"Harm Reduction sits at the intersection between public health and human rights"
No Fire, No Smoke: Global State of Tobacco Harm Reduction
smoking
- Every 6 seconds a person dies from a smoking-related disease
- Half of all people who smoke will die prematurely from a smoking-related disease
- Over 6 million people die from a smoking-related disease every year
- More people die from smoking cigarettes than from malaria, HIV, and tuberculosis combined
- The WHO estimates 1 billion people will have suffered from a smoking-related disease by the end of the century
- The global cost of smoking-related diseases is estimated at $1 trillion per year
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facts & myths
Facts & Myths
About Smoke Free Alternatives and Reduced-Harm Products
False. As of August 8, 2016, all new nicotine products introduced into the market after February 15, 2007 must go through a premarket review by FDA. While PMTA enforcement did not begin until September 2019, vapor products have existed under some form of regulation at the state and local levels since 2009. If marketed as a smoking cessation or any other therapeutic product, nicotine falls under FDA’s jurisdiction over drugs and devices. The US District Court for the District of Columbia stated as much in its ruling against the FDA in 2010 when the agency attempted to stop e-cigarettes from being imported to the US as “unapproved drugs/devices.”
True. E-cigarettes and vapor products are a form of Tobacco Harm Reduction, designed as a safer alternative to smoking. When discussing the safety of vaping, the comparison must always be to cigarette smoking. Numerous studies show that people who vape are exposed to significantly lower levels of toxicants and carcinogens than people who smoke, thus making them safer than smoking. Safer does not mean 100% safe, but for people who smoke, the science tells us switching completely can be extremely beneficial.
False. A variety of studies conclude that vapor products do help people quit smoking. Most notable is a randomized controlled clinical trial published in the New England Journal of Medicine in 2019 which found that nicotine-containing vapor products were nearly twice as effective as traditional nicotine replacement therapies (like gums and patches) to help people quit smoking. Additionally, the highly respected Cochrane Library published an updated analysis of e-cigarettes for smoking cessation in 2020, which found moderate-certainty evidence that quit rates were higher for people using nicotine vapor products than with traditional nicotine replacement therapies. Cochrane’s conclusions were based on a meta-analysis of 50 different studies across 13 different countries.
False. The first commercially successful e-cigarette was invented by Chinese pharmacist Hon Lik in 2003 to help him quit smoking. Independent consumers and small businesses around the world, but especially in the United States, innovated and grew the product category out of sheer passion for a more effective cessation method. It wasn’t until 2012 that the first large tobacco company entered the vaping market. While it’s true that most every major tobacco company now has their own branded e-cigarette, these products were not created by tobacco companies to “hook future generations,” as many activists claim. Vapor products were invented by people who smoke, for themselves, because they were frustrated with the low success rates of traditional nicotine replacement products. Read more about the history of vaping and e-cigarettes.
Possibly. Heavy metals have been detected in some vapor products at varying levels, some concerning, and some not. Researchers have theorized that metals found in some products could be from the coils used to heat the liquid, however some of the testing methods used in these studies have been called into question. Overheating the coils, failing to account for metals from testing equipment, and not excluding participants who were still smoking are all potential causes of abnormally high test results.
While the presence of any level of heavy metals is certainly a concern, heavy metals are just one component contributing to the potential risks from cigarette smoke. The fact that vapor products still contain far lower levels of other carcinogens and toxins – and none of the carbon monoxide and harmful particulates – found in cigarette smoke should not be overlooked, as the overall benefits of switching to vaping still outweigh the risks of smoking. Ideally, regulation should allow manufacturers to develop products that would mitigate the risk of metals leaching into liquid.
False. This claim comes from a single defective study published in 2015 in the New England Journal of Medicine in which researchers improperly used e-cigarette devices by overheating them, and effectively “burning” the wicking material, instead of aerosolizing the liquid. This phenomenon, referred to as “dry hits” or “dry puffs,” is well known by people who use vapor products because of how harsh and intolerable the resulting vapor is. “Dry puffing” a vapor device is the only way to achieve these high levels of formaldehyde, but due to the extreme level of discomfort this is not a realistic usage scenario – the user immediately stops vaping when this happens, as it means something is wrong with the device.
This same experiment was reproduced in 2017 by researchers more familiar with how vaping devices should work, and with participation from people who vape. They found that achieving high formaldehyde levels was essentially impossible in a normal use scenario because people could not tolerate the accompanying level of discomfort and foul taste. When used properly and under normal conditions, a person’s exposure to formaldehyde from vaping is well within levels considered to be safe.
False. Vaping liquids contain the ingredient propylene glycol (PG), which is also an ingredient used in antifreeze. What this myth leaves out is that PG is also a common food additive, and it is used in antifreeze as a replacement for ethylene glycol in order to make antifreeze safer and non-toxic – especially for small children and pets.
