tag:theconversation.com,2011:/ca-fr/topics/smoking-cessation-4696/articlesSmoking cessation – La Conversation2023-12-31T20:28:06Ztag:theconversation.com,2011:article/2188162023-12-31T20:28:06Z2023-12-31T20:28:06ZFrom today, new regulations make it harder to access vapes. Here’s what’s changing<figure><img src="https://images.theconversation.com/files/565086/original/file-20231212-23-grq40b.jpg?ixlib=rb-1.1.0&rect=5%2C1988%2C3946%2C3443&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/man-in-gray-sweater-smoking-cigarette-sitting-on-bench-during-daytime-3athPFPd5rs">Ryan Grice/Unsplash</a></span></figcaption></figure><p>This year the Australian government is introducing a <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/next-steps-on-vaping-reforms?language=en">series of measures</a> to restrict the availability of vapes, starting today.</p>
<p>The new reforms address loopholes in the current laws that allow easy access to highly addictive, flavoured, cheap, and harmful vaping products that are <a href="https://theconversation.com/tiktok-promotes-vaping-as-a-fun-safe-and-socially-accepted-pastime-and-omits-the-harms-203423">marketed to kids</a>. </p>
<p>Vaping products will still be available through a prescription for anyone using them to quit smoking. But the Therapeutic Goods Administration will <a href="https://www.tga.gov.au/news/media-releases/new-regulations-place-stronger-controls-importation-manufacture-and-supply-vapes">tightly regulate</a> prescription-only vapes.</p>
<p>So what are the new regulations? And why are they needed? </p>
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<p>
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<strong>
Read more:
<a href="https://theconversation.com/whats-in-vapes-toxins-heavy-metals-maybe-radioactive-polonium-210462">What's in vapes? Toxins, heavy metals, maybe radioactive polonium</a>
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<h2>What was wrong with the previous regulations?</h2>
<p>Before the 2024 rule changes, vaping products imported and sold in Australia were required to be nicotine-free, unless accessed through a pharmacy with a prescription from a qualified health professional. </p>
<p>Individual users were also allowed to import nicotine-vapes from overseas through the <a href="https://www.tga.gov.au/products/personal-importation-scheme">Personal Importation Scheme</a>, provided they had a valid prescription. </p>
<p>The vaping industry – including manufacturers, importers and retailers – exploited these loopholes and openly sold <a href="https://www.health.nsw.gov.au/tobacco/Publications/e-cigarette-analysis-project-summary-report.pdf">products containing nicotine</a> to young people by falsely claiming the products were “nicotine-free”. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1575083639586660353"}"></div></p>
<p>But the only way to tell the difference between a nicotine and nicotine-free vape is to test it in a lab – a time consuming and expensive endeavour, given the high volume of products imported. </p>
<p>So enforcing the nicotine/nicotine-free standards essentially proved <a href="https://www.theguardian.com/australia-news/2023/nov/29/nsw-vape-sales-retailers-increase-government-ban-2023">near impossible</a> against an industry determined to addict a new generation of users.</p>
<h2>So what’s changing?</h2>
<p>The new laws help tidy up the confusion and make the rules much clearer and easier to enforce. </p>
<p>They also address the ready access to vapes, which is the single <a href="https://theconversation.com/we-asked-over-700-teens-where-they-bought-their-vapes-heres-what-they-said-190669">biggest challenge</a> to preventing young people from vaping.</p>
<p>The regulatory changes will be rolled out in three phases:</p>
<h2>1. Importation ban</h2>
<p>The first phase, being implemented from today, includes a ban on the importation of all disposable, single-use vapes. These are the products that are <a href="https://www.cancercouncil.com.au/wp-content/uploads/2023/10/Gen-Vape-W4-Infographic-National.pdf">most popular with young people</a> and come in a variety of flavours, including fruit, confectionery, cocktails and tobacco. </p>
<p>Single-use, disposable vapes cannot be refilled, but <a href="https://www.health.nsw.gov.au/tobacco/Pages/vaping-types.aspx">come in a wide range</a> of sizes, from a few hundred of puffs, to upwards of 10,000 puffs. </p>
<p>Disposable vapes have flooded into Australia and fuelled the explosive rise in vape use among teens and young adults.</p>
<figure class="align-center ">
<img alt="Vape liquids in a shop" src="https://images.theconversation.com/files/565088/original/file-20231212-17-1bwxdr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/565088/original/file-20231212-17-1bwxdr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=480&fit=crop&dpr=1 600w, https://images.theconversation.com/files/565088/original/file-20231212-17-1bwxdr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=480&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/565088/original/file-20231212-17-1bwxdr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=480&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/565088/original/file-20231212-17-1bwxdr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=603&fit=crop&dpr=1 754w, https://images.theconversation.com/files/565088/original/file-20231212-17-1bwxdr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=603&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/565088/original/file-20231212-17-1bwxdr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=603&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Disposable vapes come in a range of flavours that appeal to young people.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/woman-in-black-shirt-standing-in-front-of-store-shelf-8RN9UZeL-fo">E-Liquids UK/Unsplash</a></span>
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<p>The importation of all other vapes, including refillable products, will be banned from March 1 2024, unless importers hold a licence and permit from the <a href="https://www.odc.gov.au/">Office of Drug Control</a> to lawfully import vapes. These legally imported vapes will only be sold in pharmacies to users with a prescription. </p>
<p>The Personal Importation Scheme allowance for vapes will also end on March 1 2024, meaning all vape users must access vaping products from a pharmacy in Australia.</p>
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<strong>
Read more:
<a href="https://theconversation.com/tga-review-strengthens-case-for-much-tighter-vape-restrictions-at-the-border-202506">TGA review strengthens case for much tighter vape restrictions at the border</a>
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<p>This initial phase, while effectively stopping illegal vapes from coming in to Australia, doesn’t address the high volume of product that is already here. Retailers will be able to continue to sell their existing stock of “nicotine-free” vapes. But as we know, these products often <a href="https://www.tga.gov.au/news/media-releases/infringement-notices-totalling-588840-issued-three-sydney-based-tsg-stores-and-jaradat-and-sabbagh-group-pty-ltd">do contain nicotine</a>. </p>
<h2>2. Domestic manufacture and sales ban</h2>
<p>The next phase of reforms, expected to come into effect in late 2024, will eliminate the retail sale of all types of vaping products, regardless of their claimed nicotine content.</p>
<p>This second phase will include a ban on the manufacture, supply, advertising and commercial possession of vapes that fall outside of the prescription framework. </p>
<p>These changes will require amendments to the <a href="http://www6.austlii.edu.au/cgi-bin/viewdb/au/legis/cth/consol_act/tga1989191/">Therapeutic Goods Act 1989</a>, and will likely be introduced in Autumn 2024 for federal Parliament’s consideration, but the exact date is yet to be set.</p>
<h2>3. Prescription access</h2>
<figure class="align-center ">
