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The tobacco industry is taking advantage of a rare and unprecedented marketing opportunity being offered to it by none other than the anti-tobacco movement. Based solely on statements made by tobacco control organizations, Big Tobacco (@BigTobaccoUS) is urging America's 12 million vapers (3 million of whom do not use cigarettes at all) to return exclusively to smoking in order to protect their health.

Cleverly, Big Tobacco is not making any statements of its own. It is simply relying on statements already made by anti-tobacco groups. For example, Big Tobacco stated: "Most public health experts agree that vaping is dangerous and you're better off if you keep smoking. We share their opinions."

To support its claims, Big Tobacco cited a Twitter headline from Clear Way Minnesota, which said: "Switching from vaping to smoking does reduce your carcinogens."

It would be absurd to think that Big Tobacco, in 2019, would have the gall to make such a preposterous claim -- that switching from vaping to smoking will improve a person's health. But Big Tobacco isn't directly making that claim. They are simply repeating statements made by supposedly anti-smoking organizations.

The statements being made by Big Tobacco are also being supported by policy decisions announced in recent months by city councils and boards of health throughout the country. For example, the city of San Francisco recently banned the sale of e-cigarettes, while allowing Marlboros to stay on the shelves. The town of Brookline, Massachusetts recently banned the sale of nearly all e-cigarettes, while allowing the majority of cigarette brands to remain on the shelves. Similar laws have been enacted by at least 26 other cities and towns.

The Rest of the Story had an exclusive opportunity to interview a spokesperson for Big Tobacco. Here is a transcript of the interview:

Siegel: Thanks for taking the time to speak with me today. I have to just start by asking: Did you ever dream that one day, groups that you thought were anti-smoking organizations would be promoting smoking over a much safer, fierce competitor to your combustible products?

Big Tobacco: Never. We really believed, deep in our hearts, that anti-smoking groups were our enemies. Our opponents. Naturally ... they were calling themselves anti-smoking groups. So we assumed that they would be doing everything in their power to discourage people from smoking and to emphasize the severe health effects of cigarette smoking, effects that even we now acknowledge. It never occurred to us that these "anti-smoking" groups would one day be promoting laws to pull all of our competition off the shelves and allow our most toxic products - our combustible cigarettes - to remain on the market. This is a dream come true. And frankly, some days I wake up and think that I am dreaming.

Siegel: For years, the anti-smoking groups complained and attacked you for not doing anything to make your products safer. They condemned you for not doing any research on how to make a safer product. Now that you have actually gotten into the business of selling a much safer product (e-cigarettes), they immediately take that product off the shelves and force you to only sell your most toxic combustible product. Does that make any sense to you?

Big Tobacco: Not at all. We had recently announced plans to start converting our U.S. business portfolio from our most toxic products - the combustibles - to a range of vaping products, which are much safer and we assumed over time would become more and more popular. Based on the popularity of vaping products and statistics on the unprecedented number of people who were quitting smoking using these alternative products, market analysts were predicting that within about two to three decades, we would literally cut cigarette consumption in half. So much for that! We can now go back to business as usual: we'll actually be adding more Marlboro rolling machines, something that wasn't in our long-range business plan because we made the apparently errant assumption that the anti-smoking groups would actually want to see a lowering of cigarette consumption.

Siegel: The City Attorney of San Francisco and the Board of Supervisors said that they were standing up to Big Tobacco when they enacted a law that bans the sale of all e-cigarettes. I assume that your stock prices must have tumbled since then. How are you coping with those huge financial losses?

Big Tobacco: Oh, no, that's not what happened at all. From the day the mayor of San Francisco signed the ordinance, our stock has risen from $47.35 to $49.54. A consensus of the major analysts now rate us as a "Strong Buy."

Siegel: Ok. Well we've talked about your competition from vaping products, which have now been taken off the market or severely restricted in many cities. Let's talk now about your competition from other cigarette brands. Although your Marlboro brand has always been #1, Newport has long been your chief competitor at #2. What are your plans to decrease that competition and further improve your market position?

Big Tobacco: We have none.

Siegel: You have none! How could you possibly have no plans to help fight off competition from Newport cigarettes?

Big Tobacco: Well, we don't have to make any plans because the anti-smoking groups are doing all of that work for us. You are not going to believe this, but our so-called enemies are promoting ordinances and state laws throughout the country that essentially ban the sale of Newport cigarettes while allowing Marlboro cigarettes to remain on the shelves, unfettered and untouched. 

Siegel: Wait a second. You have me here. Why ban one cigarette brand but not another one that is equally dangerous?

Big Tobacco: They have somehow got it into their minds that Newport cigarettes - which have menthol - are a much greater threat to the public's health than Marlboro cigarettes ... [laughing] ... [laughing] ... [choking] ... So the Newports are coming off all the shelves and the Marlboros are staying put [laughing] ... And the irony is that for years, the anti-smoking groups attacked us for even insinuating that one cigarette brand was safer than another. Now those same groups are telling policy makers throughout the country that some cigarettes are safer than others. And we got the long end of the stick! [laughing almost out of control]. No pun intended.

Siegel: The "anti-smoking" groups are claiming that vaping is as dangerous as smoking. Now, how many people does smoking kill every year?

Big Tobacco: We no longer make up our own estimates. We now really on public health authorities. They estimate the number to be around 400,000.

Siegel: So I take it that vaping also kills around 400,000 people each year.

Big Tobacco: Not quite that many.

Siegel: Well then how many exactly?

Big Tobacco: So far zero.

