A. ST use gateway to smoking cessation, not smoking initiation

Data from research studies in Sweden and the U.S. do not support the allegation that widespread use of ST serves as a gateway to smoking, especially among youth. A 2003 policy statement published in Tobacco Control, coauthored by Clive Bates, former director of Action on Smoking and Health (U.K.) and five other eminent tobacco research and policy experts, dismissed the notion that ST use led to smoking in Sweden “To the extent there is a ‘gateway’ it appears not to lead to smoking, but away from it and is an important reason why Sweden has the lowest rates of tobacco related disease in Europe” 148 . Foulds reached a similar conclusion “This review in Sweden snus has served as a pathway from smoking, rather than a gateway to smoking among Swedish men” 145 .

A 2005 study examined tobacco use among 15 to 16 year old schoolchildren over a 15 year period, from 1989 to 2003 149 . The investigators found that the prevalence of regular snus use among Swedish boys increased from about 10% to 13% from 1989 to 2003, but the prevalence of regular smoking was very low and declined, from about 10% to under 4%. The prevalence of snus use among girls was very low, and the prevalence of smoking was about double that of boys over the entire period. The authors concluded that snus use did not appear to be a gateway to smoking among Swedish youth but instead was associated with low smoking prevalence among boys.

In the U.S. investigators have not found credible evidence that ST use is a gateway to smoking among American youth. In 2003 Kozlowski et al analyzed data from the 1987 NHIS survey and concluded that there was little evidence that ST use was a gateway to smoking, because the majority of ST users had never smoked or had smoked cigarettes prior to using ST 133 . The investigators noted that their results coincided with earlier work from Sweden and with a tobacco industry sponsored survey from 1984 150 .

In 2003 O’Connor et al. examined data from the 2000 National Household Survey on Drug Abuse 151 . They described the impact of ST use on subsequent cigarette smoking initiation as “minimal at best.” O’Connor et al. also examined data from the CDC’s Teenage Attitudes and Practices Survey for evidence that ST use served as a gateway to smoking among youth 152 . They concluded that ST use was not associated with smoking initiation after appropriate control for confounding by well recognized psychosocial predictors of smoking. This is in contrast to an earlier report that did not control for confounding and found a positive association 153 .

Claims of a gateway effect persist, even with lack of credible evidence, prompting O’Connor et al. to note in 2005, “Continued evasion of the harm reduction issue based on claims that ST can cause smoking seems, to us, to be an unethical violation of the human right to honest, health relevant information” 154 . That quote introduces the next topic, information and misinformation about ST and tobacco harm reduction.

B. Information and misinformation about ST and tobacco harm reduction

Kozlowski et al. have argued persuasively that smokers have a fundamental right to accurate information about safer forms of tobacco use 155 157 . The research group established the underlying rationale for the provision of this information, citing principles of the Universal Declaration of Human Rights, the doctrine of informed consent, and business ethics contract theory, under which companies have a moral obligation to inform customers about important information regarding their products.

In 2001 the U.S. Supreme Court may have provided a legal basis for holding tobacco manufacturers responsible for providing truthful information about the differential risks of ST use and smoking. Writing the majority opinion in Lorillard v. Reilly, in which a 5 4 majority of the Court ruled that broad advertising restrictions by the Commonwealth of Massachusetts violated the commercial free speech rights of tobacco manufacturers, Justice Sandra Day O’Connor wrote that “the State’s interest in preventing underage tobacco use is substantial, and even compelling, but it is no less true that the sale and use of tobacco products by adults is a legal activity. We must consider that tobacco retailers and manufacturers have an interest in conveying truthful information about their products to adults, and adults have a corresponding interest in receiving truthful information about tobacco products” 158 .

1. Fundamental right to information

Over the past 20 years, many public health and tobacco policy experts have argued that smokers have a fundamental right to accurate information about less hazardous products so that they can make informed choices if they are unable or unwilling to quit tobacco altogether. In 1984 Kozlowski commented on both the challenges and the potential of tobacco harm reduction, writing that “the use of less hazardous tobacco, if prohibitionist impulses can be put aside, may have an important role in the treatment of the smoking and health problem…” 9 .

In 1994 Rodu proposed that a “public health policy that recognizes ST as an alternative to smoking would benefit individuals confronted with the unsatisfactory options of abstinence or continuing to smoke” 10 . In a 1995 book, Rodu told smokers that “ST products allow you, the hard core and long term smoker, to take back a measure of control over your health by indulging in a far safer form of tobacco use” 13 .