<img alt="GP listens to patient" src="https://images.theconversation.com/files/565089/original/file-20231212-29-grq40b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/565089/original/file-20231212-29-grq40b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/565089/original/file-20231212-29-grq40b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/565089/original/file-20231212-29-grq40b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/565089/original/file-20231212-29-grq40b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/565089/original/file-20231212-29-grq40b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/565089/original/file-20231212-29-grq40b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Vapes will only be available on prescription.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/female-consultant-meeting-teenage-patient-284516786">Shutterstock</a></span>
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<p>The prescription access to vapes for therapeutic purposes is also being changed to allow access to products that meet a quality standard. </p>
<p>From today, all medical and nurse practitioners will now be able to prescribe therapeutic vapes for quitting smoking or to manage nicotine dependence. </p>
<p>Further changes that strengthen the standards for therapeutic vapes are expected to be made by March 1 2024. For example, prescription vapes will have limits on the amount of nicotine, the types of flavours permitted, and be in standardised medical-style packaging. </p>
<h2>What do the changes mean for vape users?</h2>
<p>Vapes for therapeutic purposes will continue to be permitted in Australia and more medical professionals will be able to prescribe them. Prior to 2024, only select medical professionals could prescribe vapes (they had to register as an authorised prescriber). This is being widened to ensure the prescription model works as intended. </p>
<p>While vaping products will be available by prescription it’s important to know they <a href="https://www.tga.gov.au/resources/resource/guidance/nicotine-vaping-products-information-prescribers">remain unapproved medicines</a> that have not been subjected to the same rigorous safety and effectiveness testing as other evidence-based quit smoking aids. </p>
<p>If you’re thinking of quitting smoking (or quitting vaping), get support by talking to your doctor, calling the Quitline (13 7848), or accessing <a href="https://www.icanquit.com.au/">help online</a>.</p>
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Read more:
<a href="https://theconversation.com/my-teen-is-addicted-to-vaping-how-can-i-help-them-quit-and-manage-their-withdrawal-symptoms-208586">My teen is addicted to vaping. How can I help them quit and manage their withdrawal symptoms?</a>
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<img src="https://counter.theconversation.com/content/218816/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Becky Freeman is an Expert Advisor to the Cancer Council Tobacco Issues Committee and a member of the Cancer Institute Vaping Communications Advisory Panel. These are unpaid roles. She has received relevant competitive grants that include a focus on e-cigarettes/vaping from the NHMRC, MRFF, NSW Health, the Ian Potter Foundation, VicHealth, and Healthway WA; relevant research contracts from the Cancer Institute NSW and the Cancer Council NSW; relevant personal/consulting fees from the World Health Organization, the Hong Kong Special Administrative Region Department of Health, BMJ Tobacco Control, the Heart Foundation NSW, the US FDA, the NHMRC e-cigarette working committee, NSW Health, and Cancer Council NSW; and relevant travel expenses from the Oceania Tobacco Control Conference and the Australia Public Health Association preventive health conference.</span></em></p>Vapes will be harder to access from today, but the restrictions are staged, with some due to roll out later in the year. Here’s what’s changing.Becky Freeman, Associate Professor, School of Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2085862023-09-04T20:04:37Z2023-09-04T20:04:37ZMy teen is addicted to vaping. How can I help them quit and manage their withdrawal symptoms?<figure><img src="https://images.theconversation.com/files/540952/original/file-20230803-29-ilkf8h.jpg?ixlib=rb-1.1.0&rect=44%2C440%2C4913%2C3547&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/a-man-young-man-sitting-on-a-chair-with-a-vape-on-hand-10951435/">Pexels/Mushtaq Hussain</a></span></figcaption></figure><p>The Australian government is <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/taking-action-on-smoking-and-vaping">cracking down</a> on vaping. Recreational vapes of any type – whether they contain nicotine or not – will be banned from retail sale across Australia after <a href="https://www.theguardian.com/australia-news/2023/aug/16/australia-vaping-crackdown-new-laws">legislation</a> is introduced (though the date is yet to be set).</p>
<p>Rates of teen vaping have been <a href="https://www.aihw.gov.au/reports/children-youth/health-of-young-people">rising rapidly</a> in Australia, <a href="http://www.health.gov.au/sites/default/files/2023-06/current-vaping-and-smoking-in-the-australian-population-aged-14-years-or-older-february-2018-to-march-2023.pdf">from</a> 0.8% of 14- to 17-year-olds describing themselves as a current vaper over the past six months in 2018 <a href="https://www.health.gov.au/sites/default/files/2023-06/current-vaping-and-smoking-in-the-australian-population-aged-14-years-or-older-february-2018-to-march-2023.pdf">to</a> 14.5% in 2023. Among 18- to 24-year-olds, 19.8% have been a current vaper over the past six months. </p>
<p>Teens <a href="https://www.cancercouncil.com.au/news/new-research-finds-aussie-teens-find-illegal-vapes-easy-to-access/">mainly get</a> vaping products from their friends, retail vaping stores or the internet. Once the government restricts the distribution of vaping products, many will suddenly lose access to supplies. </p>
<p>In anticipation of this loss, people <a href="https://edition.cnn.com/2019/09/21/us/vape-stockpiling-legislation-trnd/index.html">may start stockpiling</a> vapes. But at some stage, they will have a drastic reduction in their use of vaping. </p>
<p>The majority of e-cigarettes <a href="https://www.uow.edu.au/the-stand/2022/whats-in-a-vape-.php">contain nicotine</a>, even when they’re not labelled as such. <a href="https://www.watoday.com.au/national/western-australia/largest-bust-of-vapes-nangs-in-australia-found-in-perth-s-north-east-20230812-p5dvyu.html">Some vapes tested in Australia</a> contained 900 milligrams of nicotine – the equivalent of the nicotine in almost 100 cigarettes. </p>
<p>So we can expect teenagers who vape will experience nicotine withdrawal symptoms. </p>
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Read more:
<a href="https://theconversation.com/how-bad-is-vaping-and-should-it-be-banned-197913">How bad is vaping and should it be banned?</a>
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<h2>What is nicotine dependence and withdrawal?</h2>
<p>Nicotine dependence means a person is physically and psychologically addicted to nicotine. This produces a strong desire for, and difficulty controlling, nicotine use. </p>
<p>Young people are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8287334/#:%7E:text=In%20adolescents%2C%20even%20infrequent%20smoking,smokers%20(7%E2%80%9310)">at greater risk of nicotine dependence</a> than adults and can develop dependence faster. </p>
<p>Once nicotine-dependent, a person will <a href="https://ctimaine.org/wp-content/uploads/2018/09/Tobacco-Diagnosis-Coding.pdf">experience withdrawal symptoms</a> if they reduce or cease their use. These symptoms can include irritability, frustration, or anger; anxiety; difficulty concentrating; increased appetite; restlessness; depressed mood; and insomnia. </p>
<p>The <a href="https://kidshealth.schn.health.nsw.gov.au/sites/default/files/honc_june_2022.pdf">Hooked on Nicotine Checklist</a> is helpful for teens and their parents. It’s a ten-item checklist to assess dependence on smoking cigarettes or vaping, specially designed for adolescents. The higher the score, the less control your teen will have over their nicotine addiction. </p>
<p>Feeling a loss of control can begin after using vapes for only a short time. Some adolescents <a href="https://tobaccocontrol.bmj.com/content/9/3/313">start showing signs</a> of becoming dependent on nicotine within days of occasionally using it – before they are smoking or vaping daily.</p>
<figure class="align-center ">