Siegel: Well that doesn't seem possible. The anti-smoking groups, especially the American Lung Association, say that vaping causes popcorn lung. That is a rapidly progressive and fatal disease. With 12 million vapers in the United States, the product on the market for 13 years, and such a high risk of popcorn lung, there must be thousands of cases by now.

Big Tobacco: [laughing] ... Actually... [laughing] ... not a one!

Siegel: But a researcher at Harvard Medical School stated, and I'm quoting here, "Vaping can cause something called bronchiolitis obliterans, or popcorn lung."

Big Tobacco: [snicker] ... Not a one.

Siegel: Ok. But a physician and researcher from the University of North Carolina School of Medicine stated, and I'm again quoting here, "Yes, vaping can cause popcorn lung. The first thing to understand is that vape juice flavorings are not designed to be inhaled; they’re designed to be eaten. So these flavorings, when inhaled at higher temperatures, can be toxic to the lungs and cause damage, including the possibility of popcorn lung."

Big Tobacco: Not a one.

Siegel: And a specialist in substance abuse prevention stated, again I'm quoting, "The one thing we do know for sure in terms of long-term effects is that those who vape long term develop popcorn lung."

Big Tobacco: They're lying. Believe me, we know all about lying. We did it for years. And the anti-smoking groups attacked us for it. Even took us to federal court.

Siegel: Well that seems quite hypocritical of them.

Big Tobacco: If you say so.

Siegel: Let's talk for a minute about cancer risk. Tobacco smoke has more than 10,000 chemicals including more than 60 known human carcinogens. One carcinogen - formaldehyde - has been found to be present in some brands of e-cigarettes, although your own Mark Ten brand did not contain any detectable formaldehyde. How in your right mind could you possibly claim that vaping poses a greater carcinogenic risk than smoking?

Big Tobacco: Oh, simple. We're not the ones making that claim. That statement was made by researchers at Portland State University. And we are in no position to contest a conclusion made by academicians at a reputable university. If I recall correctly, and it's been a while, their exact statement was that "If we assume that inhaling formaldehyde-releasing agents carries the same risk per unit of formaldehyde as the risk associated with inhaling gaseous formaldehyde, then long-term vaping is associated with an incremental lifetime cancer risk of 4.2×10−3. This risk is 5 times as high ... or even 15 times as high ... as the risk associated with long-term smoking."

Siegel: Well if vaping poses a 15 times higher risk of cancer than long-term smoking, why would anyone in their right mind quit smoking by switching to vaping? And wouldn't ex-smokers who did quit smoking successfully by switching to vaping want to immediately go back to smoking?

Big Tobacco: That's precisely what the "anti-smoking" groups are telling them.

Siegel: Ok, one last question. The tobacco industry has a long history of reaching out to various groups to develop allies, or "friends" as you may call them. You had the Tobacco Institute, the National Smokers' Alliance, I can't recall the others. Who are your current allies?

Big Tobacco: There are a large number of groups that are working to promote laws that get rid of vaping products and leave retail stores with cigarettes as the only available nicotine product. The American Lung Association, the American Cancer Society, and the American Heart Association come to mind.

Siegel: Whoa. I thought those were anti-smoking groups. In fact, I spent two decades working closely with all 3 of those groups to pass smoke-free bar and restaurant laws throughout the country.

Big Tobacco: Yeah we know. You're in our files. Well, we now refer to those groups as our Marketing Department ... [laughs] ... Heck, with enemies like that, we really don't need friends.

Siegel: Thank you for taking the time to provide me with this exclusive interview.
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Prompted by the statements of anti-tobacco groups throughout the country claiming that vaping causes popcorn lung, a new organization was launched this past Thursday to confront this new and alarming epidemic among young people. The organization is called the American Popcorn Lung Association (APLA) and it has a Twitter feed (@LungPopcorn).

"Popcorn lung" is a serious, progressive lung disease that is technically known as bronchiolitis obliterans. The disease results in obstruction of the smallest airways in the lung. The disease is irreversible and can be fatal. A lung transplant is the only definitive treatment. The most common cause of popcorn lung is inflammation following a lung transplant. But it has also been associated with exposure to toxic fumes, especially with extremely high exposure to the chemical diacetyl, which occurred in a group of popcorn factory workers (hence the name popcorn lung).

Popcorn lung is a very rare disease. Smoking is not recognized as a cause of popcorn lung and the disease is not observed in smokers (in the absence of other risk factors such as lung transplant).

The Rest of the Story

Despite the presence of electronic cigarettes on the U.S. market for 13 years and despite the fact that there are literally millions of vapers, there has never been a confirmed case of popcorn lung occurring in a vaper. The annual incidence of popcorn lung among electronic cigarette users between 2007 and 2018 was 0.0 per 100,000. The current prevalence of popcorn lung among current (past month) vapers (as of the end of 2018) was 0.0%.

Despite the complete absence of a single case of popcorn lung having been caused by vaping, the American Popcorn Lung Association is hard at work trying to discourage smokers from trying to quit smoking using e-cigarettes because of what it says is the severe risk of developing popcorn lung from vaping.

When asked to defend its statement that vaping can cause popcorn lung--even though there has never been such a case and even though smoking itself is not a cause of popcorn lung--a spokesperson for the American Popcorn Lung Association told The Rest of the Story that there is solid evidence that vaping causes popcorn lung because e-cigarette aerosol has been found to contain small amounts of diacetyl, 750 times lower than what is present in cigarette smoke, which is not a cause of popcorn lung.