One concern about tobacco harm reduction is that dissemination of information about less hazardous tobacco products might adversely affect public health if it creates new users. However, the risk/use equilibrium addresses this issue 159 . If ST use is 50 to 100 times less hazardous than smoking, it would require 50 to 100 more ST users to reach the level of public harm produced by smoking. In other words, it would take 2.3 to 4.5 billion ST users to have the same death toll as 45 million American smokers do today, an impossible scenario in the U.S. population of 290 million people.

Kozlowski’s message in 2002 was clear “Cigarettes kill about half of those who smoke is urgent to inform smokers about options they have to reduce health policy in this instance lacks compelling justification to override the human rights of the individual. Individuals have the right to such relevant information on tobacco risks ” 155 . That same year, the prestigious Royal College of Physicians of London made its hopeful statement that “some manufacturers may want to market ST as a ‘harm reduction’ option for nicotine users, and they may find support for that in the public health community” 128 .

Since then a growing number of experts have weighed in on the case for providing smokers relevant risk information and safer tobacco options. In 2002 Cummings argued for a market approach involving risk information “Until smokers are given enough information to allow them to choose products because of lower health risks, then the status quo will remain. Capitalism, and not government regulation, has the greatest potential to alter the world wide epidemic of tobacco related disease” 160 .

In 2003 Kozlowski et al expanded on the rationale that smokers are entitled to information about safer products, addressing concerns that provision of risk information might adversely affect public health “Public health concerns should trump individual rights only when there is clear and convincing evidence of harm to society. Lacking that evidence, individual rights should prevail” 161 .

2. Misinformation from governmental and other organizations

Americans are badly misinformed about the risks of ST use, especially in comparison with smoking. In 2005 a survey of 2,028 adult U.S. smokers found that only 10.7% correctly believed that ST products are less hazardous than cigarettes 154 . In another survey, 82% of U.S. smokers incorrectly believed that chewing tobacco is just as likely to cause cancer as smoking cigarettes 162 .

A 1999 2000 survey of 36,012 young adults entering the U.S. Air Force found that 75% of males and 81% of females incorrectly believed that switching from cigarettes to ST would not result in any risk reduction, while another 16% of males and 13% of females incorrectly believed that only a small risk reduction would occur. Only 2% of males and 1% of females correctly understood that a large risk reduction would occur by switching from cigarettes to ST 163 . That survey also found that the overwhelming majority of subjects believed that switching from regular to low tar cigarettes conferred greater reduction in risks than switching from cigarettes to ST.

It is not clear how Americans have become so confused about tobacco risks. But it is clear that misinformation about ST products is available in copious quantities from ostensibly reputable sources, including governmental health agencies and health oriented organizations. Phillips et al have made some of the most pointed comments about this phenomenon

“Certain health advocates believe it is acceptable to mislead people into making choices they would not otherwise the use of various tactics, advocates who oppose the use of ST as a harm reduction tool have managed to convince most people that the health risk from ST is several orders of magnitude greater than it really is. The primary tactic they use is making false or misleading scientific claims that suggest that all tobacco use is the same. . . . Apparently motivated by their hatred of all things tobacco, they are trying to convince people to not switch from an extremely unhealthy behavior to an alternative behavior that eliminates almost all of their risk” 164 .

The tactic has worked in the U.S., as Americans, almost without exception and regardless of general and health education levels, believe that the risks from ST are similar to those from smoking. In particular, Americans incorrectly believe that switching from smoking to ST use will create a large increased risk for oral cancer. Phillips has characterized this popular misinformation as the “you might as well smoke” message, since it tells people that if they are using ST, they could switch to smoking with no increase in risk, while smokers considering switching to ST should not bother 165 .

Phillips et al. systematically reviewed content about ST use on the web in 2003 and found that the risks of ST use are almost always conflated with those of smoking 165 . Roughly one third of the time, there are explicit claims that ST is as bad as or worse than smoking. Most of the rest of the time the information is arranged to imply similar risks, though there is no such explicit statement. There are also a variety of specific claims that are not supported by the literature.

Government agencies, other organizations and members of the public health community have a moral obligation


to misinform smokers about products that have fewer risks than cigarettes. Nevertheless, researchers have exposed numerous cases of misinformation from governmental sources. For example, in 2003 Kozlowski and O’Connor criticized websites of the CDC and the Substance Abuse and Mental Health Services Administration for erroneously reporting that ST products were not safer than cigarettes, pointing out that “the misleading health information on ST fails to meet the government criteria against deception in research” 156 .