<img alt="Mother talks to teen" src="https://images.theconversation.com/files/541400/original/file-20230807-19-6usu56.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/541400/original/file-20230807-19-6usu56.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/541400/original/file-20230807-19-6usu56.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/541400/original/file-20230807-19-6usu56.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/541400/original/file-20230807-19-6usu56.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/541400/original/file-20230807-19-6usu56.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/541400/original/file-20230807-19-6usu56.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Teens who have a nicotine dependence are likely to experience withdrawal symptoms when they stop vaping.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/worried-parent-young-mom-comforting-depressed-1701862456">Shutterstock</a></span>
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<h2>I don’t even know if my teen vapes …</h2>
<p>Nicotine exposure during adolescence can <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8287334/#:%7E:text=In%20adolescents%2C%20even%20infrequent%20smoking,smokers%20(7%E2%80%9310)">disrupt</a> the brain’s normal development, <a href="https://www.cancercouncil.com.au/news/5-things-parents-should-know-about-vaping/">impacting</a> their mood, impulse control, memory and ability to focus and learn. </p>
<p>If your teen is <a href="https://www.health.nsw.gov.au/tobacco/Pages/vaping-factsheet-young.aspx">unusually irritable or has an unexplained low mood</a>, consider the possibility of nicotine withdrawal, particularly after vapes are no longer readily available. Many adolescents are vaping without the adults in the household being aware. Vapes can be hidden in plain sight, as they look like a highlighter pen or USB stick.</p>
<p>Initiating a conversation is <a href="https://adf.org.au/talking-about-drugs/vaping/vaping-youth/talking-about-vaping/">sometimes easier</a> when side-by-side, not face-to-face with a young person – for example, when walking together or if your teen is in the car with you. One way to bring the subject up is to ask whether any of their friends are vaping or if they’ve seen it at school. Then gradually move on to whether they have tried it themselves and their usage. </p>
<p>During the conversation listen out for hints that mean your teen could be a heavy user of vaping, <a href="https://research.avondale.edu.au/cgi/viewcontent.cgi?article=1000&context=oer_materials">such as</a>:</p>
<ul>
<li>vaping alone, instead of only socially</li>
<li>vaping within 30 minutes of waking up in the morning, or</li>
<li>vaping through the night (this might mean keeping an e-cigarette under the pillow for night-time use). </li>
</ul>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/tiktok-promotes-vaping-as-a-fun-safe-and-socially-accepted-pastime-and-omits-the-harms-203423">TikTok promotes vaping as a fun, safe and socially accepted pastime – and omits the harms</a>
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<h2>So how do I help my teen quit?</h2>
<p>Once you know your teen is vaping, broach the subject of quitting with them in a non-judgemental way. Try questions like “have you ever tried having a break from them?” and “how did that feel?”</p>
<p>If they are willing to attempt quitting, or are already withdrawing due to reduced access to vaping products, let them know you are there to support them and help is available. </p>
<h2>First try counselling and cold turkey</h2>
<p>The Quitline or a GP can help with goal setting, such as setting a quit date, <a href="https://www.quit.org.au/make-a-plan/">making a quit plan</a> and identifying triggers for vaping and strategies to address them. </p>
<p>There are also online tools your teen may like, such as <a href="https://www.health.gov.au/resources/apps-and-tools/my-quitbuddy-app">My Quit Buddy</a>, an app that provides practical tips, progress charts and health information to help with quitting.</p>
<h2>Nicotine replacement therapy</h2>
<p>If counselling alone is not successful, <a href="https://www.aap.org/en/patient-care/tobacco-control-and-prevention/youth-tobacco-cessation/nicotine-replacement-therapy-and-adolescent-patients/#:%7E:text=Overall%20efficacy%20findings%20have%20been,US%20Preventive%20Services%20Task%20Force.">nicotine replacement therapy</a> <a href="https://www.cancer.org.au/cancer-information/causes-and-prevention/smoking/quit-smoking">may help</a>. </p>
<p>Nicotine-replacement therapy is <a href="https://www.quit.org.au/articles/nicotine-replacement-therapy-frequently-asked-questions/">available</a> in a fast-release form (used by mouth via a nicotine inhalator, spray, gum, or lozenges) or a slow-release patch. For someone quitting vaping, fast-release forms are likely to work best.</p>
<p>However, sometimes a teenager might need more than one nicotine-replacement product, called “<a href="https://www.quit.org.au/articles/combination-nicotine-replacement-therapy-nrt">combination therapy</a>”. Combination therapy is better when the teen is highly dependant on nicotine and has strong and frequent urges to vape. </p>
<p>Be sure to follow the instructions for each product and encourage regular doses so withdrawal symptoms are controlled. </p>
<figure class="align-center ">
<img alt="Teen talks to nurse in waiting room" src="https://images.theconversation.com/files/543890/original/file-20230822-29-bb1bls.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543890/original/file-20230822-29-bb1bls.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543890/original/file-20230822-29-bb1bls.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543890/original/file-20230822-29-bb1bls.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543890/original/file-20230822-29-bb1bls.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543890/original/file-20230822-29-bb1bls.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543890/original/file-20230822-29-bb1bls.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Teens should try counselling and going cold turkey first.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/nurse-talking-african-american-female-teenager-1979853032">Shutterstock</a></span>
</figcaption>
</figure>
<p>Eighteen year olds can buy nicotine-replacement products without a script at a supermarket or pharmacy. A pharmacist can advise on the correct use. </p>
<p>If your child is aged 12–17, it’s recommended they are first assessed by their GP, who <a href="https://healthinfo.healthengine.com.au/nicotine-replacement-therapy-nrt">can prescribe</a> nicotine-replacement therapy. A script from a GP may allow access to a subsidised course through the Pharmaceutical Benefits Scheme (PBS). </p>
<p>Aboriginal and Torres Strait Islander youth can get <a href="https://www.icanquit.com.au/quitting-methods/professional-support-and-advice/quitline/aboriginal-quitline">further help</a> from their local Aboriginal health service, which can offer culturally safe support and may also have supplies of nicotine-replacement therapy.</p>
<p>When using nicotine replacement therapy, adherence is critical to <a href="https://www.mdpi.com/1660-4601/18/22/12225">successfully quitting</a>. Use it for a <a href="https://www.cancercouncil.com.au/wp-content/uploads/2016/09/16138_CA_CAN5084_NRTFactsheet_WEB.pdf">minimum of eight weeks</a> and preferably 12 weeks to avoid relapse.</p>
<p>GPs can also <a href="https://www1.racgp.org.au/ajgp/2022/july/an-update-on-vaping-and-nicotine-prescribing">prescribe</a> nicotine liquid (non-flavoured) for a refillable e-cigarette. But clinical guidelines recommend discouraging vaping because of their ongoing addictive nature because <a href="http://www.mja.com.au/system/files/issues/218_06/mja251890.pdf">they’re a gateway</a> for smoking tobacco. </p>
<p>Teens who vape are <a href="http://www.mja.com.au/system/files/issues/218_06/mja251890.pdf">three times more likely to take up smoking</a>. So addressing your teen’s vaping is an important preventative step for <a href="https://pubmed.ncbi.nlm.nih.gov/36156328/">both smoking and vaping</a> in future. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-can-i-help-my-teen-quit-vaping-201558">How can I help my teen quit vaping?</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/208586/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gillian Sandra Gould receives funding from the National Health and Medical Research Council, Global Alliance for Chronic Disease, Cancer Australia, Cure Cancer Australia, NSW Health, RACGP Foundation, and the Dept. of Health and Aged Care.