The spokesperson referred me to multiple statements of anti-tobacco organizations and some physicians, including statements by, or quotes from researchers or staff at, the following:

Despite the absence of even a single case of popcorn lung in a vaper, APLA insisted that vaping has been demonstrated to cause popcorn lung, citing the current website of the American Lung Association, which contains an article whose headline states: "Popcorn Lung: A Dangerous Risk of Flavored E-Cigarettes."

APLA also pointed to a statement of Dr. Jonathan Winickoff, a physician and researcher at Harvard Medical School, who was quoted as stating: "Vaping can cause something called bronchiolitis obliterans, or popcorn lung."

In addition, APLA pointed to a University of North Carolina School of Medicine statement by Dr. Adam Goldstein that leaves no room for doubt: "Yes, vaping can cause popcorn lung. The first thing to understand is that vape juice flavorings are not designed to be inhaled; they’re designed to be eaten. So these flavorings, when inhaled at higher temperatures, can be toxic to the lungs and cause damage, including the possibility of popcorn lung."

APLA also cited what is perhaps the most definitive statement about the link between vaping and popcorn lung, made by a Rhode Island substance abuse prevention advocate: "The one thing we do know for sure in terms of long-term effects is that those who vape long term develop popcorn lung. Popcorn lung was first seen in popcorn plant workers who developed it from the chemicals in the butter flavor of popcorn. Popcorn lung is irreversible. Once you get it, there is no treatment to reverse it. Earlier diagnosis is better, but the longer you’re vaping … the worse it is. The only way to prevent popcorn lung is not to do it – no Juuling, no vaping."

Although I am still skeptical about the link between vaping and popcorn lung due to the fact that even lifelong, heavy tobacco smoke exposure has not been associated with the development of popcorn lung and not a single case has been confirmed in a vaper, the American Popcorn Lung Association convinced me not to worry, telling me that anti-vaping organizations throughout the country are working hard to produce evidence that vaping does cause popcorn lung. The spokesperson referred me to a recent statement by the American Lung Association, ensuring that: "Scientists have been working hard to debunk the belief that e-cigarettes are less harmful than traditional cigarettes." APLA pointed out that "among those harms is the dreaded POPCORN LUNG."

Last Friday, APLA reassured potential donors who may be skeptical about giving money to prevent a disease that does not exist: "We are taking time out from our busy schedule (assembling our professional team of popcorn lung experts and developing our strategy), to update you on the latest epidemiological research into the popcorn lung epidemic. Still no cases but we know they're out there."

A spokesperson for the newly created, multi-million dollar national organization called the "Campaign for Popcorn Lung-Free Kids" told The Rest of the Story that: "The precautionary principle is the foundation of public health. It is entirely appropriate for the American Popcorn Lung Association to advocate against a disease that does not exist. In fact, we would argue that is the ultimate in precaution."

The American Non-Vapers' Rights Association took it a step further. Their spokesperson told me they are concerned that secondhand exposure to vaping aerosol could increase a bystander's risk of developing popcorn lung, especially if the flavor being used is Juul's youth-friendly, highly popular cotton candy-flavored e-liquid. 

Just as we were about to achieve a nicotine-free generation, do you want to see that undermined by an epidemic of kids developing popcorn lung? If, like me, you want to do something about the popcorn lung epidemic, I urge you to follow my example and join the American Popcorn Lung Association.
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A July 11 column by the American Nonsmokers' Rights Foundation (ANRF) is entitled "Big Tobacco Lies. So Does Juul." A large image shows a graduating college student with the quote: "We were literally going to be the first generation not addicted to nicotine. And then they made it taste like cotton candy and everyone is vaping and ADDICTED to nicotine."

The Rest of the Story

The headline should more appropriately say: "Big Tobacco Lies. So Does Juul. And So Does the American Nonsmokers' Rights Foundation."

ANRF is lying here because they are implying that Juul created cotton candy-flavored e-cigarettes which have attracted youth and gotten large numbers of them addicted to nicotine. However, there's just one problem with that assertion ...

... Juul does not make cotton candy-flavored pods.

The truth is that it is not cotton candy-flavored products that have gotten youth addicted to vaping. In fact, the cotton candy products are not particularly addictive, and if youth were actually using cotton candy vapes, they would most likely not be addicted to nicotine.

Moreover, the cotton candy flavors are not manufactured by either Juul or by any tobacco company.

It is also not true that the generation of students graduating from college now was going to be the first generation not addicted to nicotine. The prevalence of current smoking in 12th grade among this year's college graduating class was approximately 11%. While that's obviously much better than in the past, it is hardly a generation that is not addicted to nicotine.

So why is ANRF lying? Well, I guess it is more alarming and makes for a more shocking story to try to fool the public into thinking that Juul is targeting kids with cotton candy flavoring, and that deception helps with donations to the organization. Heck, if Juul was enticing kids with cotton candy e-liquids, I would donate because that is so obviously an attempt to appeal to youth.

It's a more shocking story, but it's not true. And I don't believe that the ends justifies the means. Lying in an effort to enhance the story to solicit more donations is not justified. Especially in a column that is criticizing the tobacco industry and Juul for ...
... lying!
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An article published recently by the American Lung Association claims that vaping causes popcorn lung and COPD. There is no evidence to support either of these assertions. In fact, I'm not aware of a single case of either popcorn lung or COPD that has ever been diagnosed in a vaper without a history of cigarette smoking. Even active smoking itself is not associated with popcorn lung, and cigarette smoke contains about 750 times the amount of diacetyl (the putative cause of popcorn lung) than e-cigarette aerosol. So the American Lung Association is lying about the health risks of vaping.

