To the Editor:
Regarding Bloomberg’s Millions Funded an Effective Campaign Against Vaping. Could It Do More Harm Than Good? (Chronicle, March 23), there is still much we don’t know about e-cigarettes. But here is what we do know.
We know that 3.6 million kids currently use e-cigarettes, a threshold that in 2018 led the U.S. surgeon general to declare youth e-cigarette use an epidemic. Of these kids, 1.3 million use e-cigarettes frequently or every day, a strong sign of nicotine addiction.
We know that e-cigarette companies have infused their products with thousands of kid-friendly flavors, which are chosen by an overwhelming majority of kids who use e-cigarettes.
We know that tobacco companies have spent billions of dollars to create, distribute, and advertise e-cigarette products in a “patently youth-oriented” manner.
We know that e-cigarettes can deliver as much nicotine or more as a whole pack of cigarettes and that nicotine can have detrimental impacts on kids’ brain development and health.
All of this led our organizations to mount major campaigns to reverse the youth e-cigarette epidemic, including Bloomberg Philanthropies’ Protect Kids: Fight Flavored E-Cigarettes initiative launched in 2019 and Truth Initiative’s National Youth-Vaping-Prevention Truth® campaign, which includes This Is Quitting, a free text-message program currently helping hundreds of thousands of young vapers quit. Thanks to these and other efforts, youth e-cigarette use has started to decline, although it remains at epidemic levels, with nearly one in five high-school students vaping.
Bloomberg Philanthropies’ e-cigarette initiative is a complement to and not a substitute for Bloomberg’s ongoing $1 billion commitment to reduce traditional tobacco use, the Bloomberg Initiative to Reduce Tobacco Use, which has saved more than 35 million lives around the world over the past decade by investing in and advocating for proven policies to prevent tobacco use.
Tobacco companies have fought us tooth and nail every step of the way, and we are disappointed to see so many similarly baseless assertions receive safe haven in Mr. Gunther’s article.
For instance, the article strongly implies that removing flavored e-cigarettes from the marketplace will prevent adult cigarette smokers from quitting. That is simply not true. The FDA has approved a variety of smoking-cessation products — some with nicotine, others without — including patches, gums, nasal sprays, inhalers, lozenges, and pills.
It takes Mr. Gunther more than 2,500 words to mention that the FDA has not approved a single e-cigarette as a smoking-cessation device, and he ignores completely the fact that no e-cigarette company has even tried to prove to the FDA that its products are effective at helping smokers quit.
In fact, every major U.S. public-health authority that has comprehensively reviewed the scientific evidence has reached the same conclusion: To date, there is limited and inadequate evidence to conclude that e-cigarettes are effective for smoking cessation.
For decades, tobacco companies were permitted to run rampant, ruthlessly addicting millions, before governments finally asserted their authority to prioritize the health of children and families over tobacco companies’ profits. E-cigarette companies are counting on the “wait and see” approach repeating itself. Not on our watch.
Kelly Henning
Public Health Program Lead, Bloomberg Philanthropies
Matthew L. Myers
President, Campaign for Tobacco-Free Kids
Robin Koval
CEO, Truth Initiative
To the Editor:
Mark Gunther’s article on Bloomberg’s funding of efforts to prevent youth e-cigarette use did a good job presenting the current conflicts in the public-health community about e-cigarettes and how best to regulate them.
But it did not suggest any ways those conflicts might be resolved or, perhaps, made less important. Given the common, overriding goal of reducing tobacco-nicotine deaths and harms as quickly as possible, there are many new tobacco-control policies that all sides of the e-cigarette conflict should be able to agree on and actively support.
Most importantly, new, much stronger antismoking measures — such as minimizing nicotine levels in all cigarettes and similarly smoked tobacco products or banning all added flavors in smoked tobacco products, including menthol in cigarettes — could more quickly and sharply reduce smoking initiation and increase smoking cessation than any other politically viable policy options.
Such antismoking measures would not increase any restrictions or requirements on e-cigarettes. But they would dramatically reduce the risk that any youth who initiated e-cigarette use would ever move on to smoking, one of the major concerns about youth e-cigarette use. Moreover, if cigarettes and similarly smoked tobacco products could no longer feed smokers’ nicotine addictions (with or without a flavor ban), it would be much easier for e-cigarettes to compete against them.
Although conflicts would still arise in regard to whether new bans on flavored smoked tobacco products should also ban all or some e-cigarette flavors, all those concerned with reducing overall tobacco-related harms should at least agree that the top priority should be to get rid of all added flavors in smoked tobacco products.
Indeed, if smoked tobacco products no longer had added flavors, e-cigarettes would not need flavors as much to compete successfully against them — although it is quite possible that having menthol e-cigarettes available after a ban of menthol cigarettes would prompt more menthol smokers to switch to using menthol e-cigarettes instead of simply switching to nonmenthol cigarettes.
