.

The tobacco marketplace has changed with the introduction of new nicotine delivery devices. While the public health community has been addressing the dramatic increase of e-cigarette use among youth, FDA recently conducted qualitative research with adult smokers to ascertain their current attitudes and beliefs about cigarettes and other tobacco products. Focus group findings underscore that quitting cigarettes remains difficult. Smokers are often navigating multiple barriers to quitting, including stressors, perceived benefits of smoking, and persistent misperceptions about nicotine and addiction. Findings also revealed an increase in the belief that reducing use is an effective strategy for cessation, and there is low motivation among smokers to abstain from nicotine. While large-scale mass media campaigns and public health cigarette education efforts have contributed to reductions in prevalence rates, an opportunity remains to further educate and address these misperceptions to support long-term cessation. 

Stigmatizing smoking has been at the heart of tobacco control efforts for decades, which may drive more people to quit but at the same time potentially create new difficulties for smokers, including self-isolation, creation of social groups that might become ‘hardened’ to changing smoking behaviors, and perceptions by the user and society that complete abstinence is the only option.  The stigma associated with a wide variety of behaviors has impeded progress toward improving population health in some cases, such as the reticence in making products and services available that could reduce the risk of communicable disease (eg needle exchanges), as well as harm reduction products that could benefit users and society when an individual addicted to a substance is not able to or chooses not to become completely abstinent (eg NRT, ENDS, smokeless tobacco).  This presentation will explore some of the conflicting aspects of stigma in tobacco control, explore similarities and differences regarding the stigma of using of different addicting substances, and consider some research, practice and policy directions.

The recent commentary ‘It is Time to Act with Integrity and End the Internecine Warfare Over E-Cigarettes’ addresses the need to achieve a lifesaving rapprochement between the tobacco control mainstream and the tobacco harm reduction community. Failure to end the warfare and reinstate fealty to good science risks millions of additional premature, smoking-related deaths that could otherwise have been prevented. Numerous instances of the undermining of science, and the scientists behind the science, threaten to impede the objective of furthering the development and dissemination of credible evidence and bringing together the major stakeholders for reconciliation and to join in common cause in this vital endeavour. Protecting youth and supporting adults can and must be achieved simultaneously. We must also listen to the pleas of consumers, many from marginalized communities, who have lived experience as smokers who have transitioned off lethal smoked products with the aid of alternative nicotine-containing products and whose voices have been wrongly ignored, distrusted, rejected, and too often dismissed as serving the interests of the “tobacco industry.”

As the debate unfolds on how best to prevent adolescents from using electronic cigarettes, we have lost sight of their potential for harm reduction in adult smokers. Despite decades of availability of evidence-based smoking cessation medications, many adults continue to smoke. In some populations, such as people with COPD, mental health diagnoses or HIV infection, rates of smoking remain 2-3 times that of the general population. I will discuss what we know about using electronic cigarettes for harm reduction in specific populations, as well as where we need additional information.

How do we end the toxic culture that has emerged?

In early 2020 the FDA finalized its enforcement policy on unauthorized flavored cartridge-based e-cigarettes, such as fruit and mint.  Consistent with this policy, the JUUL vaping brand removed all cartridge flavors other than menthol and tobacco from the market.  In this presentation I present national, U.S. data on adolescent e-cigarette use and attitudes before and after these restrictions on flavored cartridges.  Outcomes include e-cigarette prevalence, perceived availability of flavored e-cigarettes, as well as changes in use of JUUL and other vaping brands.  The presentation concludes with an assessment of the current state of the evidence on flavors and adolescent use of e-cigarettes and avenues for future investigation.

A myriad of studies find that tobacco control policies targeting e-cigarettes can increase combustible tobacco use, presumably by reducing incentives to choose vaping over smoking. Given evidence that vaping nicotine is likely far less harmful than smoking combustible cigarettes, these unintended consequences may translate into substantial costs for population health. This presentation will summarize published work on such policies’ intended and unintended effects, present new results estimating effects of banning flavored tobacco product sales, and discuss implications for tobacco control going forward.

This study demonstrates that when controlling for more potential covariates, the strong and positive relationship between vaping by adolescent never smokers and subsequent trial of cigarettes decreases steadily. Using longitudinal data from PATH on U.S. adolescents, ours is the first study to control for both use of other tobacco products and other drugs (marijuana and alcohol in our case), along with commonly included variables. Using earlier waves of PATH data, we report reduced associations between vaping and subsequent smoking, adjusting for these covariates. This association became non-significant when we analyzed the two most recent waves of PATH, wave 4 and wave 4.5. Our study provides empirical evidence that raises questions about the strength of the relationship between youth vaping and subsequent trial of cigarettes.

Adolescents who are frequent users of multiple substances such as alcohol, marijuana, and cigarettes are at significantly higher risk of negative mental, physical, and substance use outcomes in adulthood, but studies often fail to focus on poly substance use, especially among younger adolescents. Dr. Pearson will present recent Youth Risk Behavior Survey data from adolescents ages 11-13 and 14-18 in Nevada, examining patterns of recent poly substance use that account for use of cigarettes, e-cigarettes, alcohol, marijuana, and non-prescription pain medication, and their correlations with mental distress and risk and protective factors that offer potential targets to reduce the prevalence of the riskiest poly substance use patterns.

As a new researcher focused on eliminating health disparities, particularly death and disease from combustible tobacco use, how should I feel about tobacco harm reduction?  Working in tobacco control in an area with higher than average smoking prevalence, much of the current tobacco control agenda is focussed on preventing youth vaping. I find that I have more questions than answers: Should our focus be on nicotine addiction or combustible use? Is youth vaping similar to youth marijuana use – an experimental phase that will pass? What is the endgame?

• Are we protecting kids or just the “right kind” of kids?
• Can we de-couple the concern over youth initiation from the concern that youth vaping is a gateway to youth smoking
• Is youth abstinence more important than adult cessation to achieve a smoke free future
• Youth use and surveillance – are we asking the right questions and how can this be improved
  

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