The Rest of the Story

However, that's not what this commentary is about. This commentary is about something very interesting that the American Lung Association inadvertently revealed about the way they think about science.

In the very first sentence of the article, the American Lung Association writes: "Scientists have been working hard to debunk the belief that e-cigarettes are less harmful than traditional cigarettes."

So this is how the American Lung Association thinks about science? According to them, scientists are not doing objective research to compare the health effects of vaping and smoking. Instead, they have come up with a pre-determined conclusion that vaping is more dangerous than smoking and they are frantically trying to come up with evidence to prove that conclusion. The truth, of course, is that there is no legitimate scientific debate about whether vaping is less harmful than smoking. It is much safer and no credible scientist can deny that based on a multitude of evidence.

So what the American Lung Association is basically saying is tantamount to its stating that "Scientists have been working hard to debunk the belief that global warming exists."

It's obvious that the writers of this article didn't think about what they were writing very carefully. So what we were left with is a revelation of the true thinking of the American Lung Association. Apparently, their true thinking is that they want to be able to claim that vaping is more dangerous than smoking, they have come to a pre-determined conclusion that vaping is more dangerous than smoking, and now they are hoping that scientists will somehow come up with evidence that vaping is more harmful than smoking.

This is no less damaging and no less unethical than the behavior of groups that are denying global warming or claiming that vaccines cause autism.

This is painful for me to watch because I have a long history of working with and for the American Lung Association and have many dear colleagues with whom I have worked over the years, especially in the movement to achieve smoke-free workplaces, bars, and restaurants.

Sadly, the scientific integrity of the American Lung Association has apparently deteriorated to the point that they have become just another denialist organization - like the global warming deniers or anti-vaxxers. Their actions are completely undermining the public's appreciation of the severe health hazards associated with smoking, something I worked for decades with the American Lung Association to achieve.
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This Tuesday, the San Francisco Board of Supervisors is scheduled to vote on a proposed ordinance that would ban the sale of cigarettes, cigars, and marijuana in the city until the FDA conducts a safety review of these products.

The impetus for the proposed ordinance was new data showing that a large proportion of San Francisco youths are still smoking, that tobacco companies are now marketing flavored cigars, and that the use of marijuana may even be increasing, especially with the recent legalization of recreational marijuana use. The city attorney explained that: "The epidemic is real. It needed attention. We felt it was necessary to step in and make sure we were protecting young people on our streets." He criticized the FDA for not properly vetting cigarettes, cigars, and marijuana and failing to test the safety of these products, saying that the federal government "abdicated" its responsibility and therefore, the city "had to step in."

The supervisor who introduced the ordinance told The Rest of the Story that: "there are strong indications that marijuana actually alters receptors in the brain, making youth more susceptible to addiction." He called marijuana a "gateway" to harder drugs, citing evidence that youth who use marijuana are more likely to initiate the use of other drugs, including cigarettes, inhalants, stimulants, and even opiates. He cited a recent statement from the National Institute on Drug Abuse (NIDA) that "underscore[s] the need for effective prevention to reduce adolescent use of ... tobacco and marijuana in order to turn back the heroin and opioid epidemic and to reduce burdens of addiction in this country."

One supporter of the ordinance, a professor at UCSF, warned that: "According to data from the Monitoring the Future study, the use of marijuana among teens has reached epidemic proportions. In 2018, a whopping 36% of high school seniors reported using marijuana in the past year. This is a 50% increase from the level in 1991, which was just 24%." He also noted that in 2018, the prevalence of smoking among high school seniors was still 8%, despite decades of anti-smoking campaigns. During the same year, 9% of high school seniors reported smoking flavored little cigars in the past year. In its testimony before the Board of Supervisors, the cancer society in San Francisco cited a statement from the Truth Initiative that: "The use of flavors in cigar products, including little cigars and cigarillos, may play a role in leading youth and young adults to believe that they are less harmful than cigarettes."

According to a spokesperson for the local lung association, "there are numerous flavored marijuana products on the market in San Francisco that are clearly designed to appeal to young people." A review of the menu offered at one San Francisco pot shop -- Urban Pharm on 10th Street in the SOMA district -- revealed a variety of kid-friendly flavors including "super fruit," "jelly roll," "slurricane," "sugar cookies," "sundae driver," "chocolate chip cookies," "orange soda," and "watermelon zkittlez."

The Campaign for Marijuana-Free Kids, in testimony before the Board of Supervisors, asked how supervisors could possibly not think that flavors like watermelon Skittles, slurry, chocolate chip cookie, and jelly roll are targeted at youth. "Prohibiting marijuana products in kid-friendly flavors is one of the most important actions we can take to reverse the youth marijuana epidemic and continue reducing youth marijuana use."

The UCSF professor was quoted as stating that: "The FDA is complicit in allowing this epidemic to develop. Other cities and states should follow San Francisco’s lead: pass comprehensive flavor bans, followed by legislation to prohibit the sales of cigarettes, cigars, and marijuana products until they are properly assessed by FDA."

The San Francisco city attorney noted that smoking kills more than 400,000 Americans each year, saying: "Young people have almost indiscriminate access to a product that shouldn’t even be on the market. Because the FDA hasn’t acted, it’s unfortunately falling to states and localities to step into the breach." He also praised the city's supervisors for making San Francisco a national leader in the effort to confront cigarette use, which is the leading cause of preventable death in the nation. "San Francisco has never been afraid to lead. That will always be the case when the health of our children is on the line. I want to thank the Board of Supervisors for taking this pioneering step to protect our youth. This temporary moratorium wouldn’t be necessary if the federal government had done its job. Cigarettes are a product that should not be allowed on the market without FDA review. For some reason, the FDA has so far refused to act. If the federal government is not going to act to protect our kids, San Francisco will."