False. E-cigarettes use lithium-ion batteries, the same battery chemistry used in many cell phones, laptops, and other consumer electronics. While battery explosions and fires can happen with any of these products (usually due to improper use or a manufacturing defect) it is generally rare.
False. This claim was largely popularized by an erroneous study published in 2019 that was subsequently retracted in 2020 (although it’s not the only one). The authors of this study claimed they found that vaping was associated with increased risk of having had a myocardial infarction, even after controlling for a history of cigarette smoking. However, what the researchers did not disclose is that the majority of the heart attacks occurred before the users started vaping, rendering the conclusions null and void, and resulting in the study being retracted by the Journal of the American Heart Association.
Nicotine use is not without risk, especially for those with pre-existing cardiovascular issues, but there is substantial evidence that switching from cigarette smoking to vaping significantly improves vascular health.
False. This claim comes from a handful of studies exposing rodents to high levels of nicotine. Mice brains are not equivalent to human brains, so this conclusion is far from solid. In fact, there is no evidence to support the idea that nicotine damages the adolescent brain. If there were it would be visible in the multiple generations of adults who began smoking as teenagers. Furthermore, there is ample research to suggest that nicotine may have some neuroprotective qualities.
Unlikely. In 2019 the Food & Drug Administration (FDA) expressed concern over a possible link between youth nicotine vaping and seizures, but no causal link has ever been established. Nicotine inhaled from tobacco cigarettes has never been shown to cause seizures, so it seems unlikely that nicotine inhaled from e-cigarettes would, especially since vapor products do not deliver the same nicotine yield as cigarettes. Additionally the evidence gathered by FDA consisted of only 122 reports gathered over 9 years, and the cases varied widely in the timing of the seizures in relation to vaping.
False. There are no confirmed cases of popcorn lung (bronchiolitis obliterans) in people who use e-cigarettes, and there is no evidence that e-cigarettes could cause popcorn lung. The name comes from an incident involving a group of popcorn factory workers breathing in a chemical called diacetyl who developed this rare condition. Diacetyl was an ingredient used in many vaping liquids, but due to an overabundance of caution most manufacturers no longer use it. Additionally, combustible cigarettes contain much higher levels of diacetyl than vapor products ever did, and popcorn lung has never been associated with smoking.
False. The CDC identified the cause of poorly named EVALI (Electronic Cigarette, or Vaping product use-Associated Lung Injury) in December of 2019 as “exposure to THC-containing vapor products that also contained Vitamin E acetate.” Lung injuries were not caused by nicotine-containing e-cigarettes. Conflating THC vapor products with nicotine vapor products in the case of EVALI is comparable to blaming all leafy-green vegetables for an outbreak of e-coli, when it’s really just a bad batch of spinach. It is unscientific, wholly inaccurate, and not consistent with CDC’s protocols for communications about an outbreak of disease.
False. This claim comes from a single mathematically flawed study published in 2020 in the Journal of Adolescent Health. Researchers gathered data from an anonymous and self-reported online survey and claimed that “e-cigarettes and cigarettes are significant underlying risk factors for COVID-19.” However, they later recanted and admitted “our study does not imply causality” after other researchers heavily criticized the study’s math and methods. A much larger study, conducted by the Mayo Clinic, found no increased risk of COVID-19 in people who vape.
Multiple countries have reported unusually low rates of severe COVID-19 in people who smoke, leading some researchers to begin studying if nicotine can be a potential therapeutic option or provide a protective effect against contracting the disease to begin with.
Unlikely. A variety of air quality tests have been performed by researchers, state health departments, and even the U.S. Department of Health and Human Services inside vapor product stores – where exposure should arguably be the highest. All the reports consistently found that concentrations of vaping-related chemicals in the air were below occupational exposure limits or not detectable at all, including nicotine, flavoring chemicals, and formaldehyde.
False. This claim comes from data showing that youth who experiment with cigarette smoking are likely to experiment with vaping, and vice versa. There is currently no data to support a causal link between the two, let alone a “gateway” effect. In fact, youth smoking rates have fallen to historic lows, even as youth experimentation with e-cigarettes has increased in some recent years. According to the latest research, the most likely causal link between vaping and smoking is that vaping is diverting young people from experimenting with smoking.
False. While it’s true that youth experimentation with vaping did increase in 2018 and 2019, it actually decreased in 2020 (data was collected before the COVID-19 pandemic). Additionally, the data most often reported only covers experimentation (trying vaping –even one puff – in the last 30 days), not regular or habitual use. Daily use of vapor products by adolescents remains relatively low, under 5% as of 2020.
False. Flavored vape products, including fruit, candy, and dessert flavors, were designed by and for adults. Surveys of adult vapers clearly show a strong preference for fruity, dessert, and sweet/candy flavors over all other flavor categories. Additionally, several researchers have noted that the “use of fruit and other sweet flavored e-liquids positively related to smokers’ transition away from cigarettes.”
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