The new prohibitionists
In the epilogue to Last Call: The Rise and Fall of Prohibition, Daniel Okrent’s lively and deeply-researched history of prohibition, he writes:
In almost every respect imaginable, Prohibition was a failure. It encouraged criminality and institutionalized hypocrisy. It deprived the government of revenue, stripped the gears of the political system, and imposed profound limitations on individual rights. It fostered a culture of bribery, blackmail and official corruption.
Much the same could be said about the 50-year-old war on drugs, which has been prosecuted with enthusiasm by every president since Nixon.
No matter that the drug war was rooted in racism and xenophobia, and sustained by lies. It took a heavy toll on African Americans and poor people, and helped make the US the world leader in incarceration. It fostered violent drug cartels, while keeping psychedelic chemicals with the potential to heal away from those who might have benefited from their use.
Why, then, do people want to ban e-cigarettes? Or flavored e-cigarettes? Have anti-tobacco warriors like the Campaign for Tobacco-Free Kids and the Truth Initiative and their political allies forgotten history?
This is not to suggest that bans on e-cigarettes or menthol cigarettes would have the impact of Prohibition or the drug war. But it is a near certainty that bans on substances that people desire — especially addictive substances — will generate negative and unintended consequences.
In the case of vaping, the most important negative consequence will likely be an increase in smoking, which remains the world’s leading preventable cause of death. The vast majority of tobacco researchers agree that vaping, while not safe, is safer than smoking combustible tobacco.
This is why partial or total vaping bans — which have been enacted by five states and numerous cities — make little sense, especially as evidence accumulates that e-cigarettes help adults quit smoking. Meantime, recent developments suggest that a combination of regulation and persuasion can limit youth access to vapes. This story will look at research that points to a path forward for e-cigarettes that, at least in theory, could satisfy all but the most uncompromising voices on both sides of the great vape debate.
Good news for those who smoke and vape
First up is a study published in The Lancet Public Health from a research group including Thomas Brandon, director of Tobacco Research and Intervention Program at the Moffitt Cancer Center in Tampa, FL. Brandon and colleagues recruited about 2,900 people who both smoked and vaped — they’re called dual users — divided them into three groups. One group was sent monthly booklets or pamphlets with advice specifically designed to help dual users quit smoking. A second group was sent generic quit-smoking advice, also once a month. The rest were left on their own.
The study was the first to test an intervention aimed at dual users. “At the time we started the study, the fear was that dual users would be stuck in dual use forever,” Brandon told the Let’s talk e-cigarettes podcast of the Cochrane Tobacco Addiction group. “That doesn’t seem to be the case. That’s really good news right there.”
Smokers who were sent materials targeted at dual users quit at a slightly higher rate than the others. That’s good to know because letters or emails are a relatively low-cost intervention that can, it appears, help people quit.
More important, though, is the finding that after two years, about 42 percent of all the dual users in the study had stopped smoking for a minimum of seven days.
“That’s a pretty high rate,” Brandon said. Indeed it is — the quit rate for smokers using e-cigs compares favorably to those who try to quit with FDA-approved nicotine replacement therapies (NRTs) and other smoking cessation treatments.
Other evidence points the same way. Last month, Addiction published the results of a small randomized controlled trial that sought to determine how e-cigarettes compare with nicotine replacement treatment. British researchers divided 135 smokers who had tried but failed to quit into two groups, and found that abstinence rates after six months were 19 percent for those using e-cigarettes and just 3 percent for those using NRTs. Unlike the Florida research group, those in the UK validated abstinence through biochemical tests.
Then there is the most recent Cochrane review of e-cigarettes for smoking cessation, which looked at 56 studies of more than 12,000 smokers and concluded, in plain language, that “nicotine e-cigarettes probably do help people to stop smoking for at least six months.”
While randomized controlled trials are deemed the gold standard of evidence, broader observations of large populations also have found that e-cigarettes help people stop smoking. (Vapes are recommended as a smoking cessation tool in the UK.) Economists who look at market data find that as e-cigarette sales rise, sales of cigarettes decline.
Says Michael Pesko, an economist at Georgia State University: “The evidence base is growing that when you regulate e-cigarettes so they are harder to purchase and/or less appealing to use, there is more combustible tobacco product use across all populations.”
But what about the kids?
Yet anti-vaping politicians want to make e-cigarettes more expensive and harder to obtain. One example: Buried in last year’s 5,500-page COVID-19 relief bill was a provision banning the U.S. Postal Service from shipping vaping and e-cigarette products to consumers.
Does this sound familiar?
Ah, but what about the kids, you ask? All of this — the bans, the restrictions, the calls for higher taxes — is justified as a way to protect kids. And, in fact, no one wants kids to vape or smoke. But there are steps, short of a ban, that could protect young people without taking vapes away from adult smokers.
Less than two years ago, for example, federal law increased the age of sale for all tobacco products from 18 to 21. Beefing up enforcement to Tobacco21, as it’s known, could go a long way to keeping e-cigarettes away from young people.
In last month’s settlement of a lawsuit brought against e-cigarette maker Juul by the state of North Carolina, Juul agreed to require its retailers in North Carolina to adopt automated systems to verify shoppers’ ages and to send “mystery shoppers” to nearly 1,000 stores each year, to see whether they are following the law.
New evidence also suggests that This is Quitting, a free, anonymous text-message program from Truth Initiative, is succeeding at its goal of helping young people to quit vaping. Most of the messages in This is Quitting are written by young people who offer strategies, tips and encouragement.
In a recent webinar called Unvaping America’s Youth, Amanda Graham, a tobacco researcher and chief of Innovation at Truth Initiative, said: “What that says is that lots of other people are quitting and quitting is possible.”
Since the program launched in January 2019, nearly 350,000 young people signed up. Two-thirds completed the program. Separately, a randomized clinical trial of 2,588 young adult vapers found that the abstinence rates of those assigned to the This Is Quitting program were 24.1 percent, compared to an 18.6 percent quit rate of the control group. In a report in JAMA Internal Medicine, Graham and colleagues conclude that “a tailored and interactive text message intervention was effective in promoting vaping cessation among young adults.” More than 90 percent of the participants had high levels of nicotine dependence.
Interestingly, Graham mentioned during her online talk that about one-third of the young people in the trial reported that they also smoked cigarettes and 60 percent reported that they used marijuana. “Binge drinking was extremely common,” she said, “and about half the sample screened positive for anxiety or depression.”
These kids, in other words, have issues, which raises questions: Are flavored vapes the problem? Is prohibition the solution? Vaping isn’t going to kill these young people; smoking, binge drinking or suicide might.
It’s no surprise, of course, that the Campaign for Tobacco-Free Kids, Truth Initiative and Parents Against Vaping see kids through the narrow lens of vaping. Like the Anti-Saloon League and the Women’s Christian Temperance Union, they focus on the drug, not the user.
Those who care about the health of kids — as well as the millions of adults who can benefit from vaping — need not be so myopic.