According to the website of the office of the city attorney: "Tobacco use is the leading cause of preventable disease and death in the United States. Tobacco kills more than 480,000 people a year in this country. That’s more than AIDS, alcohol, car accidents, illegal drugs, murders and suicides combined."

Many small businesses in San Francisco, including marijuana dispensaries, convenience stores, and smoke shops complained that if enacted, this law will severely hurt their sales. The owner of "Store 420" on Powell Street couldn't understand why sales of cigars and marijuana had to be completely banned, rather than just restricting them to stores that do not allow minors. "We have strict age verification procedures and I can tell you that we only sell marijuana products to adults. Why does our business have to be sacrificed to protect kids from a product that - while it may be addictive - does not cause any severe acute health effects and it's not even clear that it causes serious long-term health consequences either?"

But the city attorney took issue with the stores' calling this policy a "ban," saying: "This legislation takes a reasoned approach. It doesn’t ban cigarettes, cigars, or marijuana outright. It simply says that a product can’t be sold in San Francisco until it receives FDA approval. That’s just common sense. If Philip Morris or any company like it wants to sell their product in San Francisco, they should apply to the FDA today for review. If their product really has some kind of psychological benefit to adult smokers, as they claim, rather than a lure to addict another generation, they have the opportunity to get certified before this legislation takes effect."

CORRECTION (June 22, 2019 - 12:55 pm EDT): I have just been informed that I didn't get the story quite correct. Cigarettes, cigars, and marijuana products are all being allowed to stay on the shelves with no regulation at all, regardless of scientific evidence regarding their serious health hazards, their widespread use among youth, and the targeting of youth by flavors like "slurry" and "jelly roll" that are intended to appeal to youth. Instead, the Board of Supervisors is banning the sale of fake cigarettes (i.e., electronic cigarettes) that contain no tobacco, involve no combustion, and have been demonstrated to be much safer than cigarettes and which also have been used by more than 2.5 million Americans to successfully quit smoking completely. I apologize for this error.
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Philip Morris - the nation's largest cigarette manufacturer - is about to land a huge legislative gift from the most unlikely of sources: the San Francisco Board of Supervisors.

Earlier today, the Board approved an ordinance that will ban the sale of all electronic cigarettes in the city, including both brick-and-mortar and online sales. Before it becomes law, the ordinance is subject to a final vote, which is expected to take place next week.

The Philip Morris USA cigarette company could not have dreamed for a more favorable legislative gift from the city of San Francisco. Right now, the chief competitor to the sale of the company's deadly cigarettes is vaping products, which are today the most widely used and most effective product for smoking cessation. In fact, there are at least 2.5 million ex-smokers in the United States who have successfully quit smoking using e-cigarettes and who remain dependent on the availability of these products to stay off cigarettes. However, in San Francisco, unless the Board reverses its decision, these products will soon be taken off the market.

Absurdly, the San Francisco Board of Supervisors is allowing the continued, unfettered sale of real cigarettes -- the ones that kill more than 400,000 Americans (including more than 40,000 Californians) each year. The nation's leading brand of cigarettes - which is literally the #1 cause of preventable death in the country - is Marlboro. Due to a giant exemption in the ordinance, Philip Morris will be able to continue selling its deadly Marlboros thanks to the hospitality being shown to the company by the San Francisco Board of Supervisors, which is, ironically, requiring e-cigarettes to gain FDA approval before being sold in the city but not requiring any further assessment or regulation of the safety of Marlboros and other combustible cigarettes.

From a public health perspective, this is the most insane piece of legislation I have ever seen. The Board of Supervisors apparently thinks that it is in the interest of the public's health to ban much safer e-cigarettes while allowing deadly cigarettes to remain on the shelves.

The San Francisco City Attorney argued that e-cigarettes are "a product that shouldn't even be on the market." So let's get his reasoning straight. He is saying that e-cigarettes shouldn't even be on the market, but cigarettes should! This is contrary to every public health principle in the book. We aim to help the public make healthier choices. Forcing them to consume the most deadly and toxic consumer product on the market is the last thing in the world that any policy maker concerned about public health should be doing.

There is no question that this ordinance will result in the deaths of a large number of ex-smokers in the city, who will almost certainly return to cigarette smoking when their vaping products are no longer available. It will be far easier for them to just pick up a pack of Marlboros then to cross the Bay Bridge, the Golden Gate Bridge, or venture down into Daly City to locate a store that sells the e-cigarettes upon which they are currently relying to stay smoke-free. The ordinance will also deter thousands of smokers from trying to quit smoking using e-cigarettes, since the absence of vaping products on convenience store and gas station shelves will leave the market wide open for Marlboro and Camel to retain their current customers, with little threat of losing those customers to the much safer alternative of vaping.

Sadly, the Board of Supervisors has been misled by a campaign of misinformation. They have been told that e-cigarettes are deadly - that they increase the risk of heart attacks and stroke. The truth is that there is no evidence to support this claim. In fact, data from the National Health Interview Survey demonstrate that among nonsmokers, vaping is not associated with any increase in the risk of cardiovascular disease.

The data that supporters of the e-cigarette ban are citing to buttress their claim that vaping causes heart attacks is actually from a cross-sectional study which shows an association with people reporting ever having had a heart attack and currently vaping. But the explanation for this association is quite simple: when people have a heart attack, they are highly motivated to quit smoking. Many of them switch to vaping, and that is why there are so many former smokers with a history of a heart attack who now vape.