</span></em></p><p class="fine-print"><em><span>Marilyn Clarke receives funding from Dept of Health and NHMRC for research projects involving smoking cessation and pregnant Aboriginal women.</span></em></p><p class="fine-print"><em><span>Karen McFadyen does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Teens who quit vaping or drastically cut back are likely to experience withdrawal symptoms. Here’s how to support young adults through withdrawal and quitting.Gillian Sandra Gould, Professor in Health Equity, Southern Cross UniversityKaren McFadyen, Research Fellow, Faculty of Health, Southern Cross UniversityMarilyn Clarke, Senior Research Fellow, Southern Cross UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2066212023-05-30T11:49:49Z2023-05-30T11:49:49ZTobacco use is costly, but so is quitting. Surveys of 8 African countries show who needs help<figure><img src="https://images.theconversation.com/files/528876/original/file-20230529-17-hxj4e5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Media Lens King/Getty Images</span></span></figcaption></figure><p>Tobacco use imposes a large health and economic burden worldwide. Research <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8223261/#bib10">estimates</a> that, in 2019, about 8 million deaths were attributable to tobacco smoking. Tobacco also reduces <a href="https://www.who.int/data/gho/indicator-metadata-registry/imr-details/158">years of healthy living</a>: about 200 million <a href="https://www.who.int/data/gho/indicator-metadata-registry/imr-details/158#:%7E:text=Definition%3A-,One%20DALY%20represents%20the%20loss%20of%20the%20equivalent%20of%20one,health%20condition%20in%20a%20population.">disability-adjusted life years</a> in 2019. </p>
<p>This health burden comes with high economic costs, directly through medical treatment for tobacco-related diseases, and indirectly through productivity losses. Globally, the total economic cost of smoking amounted to around <a href="https://tobaccocontrol.bmj.com/content/27/1/58">1.8%</a> of the world’s annual GDP in 2012. Global studies are rare because they are so data intensive. </p>
<p>Though overall tobacco use has been <a href="https://www.annualreviews.org/doi/10.1146/annurev-publhealth-032315-021850?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed">declining</a> in most high-income countries since the 1970s, it has been stable or rising in most low- and middle-income countries. Today, more than <a href="https://www.who.int/news-room/fact-sheets/detail/tobacco#:%7E:text=Over%2080%25%20of%20the%20world's,(WHO%20FCTC)%20in%202003.">80%</a> of the world’s smokers live in low- and middle-income countries, resulting in a skewed burden of disease. </p>
<p>This skewed burden of tobacco-related disease exists within countries too. In <a href="https://cancercontrol.cancer.gov/sites/default/files/2020-06/m21_2.pdf">most countries</a>, tobacco use is disproportionately prevalent among the poor - the very people who can least afford to finance the healthcare and financial costs associated with it.</p>
<p>Tobacco use is not only about who smokes but about who quits. In high-income <a href="https://doi.org/10.1136/jech-2014-205171">countries</a>, it’s mostly wealthier users who attempt to quit – and who succeed. But research on cessation in lower income countries has been scarce.</p>
<p>A <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0277702#sec018">study</a> I co-authored with <a href="https://www.iash.ed.ac.uk/profile/dr-laura-rossouw">Dr Laura Rossouw</a> set out to fill some gaps. We decided to measure inequalities in tobacco cessation in eight sub-Saharan African countries. Using the most recent <a href="https://www.who.int/teams/noncommunicable-diseases/surveillance/systems-tools/global-adult-tobacco-survey">Global Adult Tobacco Surveys</a> in Botswana, Cameroon, Ethiopia, Kenya, Nigeria, Senegal, Tanzania and Uganda, we found that the people most likely to try and succeed at quitting were wealthier and better-educated individuals. Inequalities in ability to stop using tobacco were associated with socio-economic status, urban or rural residence, and not knowing or believing that tobacco consumption leads to serious illness.</p>
<p>We suggest that governments in these countries can do more to support socio-economically disadvantaged smokers in their efforts to stop using tobacco. Their strategies should be aligned with the guidelines outlined in the <a href="https://fctc.who.int/who-fctc/overview">World Health Organization’s (WHO) Framework Convention on Tobacco Control</a>.</p>
<p>Providing subsidised medical support to smokers trying to quit could make these services more accessible to the poor. This would ease the <a href="https://cancercontrol.cancer.gov/sites/default/files/2020-06/m21_2.pdf">disproportionate</a> health and financial burden of the tobacco-related illnesses that they suffer.</p>
<h2>Who uses tobacco</h2>
<p>Our analysis used nationally representative surveys of individuals aged 15 and older from each of the eight countries included in our sample. The Global Adult Tobacco Survey captures information about who is using tobacco and in what form, as well as demographic and socio-economic variables. It’s a standard survey design which allows comparison of countries. </p>
<p>We chose the eight sub-Saharan countries based on availability of data. The earliest survey was conducted in 2012 in Nigeria; the most recent, in Tanzania in 2018. Each survey recorded information on thousands of individuals – tobacco users and non-users. It also showed who had attempted to quit.</p>
<p>Across the countries, tobacco users were more likely to be in the lowest income group. In Uganda, Tanzania, Kenya, and Botswana, more than 40% of current and past tobacco users were in the lowest fifth of the income spectrum. And in Cameroon, Ethiopia, Kenya, Senegal and Uganda, more than 50% of current and past tobacco users had not completed any formal education.</p>
<p>Smokers who had tried to stop in the past year made up as many as 53% of current smokers (in Botswana), and at least 29% (Cameroon).</p>
<p>Our analysis showed that differences in wealth status contributed to inequalities between former and current tobacco users. Education widened the wealth-related gap. Living in an urban area (versus rural) did so too in some of the countries but not in Ethiopia, Senegal and Uganda. Tobacco health knowledge also played a part in creating inequality between richer and poorer smokers. Being misinformed about tobacco’s health consequences was concentrated among individuals with lower levels of education.</p>
<p>Our results showed that attempts to stop using tobacco – and successful attempts – were concentrated among wealthier individuals and those with higher levels of education.</p>
<h2>What helps smokers quit?</h2>
<p>The WHO’s guidelines, ratified by <a href="https://fctc.who.int/who-fctc/overview/parties">182 countries</a>, show which policies work best to reduce tobacco use. The WHO also <a>monitors</a> which countries are using the policies. </p>
<p>Among the <a href="https://www.who.int/initiatives/mpower">key policies</a> are warning about the dangers of tobacco use, banning advertising, offering help to quit, and taxing tobacco products.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-ghana-is-using-graphic-pictures-to-cut-tobacco-use-116845">How Ghana is using graphic pictures to cut tobacco use</a>
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</em>
</p>
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<p>The most recent WHO <a href="https://www.who.int/publications/i/item/9789240032095">Report on the Global Tobacco Epidemic</a> (2021) covers all 195 of the world’s countries. It shows there has been progress in following policies to reduce tobacco demand. </p>
<p>But of all the recommended measures to reduce the demand for tobacco, the least progress has been made with:</p>
<ul>
<li><p>offering tobacco users help to quit </p></li>
<li><p>raising tobacco taxes.</p></li>
</ul>
<p>A large body of <a href="https://cancercontrol.cancer.gov/sites/default/files/2020-06/m21_complete.pdf">evidence</a> conclusively shows that tobacco taxation is the most effective and efficient way to reduce tobacco consumption. But right now, out of all the policies, best-practice tobacco tax <a href="https://fctc.who.int/docs/librariesprovider12/technical-documents/who-fctc-article-6-guidelines.pdf?sfvrsn=3bee36c8_50&download=true">policies</a> protect the least number of people in the world. </p>
