# They protest far too much - what happened to scientific curiosity?



## fbb1964 (17/5/21)

https://www.bmj.com/content/373/bmj.n1247/rr

Rapid Response:
They protest far too much - what happened to scientific curiosity?

Dear Editor

The complaints about a journal publishing scientific papers from the e-cigarette company Juul and its consultants are absurd, anti-scientific and somewhat disturbing. Juul has accumulated knowledge from extensive surveys of its users and their changing patterns of smoking and use of the Juul product. The monograph published by the American Journal of Health Behavior is a fascinating collection of papers that drills into this store of data [1]. It provides highly salient information on changes in smoking status, drivers of transition, population health impact and retailer behaviours. The summary for the introduction to the series should be enough to whet the appetite of the genuinely curious and scientifically engaged: [2]

"This special issue addresses key topics relating to the public health impact of the use of electronic nicotine delivery devices (ENDS), particularly JUUL-brand ENDS. Smokers smoke for nicotine, but are harmed by the byproducts of combustion. ENDS can play a role in tobacco harm reduction offering a noncombustible alternative source of nicotine for adult smokers who would otherwise continue smoking. Papers presented here estimate the prevalence of ENDS and JUUL use among young and older adults, and document the 12-month smoking trajectories of adults who purchased a JUUL Starter Kit. Overall, smoking prevalence was halved, with most smokers switching completely as dual use declined. This held for subpopulations defined by demographics and psychiatric comorbidity. For those who did not switch, most significantly reduced (50%+) their cigarette consumption. Another study reports that dependence declines as smokers switch from smoking to using JUUL.”

"The public health potential of ENDS is undermined by use of ENDS by nonsmokers, especially underage individuals. Some smoking was reported by adult former and never smokers, with little evidence of persistent smoking, and lower risk of smoking among those using JUUL more frequently. Regarding underage use, one paper reports that technology can ensure age-verification at point of sale. Population modeling integrating impacts on diverse populations indicates that availability of ENDS is expected to avert millions of premature deaths in the US. We believe these papers make a substantial contribution to the field of tobacco science and smoking control.”

Mr Matthew Myers, the president of an activist organisation that opposes vaping and harm reduction in tobacco policy, is apparently unhappy about this. He asserts that this body of science is somehow the work of the tobacco industry, as if that is sufficient to invalidate the findings. He goes on to imply that the scientists involved are now 'previously credible' agents Big Tobacco. Not only is the attempted smear offensive, but it is also baseless. By any realistic definition, Juul is not a tobacco company (Altria has a minority, non-controlling interest and Juul does not make products that contain tobacco). In my view, Juul’s scientists have done excellent work that stands on its merits and has now been published after thorough peer review in a reputable journal with transparent disclosure of its provenance.

Many companies in this field, including some tobacco companies and Juul, produce very high-quality science. There are at least three reasons for that: (1) their own product stewardship and control of legal liabilities; (2) they have to convince sceptical regulators like the US Food and Drug Administration that their products are “appropriate for the protection of public health”; (3) they are mostly committed to pursuing innovation that will ultimately make smoking obsolete. They just wouldn't get away with vacuous PR-based science.

The real question here is why these tobacco control activists show so little curiosity about the changes that are reshaping the US tobacco and nicotine market. As Juul rose in popularity, we saw unusually rapid declines in cigarette sales and smoking prevalence in both adults and adolescents [3][4]. The right response to that is to want to know more. The wrong response is to try to suppress or discredit informative data and analysis just because it tells a story that is at variance with a narrative about the evils of both e-cigarettes and the companies that make them.

[1] American Journal of Health Behavior Volume 45, Number 3, May 2021 Special Issue on JUUL;
Available from:: https://www.ingentaconnect.com/content/png/ajhb/2021/00000045/00000003

[2] Shiffman S, Augustson EM. Introduction to the Special Issue on JUUL Use. Am J Health Behav [Internet] 2021;45(3):397–401. Available from: https://www.ingentaconnect.com/content/10.5993/AJHB.45.3.1

[3] Levy DT, Tam J, Sanchez-Romero LM, et al. Public health implications of vaping in the USA: the smoking and vaping simulation model. Popul Health Metr [Internet] 2021 [cited 2021 Apr 26];19(1):19.
Available from: https://pophealthmetrics.biomedcentral.com/articles/10.1186/s12963-021-0...

[4] Selya AS, Foxon F. Trends in electronic cigarette use and conventional smoking: quantifying a possible ‘diversion’ effect among US adolescents. Addiction 2021 add.15385.
Available from: https://onlinelibrary.wiley.com/doi/10.1111/add.15385

Competing interests: I am a long-standing advocate of tobacco harm reduction as a public health strategy and support the use of vaping products, including Juul, to displace smoking. I am the former Director of the anti-smoking organisation, Action on Smoking and Health. I have no competing interest with respect to the tobacco, nicotine or pharmaceutical industries.

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