Supporters of the ban also claim that vaping leads youth to start smoking. There is no scientific evidence to support this claim. In fact, the truth is exactly the opposite. Youths who become regular vapers are much less likely to start smoking. Talk to any kid who Juuls. They will tell you that smoking is disgusting and that they wouldn't even think of it. In fact, that is the entire appeal of Juul. It is an enticing alternative to smoking for kids who would never even think about smoking. The culture of smoking is being replaced by a culture of vaping --- not the opposite.

The press release announcing the introduction of the ordinance explained that: "Banning vaping products that target young people and push them towards addiction to nicotine and tobacco is the only way to ensure the safety of our youth."

But if it is true that vaping is pushing kids towards tobacco, then certainly banning the sale of tobacco products (i.e., cigarettes and smokeless tobacco) would be the most effective solution. I don't for a minute believe that any politician who is serious about trying to prevent youth smoking would propose as a solution allowing cigarettes to remain on the shelves without any further restrictions whatsoever. But that is precisely what the Board of Supervisors is poised to do.

In the same press release, the City Attorney boasted that: "San Francisco has never been afraid to lead, and we’re certainly not afraid to do so when the health and lives of our children are at stake."

If San Francisco wants to lead, then why isn’t it taking cigarettes off the shelves? After all, the chief concern about vaping is that it is a gateway to tobacco use. What possible sense does it make to ban e-cigarettes in order to prevent kids from smoking, but to leave the cigarettes readily accessible on the store shelves?

The truth is that the Board of Supervisors is apparently afraid to lead because they are willing to take the politically expedient step of requiring safety testing for e-cigarettes, but they are not willing to place the same requirement on real cigarettes. In fact, tobacco cigarettes have already had their safety testing and they failed miserably. That's apparently of no concern to the San Francisco Board of Supervisors.

The message that San Francisco is about to send to the rest of the nation is absurd: the best way to protect kids from cigarettes is to leave cigarettes on the store shelves.

This story is so ironic that one would think it would be fine material for the Onion. However, I'm afraid that it is so far-fetched that it wouldn't even qualify. After all, who would honestly believe that a board of policy makers who allegedly are aiming to prevent an epidemic of cigarette smoking among youth would attack that epidemic by doing nothing about the sale of cigarettes in their city and focusing their entire efforts on fake cigarettes.

Hopefully, the absurdity of what they are about to do will be realized by the Board of Supervisors this week before it is too late. They need to take a step back from the hype and hysteria and examine the issue from a public health perspective. If they truly do that, they can come to no conclusion other than that it is completely counter to the basic principles of public health to remove a safer alternative from the market, thus forcing consumers to be stuck using the single most hazardous consumer product on the market.

I'm happy to speak to any of the Supervisors and set the record straight on this issue.

If the ordinance does pass, it will have to go down as the greatest legislative favor ever done in this century to help boost a cigarette company's profits.
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Detailed interview on vaping, especially bans on flavored e-cigarettes, on WICN's Public Eye. Click on archives for Sunday, June 9th.
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Parents of a Florida teenager who became addicted to Juul have sued Juul, Altria, and Philip Morris USA based on a number of claims, including fraud, negligence, and violation of the RICO statute (the compliant is here). Dr. Stan Glantz and Lauren Lempert provide a nice summary of the reasoning behind the lawsuit and the specific claims being made. The case was filed on Monday in the federal district court for the middle district of Florida.

The Rest of the Story

Although the main complaint is that the company fraudulently provided misinformation about the product, its health risks, and its addictiveness, the complaint itself provides a huge amount of misinformation and distortion of the scientific facts related to vaping and Juul. Here is a sampling of the false or completely unsupported information that is claimed in the complaint:

1. Vaping causes chronic obstructive pulmonary disease (COPD): The lawsuit claims that "just like traditional cigarette smoke," vaping causes COPD because it "introduces foreign substances into the lung." There is absolutely no evidence to support this claim. Despite at least 12 years of use and prolonged vaping by millions of Americans, I'm not aware of a single case of COPD that has been documented to be caused by vaping. While vaping does cause acute respiratory irritation, there is no evidence at this point that prolonged exposure to e-cigarette aerosol is extensive enough to cause permanent lung obstruction.

2. Nicotine is a carcinogen: The lawsuit claims that "nicotine itself is a carcinogen." The leading, objective, international body that studies carcinogens (the International Agency for Research on Cancer [IARC]) has not declared nicotine to be a carcinogen.

3. Juul delivers carcinogens to users: The lawsuit claims that Juul "delivers toxins and carcinogens to users." However, the complaint does not specify exactly what toxins or carcinogens Juul delivers to users. Studies of the aerosol produced by Juuling, to the best of my knowledge, have not demonstrated the presence of detectable levels of carcinogens.

4. Juul is designed to transition users to cigarette smoking: The lawsuit claims that Juul is designed to make it "easier for e-cigarette users to transition to conventional cigarettes." The truth is the exact opposite. Juul was designed specifically to transition conventional cigarette smokers to vaping. Juul Labs would be stupid if they designed the product such that its users would transition back to smoking. The company makes no money if its users go back to smoking. In fact, the economic incentive for Juul is to eliminate smoking altogether. The more smokers who switch from conventional cigarettes to Juul, the more money the company makes. There is abundant evidence that Juul has succeeded in transitioning hundreds of thousands of smokers away from conventional cigarette use, but no evidence that Juul has transitioned anyone to cigarette smoking.