<p>As for offering <a href="https://theconversation.com/tobacco-control-south-africa-must-do-more-to-help-people-quit-smoking-161628">services</a> to tobacco users trying to quit: 55% of all low-income countries offer no support at all. No low-income countries offer the best-practice services. </p>
<p>Counselling and medication can <a href="https://www.cdc.gov/tobacco/data_statistics/sgr/2020-smoking-cessation/fact-sheets/healthcare-professionals-health-systems/index.html">more than</a> double a tobacco user’s chance of successfully quitting. But paying for it is a <a href="https://linkinghub.elsevier.com/retrieve/pii/S0091743519301057">challenge</a>. </p>
<p>There’s an opportunity to use tobacco taxation not only to reduce the demand for tobacco, but also to <a href="https://www.who.int/publications/i/item/9789240019188">generate revenue</a> for efforts to help users quit. </p>
<h2>Action is required</h2>
<p>Governments have an opportunity to reap health benefits for their citizens, and financial benefits for their country, through implementation of evidence-based tobacco-control policies.</p>
<p><a href="https://link.springer.com/article/10.1007/s00181-022-02226-4">Research</a> shows that a healthy population is a more productive and prosperous one.</p><img src="https://counter.theconversation.com/content/206621/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sam Filby works for the Research Unit on the Economics of Excisable Products based at the University of Cape Town. Her research is funded by the African Capacity Building Foundation through the Bill & Melinda Gates Foundation, Tax Justice Network Africa (also through the Bill & Melinda Gates Foundation), the CDC Foundation, and Cancer Research UK. Sam is also CIO of byegwaai, an app-based smoking cessation program.</span></em></p>In low-income countries, tobacco use is often associated with lower income and less education. These users can’t afford to pay for counselling and medication.Sam Filby, Research Officer, Research Unit on the Economics of Excisable Products, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2050162023-05-05T07:04:25Z2023-05-05T07:04:25ZNew funds will tackle Indigenous smoking. But here’s what else we know works for quit campaigns<figure><img src="https://images.theconversation.com/files/524535/original/file-20230504-29-jg5f4w.jpg?ixlib=rb-1.1.0&rect=0%2C88%2C1000%2C562&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/beautiful-african-american-girl-breaking-cigarette-2280036417">Studio Romantic/Shutterstock</a></span></figcaption></figure><p>Among all the talk this week about a <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/taking-action-on-smoking-and-vaping">crackdown on vaping</a> – the most significant <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/minister-for-health-and-aged-care-speech-national-press-club-2-may-2023?language=en">tobacco control reforms</a> in a decade – has been the roll-out of another major document.</p>
<p>The <a href="https://www.health.gov.au/resources/publications/national-tobacco-strategy-2023-2030">National Tobacco Strategy 2023–2030</a> was launched this week.</p>
<p>A key priority of the strategy is Aboriginal and Torres Strait Islander smoking and <a href="https://www.closingthegap.gov.au/">Closing the Gap</a>. We heard the Tackling Indigenous Smoking program would be extended and widened – <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/taking-action-on-smoking-and-vaping?language=en">with A$141 million funding</a> – to reduce both vaping and smoking among Aboriginal and Torres Strait Islander people.</p>
<p>Here’s why that’s urgently needed and what needs to happen next to reduce smoking rates among Aboriginal and Torres Strait Islander people.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-can-cut-indigenous-smoking-and-save-lives-heres-how-42119">We can cut Indigenous smoking and save lives – here's how</a>
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</em>
</p>
<hr>
<h2>Tobacco is still a killer</h2>
<p>Tobacco <a href="https://www.aihw.gov.au/news-media/media-releases/2019/october/tobacco-use-linked-to-more-than-1-in-8-deaths-but">legally kills</a> over 57 Australians a day. That’s equivalent to extinguishing an entire country town of 21,000 every year. </p>
<p>It’s still the single biggest <a href="https://www.aihw.gov.au/reports-data/health-conditions-disability-deaths/burden-of-disease/overview">preventable</a> risk factor for disease and premature death. For Aboriginal and Torres Strait Islander <a href="https://www.aihw.gov.au/reports/burden-of-disease/illness-death-indigenous-2018/summary">people</a>, <a href="https://academic.oup.com/ije/article/50/3/942/6118443">more than a third</a> of all deaths are caused by tobacco. Over the past decade we have lost more than <a href="https://academic.oup.com/ije/article/50/3/942/6118443">10,000</a> Aboriginal and Torres Strait Islander lives due to smoking.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1654018018169753600"}"></div></p>
<p><a href="https://healthbulletin.org.au/articles/review-of-tobacco-use-among-aboriginal-and-torres-strait-islander-peoples/">Multiple policy failures</a> beyond health – from poverty, education, employment, housing, family removals, dislocation and the systematic embedding of tobacco as rations <em>in lieu</em> of wages – mean Aboriginal and Torres Strait Islander people are disproportionately impacted by the harms of Big Tobacco. </p>
<p>So the <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/taking-action-on-smoking-and-vaping?language=en">funding</a> to expand the <a href="https://tacklingsmoking.org.au/">Tackling Indigenous Smoking program</a> is urgently needed to have no more than 27% of Aboriginal and Torres Strait Islander smoking by 2030 (5% of all Australians).</p>
<p>There have been huge achievements in reducing Aboriginal and Torres Strait Islander smoking. In <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/1753-6405.13049">2018–19</a>, 40% of Aboriginal and Torres Strait Islander adults smoked daily, down from 50% in 2004–05. A target of 27% is achievable. But to get there we need something “extra” to accelerate those reductions.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/heres-how-to-close-the-gap-on-indigenous-women-smoking-during-pregnancy-62347">Here's how to close the gap on Indigenous women smoking during pregnancy</a>
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</em>
</p>
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<h2>We know what works</h2>
<p>Tobacco campaigns are one of the most <a href="https://www.tobaccoinaustralia.org.au/chapter-14-social-marketing/14-1-social-marketing-and-public-education-campaig">cost-effective</a> <a href="https://tobaccocontrol.bmj.com/content/tobaccocontrol/21/2/127.full.pdf">interventions</a> when evidence-based, market-tested, sustained and with support services at the end of the call to action. When they are adequately funded, they can <a href="https://tobaccocontrol.bmj.com/content/31/2/284">impact inequities</a>.</p>
<p>Campaigns must be personally relevant and meaningful <a href="https://www.wiley.com/en-au/Health+Behavior%3A+Theory%2C+Research%2C+and+Practice%2C+5th+Edition-p-9781118629000">to be effective</a>. This makes the case for targeted approaches, including local level campaigns, reinforced by general, national activity. Audiences engage with the message when they can see themselves and their community members (sometimes actually) in the advertising.</p>
<p>We saw this nationally with <a href="https://www.youtube.com/watch?v=0yvjBU-E0aw">Break the Chain</a> starring Aboriginal actor and comedian Elaine Crombie. Originally this was a targeted campaign for Aboriginal and Torres Strait Islander people. But it then aired nationally targeting all Australians in 2014.</p>
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<figcaption><span class="caption">The ‘Break the Chain’ campaign featured Aboriginal actor and comedian Elaine Crombie.</span></figcaption>
</figure>