Similarly, anyone who wants to see a decline in tobacco-use deaths and harms should support raising the prices of smoked tobacco products through effective minimum-price laws, increased taxes, and other means. Again, conflicts could arise regarding whether the price-increase measures should also apply to e-cigarettes. But all should at least agree on raising smoked tobacco prices; and perhaps even those arguing for stronger restrictions on e-cigarettes could at a minimum agree that government tax and price measures should not make e-cigarettes more expensive than smoked tobacco products.
Another possible consensus antismoking strategy might not raise any significant conflicts, even if it were extended to e-cigarettes (or to all tobacco products). That is requiring that all tobacco products be sold only in adult-only sales outlets.
This regulation would dramatically reduce youth access while also helping shrink overall use. But that would not make finding and buying e-cigarettes any more difficult for adults than finding and buying smoked tobacco products. To promote switching from smoking to vaping (without any downside risks), even those opposing an e-cigarette harm-reduction approach should also be able to agree that all sales outlets that sell smoked tobacco products should be required to offer e-cigarettes, as well (but not vice versa).
Another point missing from the article, and rarely mentioned by either side of this e-cigarette debate, is that the availability of e-cigarettes makes implementing much stronger new antismoking measures much easier. To start, the availability of e-cigs directly addresses the argument that it would be unfair to addicted smokers to make their cigarettes and cigars less readily available or non-addiction feeding because they would be left with nowhere to go. By switching to e-cigarettes, those that do not quit all tobacco-nicotine use in response to the antismoking measures could still continue inhaling nicotine into their lungs to feed their addiction. That continuing smoker access to e-cigarettes also eliminates the already somewhat silly claim that desperate smokers would swamp our health care system if they could no longer smoke to feed their nicotine addictions.
Legally available e-cigarettes also sharply reduce the likelihood that any large black-market trade in illicit cigarettes would emerge in response to strong new antismoking measures (a favorite, already suspect, industry argument).
Faced with more expensive smoked tobacco products, no menthol cigarettes, or cigarettes and other smoked tobacco products that no longer feed their nicotine addiction, smokers who do not want to quit inhaling nicotine or cannot stop would still have the convenient and legal option of switching to e-cigarettes. Even where states or localities raise taxes on cigarettes and other smoked tobacco products, if smokers can legally evade the higher prices by switching to readily available, less-expensive e-cigarettes, fewer will take the time and trouble to go to any nearby lower-tax jurisdictions to get less-expensive smokes.
At the same time, the continued marketing of e-cigarettes, and the fact that some smokers will switch to e-cigarettes in response to new antismoking measures, further diminishes already specious cigarette-company arguments that sharply reducing smoking will reduce employment or cause other economic harms. Because of such switching, modest taxes on e-cigarettes also provide governments with a way to offset some of the tobacco tax-revenue reductions caused by sudden, sharp smoking declines (although the cost savings and harm reduction from the smoking reductions will already be much larger than any revenue losses).
Allowing the marketing of nicotine-delivering e-cigarettes also gives the tobacco industry a way to survive and remain profitable even after truly strong new antismoking measures are put into place.
That should dampen tobacco-industry opposition to such antismoking measures, especially now that the big tobacco companies have already publicly stated that they believe all smokers should quit or switch. Those public statements by the big cigarette companies also make it easier for policy makers to support new antismoking measures, even if they have protected the industry in the past. It is also possible that e-cigarette companies that do not also profit from smoked tobacco product sales will finally endorse and lobby for strong new antismoking measures (which will push many smokers to use their e-cigarettes, instead) if the new antismoking policies do not apply to e-cigarettes or do not apply as strictly.
So the public-health community and health-minded policy makers do not need to resolve the existing conflicts regarding e-cigarettes. It does not matter whether e-cigarette use harms are trivial compared with those from smoking or only some fraction less.
Nor does it matter whether the marketing of e-cigarettes, by itself, causes significant reductions in adult or youth smoking and secures significant public-health gains despite increasing nicotine addiction among otherwise nonusers.
What does matter is that the availability of e-cigarettes sharply increases the political viability of strong new antismoking measures that can reduce the overall harmful effects of tobacco use much more quickly than any other strategy.
Regardless of the contrasting views about e-cigarettes and how to regulate them, the public-health community should, first, come together and, with a single, strong voice, actively support powerful new antismoking measures as the appropriate top priority for the FDA and other tobacco-control policy makers at all levels of government. And private foundations and other funders should explore ways to try to help make that happen.
Eric N. Lindblom
Senior Scholar
O’Neill Institute for National & Global Health Law
Georgetown University Law Center
Lindblom was director of the Office of Policy at FDA’s Center for Tobacco Products from 2011 to 2014.