5. Juul is defectively designed: The lawsuit claims that the Juul e-cigarette is "defectively designed" because it delivers nicotine so effectively. The truth is that this is actually an incredibly effective design because it provides the greatest chance that a smoker will successfully quit smoking by switching to vaping. The problem with most other e-cigarettes is precisely that they do not deliver nicotine effectively. Juul corrected this problem and as a result, it has become the most effective smoking cessation product currently on the market. This is demonstrated by the tremendous market share that Juul holds among adult smokers trying to quit.

6. Juul aggravates nicotine addiction in cigarette smokers: The lawsuit claims that the company knew that Juul "posed a risk of aggravating nicotine addiction in those already addicted to cigarettes." There is no evidence to support this claim and the truth is likely the opposite. While smokers who switch to Juul are obviously still addicted to nicotine, they are no longer addicted to smoking. The behavior of smoking is a huge component of the addiction to nicotine that is observed in cigarette smokers. By eliminating that aspect of the addiction, the overall addiction is almost certainly lessened.

7. Juul fails to inform users that its product has not been found to be safe: The lawsuit claims that the company "fails to inform users that its products have not been found to be safe." The truth is that Juul says right on its web site that: "No tobacco-based or nicotine e-liquid product should be considered safe." In addition, Juul informs customers that: "Inhalation of e-vapor from JUUL may aggravate pre-existing respiratory or heart conditions. Additionally, ingestion of nicotine, at any level, may cause other conditions (such as an increase in your heart rate and blood pressure, may cause dizziness, nausea, and stomach pain)." The company also warns users about ingesting the e-liquid, informing them that the product: "Contains nicotine, which is an addictive chemical and can be poisonous. Avoid contact with skin and eyes. Do not drink."

8. Juul falsely claimed that it is not affiliated with Big Tobacco: It is true that Juul claimed that it had no affiliation with Big Tobacco. But that was prior to its partial acquisition by Altria. You can hardly blame the company for making a true statement, as long as they no longer make that claim. A Google search revealed that, ironically, the only current internet source of the claim that "Juul Labs is not Big Tobacco" is the lawsuit itself.

9. Juul and Altria plan to use Juul as an entry point for youth to start smoking Marlboro cigarettes: Not only is there no evidence to back up this claim, but it is patently ridiculous. You don't get kids addicted to Marlboro by marketing Juul. You get kids addicted to Juul by marketing Juul. Data from the PATH study demonstrate that becoming a regular vaper is a path away from smoking, not towards smoking. In fact, the only kids who currently progress to smoking are those who do not become regular vapers. Why would a company think that by addicting kids to a mango-flavored product, they would suddenly develop a desire for the harsh taste of Marlboro? Altria may have a history of being sinister, but they are not stupid.

None of this is to deny the fact that Juul use among youth has become a serious public health problem that needs to be addressed urgently. None of this is to deny that Juul carries some responsibility for having created the problem. However, it doesn't seem fair to file a lawsuit against the company for making false claims by putting false claims into the complaint.

Ultimately, I go far beyond nearly all of my colleagues in public health because I believe that the use of nicotine salts is simply not a viable long-term option for a harm reduction strategy that is based on trying to get smokers to switch to vaping. Nevertheless, I don't think it is appropriate to sue the company based on alleged facts that are either completely undocumented or simply untrue.
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A new study published online ahead of print in the American Journal of Medicine reports that there is no association between vaping and cardiovascular disease among never smokers.

Like previous studies of its kind, this was a cross-sectional study that examined the association between current vaping/smoking status and ever having been told that one has cardiovascular disease (including heart attack, coronary artery disease, or stroke). Previous studies used data from the National Health Interview Survey (NHIS) or the Population Assessment of Tobacco and Health (PATH) study; this paper used data from the Behavioral Risk Factor Surveillance Survey (BRFSS).

The authors reported no association between current vaping and self-reported cardiovascular disease among never smokers. However, they found that among current dual users there was an increased odds of having ever been told that one has cardiovascular disease.

In response to the study, one prominent tobacco control researcher concluded that dual use is causally associated with cardiovascular disease, while dismissing the negative finding that e-cigarette use was not associated with vaping among never smokers. He wrote: "The fact that the authors did not find an effect of e-cigarettes alone may be because they stratified the sample on e-cig and cigarette use, which reduces the sample size for each comparison, and so the power to detect an effect."

The Rest of the Story

This reminds me of what the tobacco industry used to do. If they saw a finding that they liked, they would emphasize that finding, but if they saw a finding that they didn't like, they would just dismiss it. This is sometimes called "cherrypicking." I've never picked cherries, but I assume that when doing so, one only picks the cherries that you like and disregards the ones that you don't.

As objective scientists, we can't cherrypick. It allows one to have a pre-conceived conclusion and then to simply publicize findings that support the conclusion while dismissing those that do not. It appears that this is what is going on here.

Cherrypicking is becoming more and more common among tobacco control researchers and advocacy groups. Recently I spoke at a conference on vaping, and one of the other speakers on the panel told the audience that there was no evidence vaping can help people quit smoking. The basis of that conclusion was that "there is no clinical trial that shows vaping to be effective ... we need a clinical trial." When I then pointed out that a randomized, clinical trial published last month in the prestigious New England Journal of Medicine found that vaping was twice as effective as nicotine replacement therapy for smoking cessation, they simply dismissed it, saying: "Well I still don't think it's effective." (The same person also did not think there is enough evidence to conclude that vaping is any safer than smoking.)

