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Finding a balance between protecting our youth and saving 40 million smokers’ lives
The Food and Drug Administration (FDA) is cracking down on the sale of e-cigarettes to kids in light of the growing popularity of the vaping device, JUUL. Simultaneously, the FDA supports the use of these much less harmful products for smokers who use them to replace smoking deadly cigarettes.
Both can be achieved in a balanced fashion without panic. Protecting youth can go hand in glove with saving the lives of the 40 million smokers who will die prematurely if they cannot quit or switch to substantially less harmful alternative products like e-cigarettes.
FDA's Scott Gottlieb and Mitch Zeller have a new vision for tobacco control that supports balance. Their two-pronged strategy is to make cigarettes less appealing and addictive while supporting safer alternative nicotine products and protecting underage youth from using any product.
But the public, regulators and legislators are sometimes confused by the mixed messages from different tobacco control tribes. I agree with leading tobacco control scientist Kenneth Warner, who calls for people to think, not feel about the rapidly changing marketplace. Regulation, policy and communication must be based on a synthesis of all the strongest science and not based on half-truths from cherry-picked data, anecdotes and hypothetical fears.
A key source of confusion is the troubling misperception that nicotine is the harmful part of tobacco. While it can be addictive and is not completely benign, it is not the main source of the problem. In sharp contrast, cigarettes and burned tobacco smoke contain more than 7,000 chemicals, including carbon monoxide and more than 70 known carcinogens. Nicotine does not kill when decoupled from smoked tobacco.
E-cigarette vape has no tobacco and is substantially less harmful than smoking. We cannot think of tobacco smoke and nicotine use the same way anymore. The new disruptive technology of delivering safer but satisfying nicotine has led to a tectonic shift in the landscape. Traditional tobacco control strategy must also adjust.
Products like JUUL, invented by two Stanford University engineers, are an American success story. JUUL is not a tobacco company; rather they have created a technology to directly compete with and disrupt the cigarette market.
To their credit, they are concerned about youth experimenting with their product and proactively contacted the FDA. JUUL is taking further steps as Attorney General Tom Miller of Iowa announced on April 25, "JUUL executives have stated from the start that they do not want kids using the product... Indeed, current youth use is far more harmful to JUUL than the cash generated. JUUL has pledged to work with me and others to keep their products from kids. This is an opportunity we have never had before."
The challenge is to help smokers while protecting youth as much as possible. Evidence is mounting that e-cigarettes are now the most popular method of quitting smoking and can complement FDA-approved nicotine replacement products like gums and patches. Flavors also help smokers to quit smoking or to switch completely.
The new products must be managed but not destroyed because of their potential to make deadly cigarettes obsolete. Nicotine can be a helpful ally in speeding the demise of smoked tobacco and that means accepting nicotine use in society like we do alcohol and increasingly marijuana.
The issue of keeping children from smoking is not an "either or" strategy but a "both and" strategy - that is both saving 40 million smokers' lives and protecting youth as much as possible - and acknowledging that complete prohibition is unattainable. We can look to other successful harm minimization strategies - as in condom use for sexually active teens - as models. Society cannot eliminate all use of all forms of nicotine but we can discourage use with age restrictions and prevention of predatory marketing by companies, as the FDA is doing. Neither FDA nor companies themselves can control what consumers or youth communicate via social media.
Some use by youth is expected and cannot be totally eliminated despite best efforts. Youth are risk takers by nature. Estimates of the association between e-cigarette and cigarette use among youth show that it is mainly experimental use and there is no evidence it leads directly (i.e. as a gateway) to regular daily cigarette use. There's also good news: during the same years e-cigarette experimentation increased the most (2012-14), the prevalence of youth smokers declined at a rate 3 to 4 times faster than the rates seen in the last 40 years.
If we continue to demonize nicotine, the real losers are the millions of smokers and future potential smokers who have been misled by fear-mongering. They do not perceive the difference between substantially safer smokeless tobacco, e-cigarettes, nicotine medications and the deadly smoke from cigarettes Research shows if most smokers switched to vaping over the next decade then we could save 6.6 million American lives.
But I fear the fading of momentum for safer consumer products as a result of confusion sown by the skeptics in the tobacco control movement who now fight smoking by demonizing any and all forms of nicotine and focus on youth prevention at the expense of saving all smokers lives.
Public health officials ought to welcome the manufacture and marketing of regulated, safer nicotine containing products and encourage innovation and competition to eliminate smoked products. Products and regulation that will make smoking obsolete will also make most concerns about youth moot once smoking disappears and safer products are available. This will take time but if we keep our eye on the prize and if cooler heads prevail, America can lead the way to get rid of burning tobacco products.
Dr. David Abrams is a professor of social and behavioral sciences at New York University College of Global Public Health and a former Director of the Office of Behavioral and Social Sciences Research (OBSSR) at the National Institutes of Health.