<p><a href="https://www.health.gov.au/resources/collections/campaign-resources-dont-make-smokes-your-story">Don’t Make Smokes Your Story</a> was launched in 2016, as part of the Tackling Indigenous Smoking program. This was created by Indigenous agency Carbon Media, starring musician <a href="https://www.youtube.com/watch?v=878H2fkw3L8">Fred Leone</a> alongside real stories <a href="https://www.youtube.com/watch?v=xCX-ZfopeSE">from community members</a>. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/1_dS1sYkLiQ?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">‘Don’t Make Smokes Your Story’ campaign.</span></figcaption>
</figure>
<p>One of the <a href="https://www.phrp.com.au/issues/september-2020-volume-30-issue-3/tackling-indigenous-smoking-a-good-news-story-in-australian-tobacco-control/">most successful</a> and innovative Aboriginal and Torres Strait Islander tobacco campaigns, it included a
<a href="https://www.health.gov.au/resources/publications/dont-make-smokes-your-story-toolkit?language=en">toolkit</a> for Aboriginal and Torres Strait Islander communities to use and adapt the national campaign to their <a href="https://tacklingsmoking.org.au/sharing-our-stories/">local contexts</a>.</p>
<p>An excellent example of this is from the <a href="https://www.apunipima.org.au/tackling-indigenous-smoking/#:%7E:text=The%20Apunipima%20Tackling%20Indigenous%20Smoking,to%20culturally%20appropriate%20quit%20support">Apunipima Tackling Indigenous Smoking team</a> with its local campaign <a href="https://www.youtube.com/watch?v=tohg0QEGVU0">Don’t Make Smokes Your Story Cape York</a>.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/tohg0QEGVU0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Campaigns can be localised, like this one from Cape York.</span></figcaption>
</figure>
<p>When Aboriginal and Torres Strait Islander people lead and promote smoke-free behaviours, communities are <a href="https://www.mja.com.au/journal/2015/202/10/predictors-wanting-quit-national-sample-aboriginal-and-torres-strait-islander">more interested in quitting</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/telehealth-has-much-to-offer-first-nations-people-but-technical-glitches-and-a-lack-of-rapport-can-get-in-the-way-201872">Telehealth has much to offer First Nations people. But technical glitches and a lack of rapport can get in the way</a>
</strong>
</em>
</p>
<hr>
<h2>What works? Product, price, place and promotion</h2>
<p>Social marketing campaigns, like the ones we’ve mentioned, really work well when they take on the <a href="https://www.cdc.gov/nccdphp/dch/programs/healthycommunitiesprogram/tools/pdf/social_marketing.pdf">Four Ps</a> of product, price, place and promotion.</p>
<p>The beautifully produced ads, the “promotion”, can’t have impact on their own. This is where the rest of the National Tobacco Strategy comes in.</p>
<p><strong>1. Product</strong></p>
<p>We’ve reduced product appeal with <a href="https://theconversation.com/world-first-plain-packaging-for-tobacco-products-a-step-closer-to-becoming-law-3053">plain packaging</a> and graphic health warnings. This will be enhanced with new warnings, including on the sticks themselves, plus greater uniformity of standardised packaging and tightened rules around additives and flavours that make smoking palatable.</p>
<p><strong>2. Price</strong></p>
<p>Price increases <a href="https://www.sciencedirect.com/science/article/pii/S2468266719302038">reduce smoking</a> and we’ll see a tax increase of 5% each year for three years across all different tobacco product types. </p>
<p><strong>3. Place</strong></p>
<p>We have known about the harms of commercial tobacco since at least 1950. Yet we still expect individuals to give up nicotine instead of removing this lethal product from sale at pretty much every supermarket, service station and convenience store. </p>
<p>The National Tobacco Strategy is considering a national licensing scheme, removing online sales and delivery services, and potential for reducing the number, type and location of tobacco outlets.</p>
<p>There will also be more action on smoke-free areas and making sure all health professionals (particularly in remote places) are equipped to support quit attempts.</p>
<p>The strategy states it will explore raising the age you can buy cigarettes and monitor how this works overseas. </p>
<p><strong>4. Promotion</strong></p>
<p>The commitment to close any last promotional loopholes for tobacco and e-cigarettes, particularly online is also important, along with local and national anti-smoking campaigns. But we know these are not enough on their own.</p>
<h2>What we also need</h2>
<p>Addressing all four Ps is what comprehensive tobacco social marketing would look like. It’s what’s required to accelerate the declines to get to the 27% target for Aboriginal and Torres Strait Islander peoples, and 5% nationally.</p>
<p>Targeted approaches are critical and can be effective, but they need to be supported by bigger, whole of population structural changes. The community-led campaigns, supported by national activity, will reinforce and amplify the policy changes that will come through on the tobacco product, its cost and its availability. </p>
<p>That’s how we realise our goals and ultimately eliminate tobacco related disease and death.</p><img src="https://counter.theconversation.com/content/205016/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christina Heris receives funding from the NHMRC Centre of Research Excellence on Achieving the Tobacco Endgame (NHMRC GNT1198301), and the Australian Government Department of Health and Aged Care for the Tackling Indigenous Smoking – Regional Grants Impact and Outcomes Assessment.</span></em></p><p class="fine-print"><em><span>Lisa J Whop receives funding from the National Health and Medical Research Council and the Australian Research Council. She is also a member and incoming chair of Cancer Australia's Leadership Group on Aboriginal and Torres Strait Islander Cancer Control.</span></em></p><p class="fine-print"><em><span>Michelle Kennedy receives funding from the National Health and Medical Research Council, Medical Research Future Fund and the National Heart Foundation. </span></em></p><p class="fine-print"><em><span>Raglan Maddox receives funding from from the NHMRC Centre of Research Excellence on Achieving the Tobacco Endgame (NHMRC GNT1198301), and the Australian Government Department of Health and Aged Care for the Tackling Indigenous Smoking – Regional Grants Impact and Outcomes Assessment.</span></em></p><p class="fine-print"><em><span>Raymond Lovett receives funding from the NHMRC. </span></em></p><p class="fine-print"><em><span>Tom Calma is the National Coordinator, Tackling Indigenous Smoking (TIS). This position is a consultancy to the Commonwealth Department of Health and Aged Care. </span></em></p>If we are to reduce the numbers of Aboriginal and Torres Strait Islander people smoking we need to consider a whole suite or approaches.Christina Heris, Research Fellow, Australian National UniversityLisa J Whop, Senior Fellow, Australian National UniversityMichelle Kennedy, Assistant Dean Indigenous Strategy & Leadership, University of NewcastleRaglan Maddox, Fellow, National Centre for Epidemiology and Public Health, Australian National UniversityRaymond Lovett, Director Mayi Kuwayu Study, Australian National UniversityTom Calma, Chancellor, University of CanberraLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2048122023-05-03T05:13:19Z2023-05-03T05:13:19ZCan vaping help people quit smoking? It’s unlikely<figure><img src="https://images.theconversation.com/files/523954/original/file-20230503-14-m0t8hk.jpg?ixlib=rb-1.1.0&rect=81%2C63%2C5925%2C3944&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/many-different-disposable-ecigarettes-hand-delicious-2049512471">Shutterstock</a></span></figcaption></figure><p>Australian Health Minister Mark Butler has announced a <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/taking-action-on-smoking-and-vaping?language=en">major policy shift on vaping</a>. Its two primary objectives are to make it harder for children and non-smokers to access vapes and to allow people trying to quit smoking to access nicotine vapes with a prescription. </p>
<p>Vapes are unquestionably popular, with many who vape saying they are trying to quit or to cut down on cigarettes. “Recreational” vapers of any age with no interest in quitting will find themselves frozen out.</p>
<p>But can vapes actually help significant numbers of people quit smoking? The evidence suggests it’s unlikely. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/a-potted-history-of-smoking-and-how-were-making-the-same-mistakes-with-vaping-200708">A potted history of smoking, and how we're making the same mistakes with vaping</a>