The reality is that many tobacco control researchers and advocates will not be convinced by any amount of data. You could have two clinical trials, both finding that vaping is effective for some smokers, and they would still dismiss the findings. (In fact, we do have two clinical trials -- it's amazing to see how many tobacco control advocates continue to insist that there have not been any clinical trials on the use of vaping for smoking cessation.)

Here, a positive finding is accepted and touted, while a negative finding is just dismissed. The reasoning given -- that the study didn't have the power to detect an effect -- doesn't hold water because the sample size of never smoking vapers in the study (15,863) exceeded the number of dual users (12,908).

But even the conclusion that dual use is causally associated with cardiovascular disease is unsupported by the evidence presented in the paper. This is a cross-sectional study, so it is entirely possible that the onset of cardiovascular disease preceded the vaping. In fact, this is almost certainly the case for most of the study subjects because e-cigarettes have been popular for only about eight years, and it takes decades for cardiovascular disease to develop.

It may actually be that the cardiovascular disease "caused" the vaping because having a heart attack or stroke is a strong stimulus for a smoker to try to quit, and many smokers try to quit by using e-cigarettes.

Moreover, dual users are almost certainly a different population from exclusive vapers and one systematic difference between the groups is likely that dual users have a heavier or more intense smoking history, making it more difficult for them to get off of e-cigarettes. If this were the case, it would explain the observed finding that dual use was associated with a higher risk of reporting cardiovascular disease. 

The bottom line is that we can't draw causal conclusions from a cross-sectional study like this one, especially one in which it is impossible to determine which came first: the heart attack or the vaping. So to tout the association between dual use and heart disease as a causal finding is bad enough. But cherrypicking findings that support a pre-determined conclusion, while dismissing those which do not support that conclusion, is sinking to the level of the tobacco industry which we once criticized for doing the very same thing.
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Somewhere along the line, I must have gone astray. During my master's in public health program, I was taught that one major goal of public health is to educate the public about the risks of various exposures. I was also taught that accurately communicating these risks, as well as helping the public to accurately understand the relative risks between different hazardous behaviors or products was critical.

Well, based on an editorial published this morning in the Journal of the American Medical Association (JAMA) Network Open, I was misguided. For in this editorial, it states that the increasing public misunderstanding of the relative risks of smoking compared to vaping is "a good thing."

The editorial responds to new research also published this morning in the same journal which documents that the majority of adults in the U.S. completely misunderstand the dangers that smoking poses compared to those posed by vaping and furthermore, that the proportion of people with this misunderstanding has been growing substantially over time. (See: Huang J, Feng B, Weaver SR, Pechacek TF, Slovic P, Eriksen MP. Changing perceptions of harm of e-cigarette vs cigarette use among adults in 2 US national surveys from 2012 to 2017. JAMA Network Open. 2019;2(3):e191047).

According to the study, in 2012, only 39.4% of adults perceived e-cigarettes as less harmful than real cigarettes. This is pitiful, given the overwhelming scientific evidence that vaping is much less hazardous than smoking. But even worse, the proportion of adults who correctly perceived vaping to be safer than smoking dropped to only 33.9% in 2017. Thus, two out of every three adults in the U.S. incorrectly believes that smoking is no more hazardous than vaping.

Perhaps even scarier, nearly 10% of adults in 2017 perceived vaping to be more harmful than smoking!

The Rest of the Story

Instead of lamenting the fact that the public's perception of the severe hazards associated with cigarette smoking has been seriously undermined over the past decade or so, the editorial almost joyfully celebrates this massive public deception that has occurred. (See: Glantz SA. The evidence of electronic cigarette risks is catching up with public perception. JAMA Network Open. 2019;2(3):e191032).

It is quite a feat of magical writing to take the dismal news that the public is increasingly downplaying the severe risks of smoking and completely misunderstands the relative risks of smoking compared to vaping and to turn that into a tremendous public health victory.

The truth is, however, that this public misunderstanding is having devastating public health consequences. Convinced that vaping is no safer than smoking, many former smokers who quit using e-cigarettes are returning to smoking. After all, what's the point of staying smoke-free using e-cigarettes if vaping is just as bad as smoking? You might as well go back to your Marlboros.

In addition, this misinformation is deterring many smokers who would otherwise have tried to quit using e-cigarettes to just continue smoking. After all, why quit smoking and switch to e-cigarettes if vaping is every bit as harmful. You might as well just stick with your Marlboros.

Huang et al., the authors of the featured article, correctly point out that: "The need for accurate communication of the risk of e-cigarettes to the public is urgent and should clearly differentiate the absolute from the relative harm of e-cigarettes." But somehow, Professor Glantz does not believe that accurate communication is the way to go. Apparently, inaccurate communication is better.

This would almost be funny, were it not for the fact that many adults are going to die because of it. As Huang et al. point out: "Perception of e-cigarette harm [compared to smoking] may deter current smokers from initiating or continuing use of e-cigarettes. This perception may also deter a complete switch from cigarettes to e-cigarettes among smokers. In light of this possibility, the observed upward trend of perceiving e-cigarettes to be more as harmful as or more harmful than cigarette smoking among US adults warrants heightened attention."

In public health, the means do not justify the ends. We do not lie to people in order to persuade them to change their behavior. Telling the truth is a core ethical value of public health practice. But maybe not so much in tobacco control. For us, it is apparently acceptable to spread hysteria using false comparisons and lies simply because we can't handle the idea that there are millions of vapers who have saved their lives using a device that delivers nicotine.

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