At a 2003 U.S. House subcommittee hearing, U.S. Surgeon General Richard Carmona testified “I cannot conclude that the use of any tobacco product is a safer alternative to is no significant evidence that suggests ST is a safer alternative to cigarettes” 166 . Scott Leischow, Chief of the Tobacco Control Research Branch at the NCI, presented similar testimony at a concurrent hearing 167 . Carmona’s statement prompted Rodu, who also presented testimony at that hearing 168 , to comment that the Surgeon General was “sadly ill informed about the nation’s No. 1 health problem, cigarette smoking.” Rodu strongly criticized Carmona, writing that he should be compelled to “tell American smokers the truth about all available options for quitting. After all, the 10 million smokers who will die over the next two decades are, in a very tangible way, his responsibility and his legacy” 169 .

In March 2004, Ken Boehm of the National Legal & Policy Center (NLPC), a non profit organization committed to promoting open, accountable and ethical practices in government, filed a request under the Data Quality Act (DQA) for correction of a document from the National Institute of Aging (NIA) that contained misinformation regarding the relative risks of ST versus cigarettes. (This other DQA requests on ST can be seen at the U.S. Department of Health and Human Services website 170 ) The request resulted in a change of wording from the original text

“Some people think ST (chewing tobacco and snuff), pipes, and cigars are safer than cigarettes. They are not.”

The revised wording from NIA was

“Some people think ST (chewing tobacco and snuff), pipes, and cigars are safe. They are not.”

The claim that ST products are not “safe” is a tactic that can be traced back to the 1986 Comprehensive Smokeless Tobacco Education Act, which required as one of three warnings on all ST products “This product is not a safe alternative to cigarettes.”

In 1995 Rodu criticized this warning as ludicrous and suggested that other consumer products like automobiles, lawnmowers, aspirin and red meat don’t meet absolute criteria for safety 13 . A decade later, Kozlowski and Edwards criticized this type of uninformative warning in a study entitled, “‘Not safe’ is not enough smokers have a right to know more than there is no safe tobacco product” 157 . These authors believe that smokers deserve more information “The ‘not safe’ or ‘not harmless’ messages don’t address the reality that some tobacco products are substantially safer than others… Saying tobacco ‘isn’t safe’ isn’t incorrect, but it isn’t saying enough. Going beyond the no safe tobacco message to provide better information on the nature of risks from tobacco products and nicotine delivery systems is necessary to respect individual rights to health relevant information.”

Ken Boehm from NLPC summarized the arguments against misinformation

“This is the kind of evidence Americans should be able to review and make their own decisions. Despite the best efforts of the largest government bureaucracy in the history of the republic, Americans still prefer to do their own thinking. And as we do our own thinking on the merits of reduced risk products such as ST, none of us needs misinformation supplied by our own government” 171 .

With regard to a policy as “credible, logical and eminently do able” as tobacco harm reduction 172 , it is unfortunate that arguments against deception are actually necessary.

Electronic cigarettes-topic overview

How to buy electronic cigarettesВ online
This information is not intended to replace the advice of a doctor. Healthwise disclaims any liability for the decisions you make based on this information.

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Electronic cigarettes are battery powered devices that turn liquid nicotine into a vapor that you inhale. Many of them are made to look like real cigarettes. Some even have a light at the end that glows when you inhale.

For smokers, electronic cigarettes may satisfy nicotine cravings. They can be used in nonsmoking areas. And they may have less of the harmful chemicals that are in cigarette smoke. These cigarettes are often called e cigarettes.

How do electronic cigarettes work?

E cigarettes have three main parts.

  1. The mouthpiece has a cartridge. The cartridge contains a nicotine solution.
  2. A heating element turns the solution into a vapor when you inhale.
  3. A battery provides power to the heating element.

The nicotine in these cigarettes comes in flavors. Flavors include “regular” and “menthol.” But they also include hundreds of other flavors like cherry, chocolate, and cola.

A chemical in the vapor turns it white so that it looks like smoke, even when you exhale.

Electronic cigars and pipes are also available.

Are e cigarettes safe?

Since most of the harm from smoking is not from nicotine but from other things in tobacco, e cigarettes may be safer than real cigarettes. But more research is needed before experts can say for sure.

The cartridges contain different levels of nicotine. So in theory, you could lower the nicotine levels over time until you no longer crave nicotine. This is why some people use them as aids to quitting smoking.

If you are thinking about using e cigarettes to help you quit smoking, talk to your doctor first.

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Under the Affordable Care Act, many health insurance plans will cover preventive care services, including checkups, vaccinations and screening tests, at no cost to you. Learn more.

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