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</p>
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<h2>Myth of the ‘hardened smokers’</h2>
<p>First, let’s bust a widely believed myth. With smoking at an <a href="https://www.health.gov.au/sites/default/files/2023-05/national-tobacco-strategy-2023-2030.pdf">all time low</a>, some experts argue today’s smokers are the die-hard addicts: frequently relapsing smokers who just can’t quit. </p>
<p>Whenever this hypothesis has been tested it has been found wanting. In nations where smoking prevalence has fallen most, we would expect (if the hypothesis was true) that indicators of hardened smokers (such as average number of cigarettes smoked per day) would be rising because the remaining smokers would be over-represented by heavy, addicted smokers.</p>
<p>But according to <a href="https://pubmed.ncbi.nlm.nih.gov/30868166/">a 2020 review of 26 studies</a>:</p>
<blockquote>
<p>Some have argued that a greater emphasis on harm reduction or intensive treatment approaches is needed because remaining smokers are those who are less likely to stop with current methods. This review finds no or little evidence for this assumption.</p>
</blockquote>
<p>In other words, there is no evidence long-term smokers are impervious to the suite of tobacco control policies and campaigns that have driven hundreds of millions of smokers around the world to quit. </p>
<figure class="align-center ">
<img alt="Ashtray close up" src="https://images.theconversation.com/files/523958/original/file-20230503-19-71ckwh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523958/original/file-20230503-19-71ckwh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=385&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523958/original/file-20230503-19-71ckwh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=385&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523958/original/file-20230503-19-71ckwh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=385&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523958/original/file-20230503-19-71ckwh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=484&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523958/original/file-20230503-19-71ckwh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=484&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523958/original/file-20230503-19-71ckwh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=484&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The idea that ‘hardened smokers’ can’t quit is a myth.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/ashtray-full-smoked-cigarettes-extreme-close-1579956118">Shutterstock</a></span>
</figcaption>
</figure>
<h2>Vapes don’t help smokers cut back</h2>
<p>The idea that vaping helps people smoke fewer cigarettes isn’t supported by the evidence. Studies of the number of cigarettes foregone by vapers who still smoke have shown that, compared with smokers who never vape, the average daily cigarette consumption is very similar. </p>
<p>Data from 2019 from the United Kingdom government’s annual <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/methodologies/opinionsandlifestylesurveyqmi">Opinions and Lifestyle Survey</a> also <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/drugusealcoholandsmoking/datasets/ecigaretteuseingreatbritain">show</a> the average number of cigarettes smoked daily by smokers who vape (8 a day) is almost identical to that by smokers who have never vaped (8.1 a day).</p>
<p><a href="https://bmjopen.bmj.com/content/8/6/e016046">A 2018 paper</a> considered the surge in e-cigarette use in England and whether this was reducing the number of cigarettes being smoked at the population level across the country. The authors concluded:</p>
<blockquote>
<p>No statistically significant associations were found between changes in use of e-cigarettes […] while smoking and daily cigarette consumption. Neither did we find clear evidence for an association between e-cigarette use […] specifically for smoking reduction and temporary abstinence, respectively, and changes in daily cigarette consumption. </p>
<p>If use of e-cigarettes […] while smoking acted to reduce cigarette consumption in England between 2006 and 2016, the effect was likely very small at a population level. </p>
</blockquote>
<h2>How effective are vapes in quitting?</h2>
<p>The most recent <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010216.pub7/full">Cochrane review</a> of randomised controlled trials compared vaping with nicotine replacement therapy (such as drugs, gums and patches). It found <a href="https://profglantz.com/2022/11/21/cochrane-collaborative-concludes-e-cigs-as-medical-interventions-help-smokers-quit-again-while-continuing-to-ignoring-stronger-more-relevant-real-world-evidence-that-they-dont/">about 82%</a> of people who vape are still smoking when followed up six or more months later. </p>
<p>This was better than those using nicotine replacement therapy: 90% were still smoking.</p>
<p>Neither nicotine replacement therapy or vapes are hugely disruptive of smoking. You certainly wouldn’t be confident using a drug for any health issue that had a 82-90% failure rate. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/drugs-gums-or-patches-wont-increase-your-chances-of-quitting-89767">Drugs, gums or patches won't increase your chances of quitting</a>
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<figure class="align-center ">
<img alt="GP listens to patient" src="https://images.theconversation.com/files/523955/original/file-20230503-26-oc0x2b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523955/original/file-20230503-26-oc0x2b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523955/original/file-20230503-26-oc0x2b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523955/original/file-20230503-26-oc0x2b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523955/original/file-20230503-26-oc0x2b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523955/original/file-20230503-26-oc0x2b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523955/original/file-20230503-26-oc0x2b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Nicotine replacement therapies aren’t very effective at helping people quit.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/female-consultant-meeting-teenage-patient-284516786">Shutterstock</a></span>
</figcaption>
</figure>
<p>Randomised controlled trials also poorly reflect the ways vapes and nicotine replacement therapy are used in the real world and aren’t representative of all smokers wanting to quit. </p>
<p>A <a href="https://pubmed.ncbi.nlm.nih.gov/21212379/">review</a> of 54 randomised controlled trials on quitting smoking, for example, found two-thirds of smokers with nicotine dependence would have been excluded from clinical trials by at least one criterion. This may result in participation biases, which reduce the applicability of the results to smokers at large, or even smokers at large who want to quit. </p>
<p>This, and <a href="https://ses.library.usyd.edu.au/bitstream/handle/2123/28576/Mass%20distraction%20with%20cover.pdf?sequence=3&isAllowed=y">other factors</a>, make randomised controlled trials likely to overestimate effectiveness, as I outline in <a href="https://ses.library.usyd.edu.au/bitstream/handle/2123/28576/Mass%20distraction%20with%20cover.pdf?sequence=3&isAllowed=y">chapter two of my book</a>. </p>
<h2>What does the real-world evidence show?</h2>
<p>The best evidence we have about how vapes perform comes from studies where large numbers of vapers are followed for several years. The <a href="https://tobaccocontrol.bmj.com/content/26/4/371">US Population Assessment of Tobacco and Health (PATH) project</a>, for example, has been collecting national cohort data on 46,000 Americans since 2013.</p>
<p>As the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6202279/pdf/nihms965122.pdf">PATH data</a> below show, when randomly selected groups of vapers are followed up at 12 months, the most common outcome is those who were smoking and vaping at the beginning of the study period will still be vaping and smoking at the end of the 12 months. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/523994/original/file-20230503-16-7qv313.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523994/original/file-20230503-16-7qv313.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=578&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523994/original/file-20230503-16-7qv313.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=578&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523994/original/file-20230503-16-7qv313.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=578&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523994/original/file-20230503-16-7qv313.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=726&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523994/original/file-20230503-16-7qv313.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=726&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523994/original/file-20230503-16-7qv313.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=726&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The most common outcome is those who were smoking and vaping at the start were still doing both 12 months later.</span>
<span class="attribution"><span class="source">Data from the US Population Assessment of Tobacco and Health (PATH) project</span></span>
</figcaption>
</figure>
<p>I’ve summarised 16 other <a href="https://simonchapman6.com/vaping-research-alerts/#smoking-cessation">reviews and expert group conclusions</a> of the evidence published since 2017. Words like “low quality”, “inconclusive”, “insufficient”, “weak”, “low level” and “limited” abound.</p>
<h2>The upshot?</h2>
<p>The prescription vapes access scheme’s most important population effect is likely to be that it will massively reduce access to vapes by children. State governments will start hitting retailers illegally selling with massive fines and Border Security will do the same with importing suppliers. </p>
<p>Taiwan fines sellers a maximum of <a href="https://en.rti.org.tw/news/view/id/2009188">US$1.65 million, with a minimum of US$330,000</a>. The current maximum fine in New South Wales is currently only A$1,600. Such a fine would barely raise dust in big retailers’ petty cash drawers.</p>
<p>Based on the research, we might expect 10-18% of vapers using the prescription scheme to quit within 12 months (with some relapse expected), but many more will <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000216">quit unassisted</a>.</p>
<p>Preventing new generations of kids from becoming addicted to nicotine and more likely to start smoking is a huge policy advance that is hugely welcome.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/vaping-and-behaviour-in-schools-what-does-the-research-tell-us-204794">Vaping and behaviour in schools: what does the research tell us?</a>
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<img src="https://counter.theconversation.com/content/204812/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Chapman does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Many people who vape saying they are trying to quit or to cut down on cigarettes.Simon Chapman, Emeritus Professor in Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1867042022-08-04T12:21:07Z2022-08-04T12:21:07ZThe US government’s call for deep nicotine reduction in cigarettes could save millions of lives – an expert who studies tobacco addiction explains<figure><img src="https://images.theconversation.com/files/476774/original/file-20220730-28629-fb4hod.jpg?ixlib=rb-1.1.0&rect=246%2C49%2C5223%2C3572&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A 95% reduction in the nicotine content of cigars and cigarettes would make these tobacco products largely nonaddictive.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com.mx/detail/foto/cigarette-butts-overflowing-outdoor-ashtray-imagen-libre-de-derechos/520644430?adppopup=true">Robert Recker/The Image Bank via Getty Images</a></span></figcaption></figure><p>The cigarette is the only legal consumer product that – when used as intended – causes the premature death of half of long-term users. </p>
<p>To address this long-standing health threat, in late June 2022, the Biden-Harris administration <a href="https://www.fda.gov/news-events/press-announcements/fda-announces-plans-proposed-rule-reduce-addictiveness-cigarettes-and-other-combusted-tobacco">announced a plan</a> to move forward with a new standard for cigarettes and other combusted tobacco products that would make them minimally or nonaddictive. </p>
<p>A similar nicotine-reduction strategy has also recently been announced by the government of New Zealand and was <a href="https://blogs.otago.ac.nz/pubhealthexpert/removing-the-nicotine-from-tobacco-the-key-component-of-the-current-smokefree-bill/">described as the key component</a> of the country’s new smoke-free plan.</p>
<p>The Biden-Harris proposal was predated by <a href="https://doi.org/10.1056/NEJMp1707409">an earlier plan</a> in 2017 during Trump’s presidency to reduce the permissible nicotine content in cigarettes. <a href="https://www.ted.com/talks/mitch_zeller_the_past_present_and_future_of_nicotine_addiction?language=en">Mitch Zeller</a>, the director of the Food and Drug Administration’s Center for Tobacco Products from 2013 to April 2022, stated in 2019 that “this one rule could have the greatest impact on public health in the history of public health.”</p>
<p>So what does the proposal mean in practice? When implemented – likely not for at least another three years – it would mean that all cigarettes and cigars sold in the United States will have to contain approximately 95% less nicotine than they currently do. As nicotine is the addictive substance in tobacco, this would mean that these tobacco products would become pretty much nonaddictive. No more young people would become addicted to cigarettes and current smokers would find it much easier to quit. </p>
<p>As a <a href="https://scholar.google.com/citations?user=oYyjpUUAAAAJ&hl=en">professor of public health sciences</a> who has been doing research on smoking cessation for over 30 years, I am impressed by any intervention that increases the quit rate among smokers with no plans to quit. In one of our recent randomized clinical trials of very low-nicotine cigarettes, my research team at Penn State, along with colleagues at Harvard, found that those assigned to use them were more than <a href="https://doi.org/10.1101/2022.05.24.22275536">four times as likely to quit smoking</a> as those who smoked normal nicotine cigarettes. </p>
<p>Research suggests that the full public health benefits of a successfully implemented reduced nicotine standard for cigarettes could be enormous. </p>
<p>A 2018 FDA study projected that by the year 2060, a reduced nicotine standard for cigarettes <a href="https://doi.org/10.1056/NEJMsr1714617">could reduce the smoking rate dramatically</a> – from around 13% now to below 2%, preventing 16 million people from becoming regular smokers and preventing more than 2.8 million tobacco-caused deaths. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/vUx-b89laPU?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Along with heart disease, stroke and cancer, smoking can cause infertility, erectile dysfunction, cataracts, premature aging, hair loss and tooth loss.</span></figcaption>
</figure>
<h2>Not just a ‘light’ or ‘low-tar’ cigarette</h2>
<p>The proposed standard would not simply result in something akin to a “light” cigarette. Light cigarettes, which have been marketed for decades, contain <a href="https://doi.org/10.1136/tc.7.4.369">about the same amount of nicotine</a> as regular cigarettes – about 10 to 15 milligrams per cigarette. To comply with the new standard, a cigarette will likely be required to contain <a href="https://doi.org/10.1093%2Fntr%2Fntz045">less than 0.5 milligrams of nicotine</a>. </p>
<p>So-called “light” or “low-tar” cigarettes have tiny holes in the filter that allow air flow into the filter to dilute the smoke. When smoked by a machine, light cigarettes deliver lower levels of tar and nicotine per puff. However, when held by a human, the holes are often blocked by the fingers, and smokers can easily puff a bit harder to <a href="https://doi.org/10.1158/1055-9965.epi-04-0667">inhale the same amount</a> of nicotine and tar.</p>
<p>Some skeptics of the proposed nicotine reductions have raised the concern that smokers might just smoke reduced-nicotine-content cigarettes more intensely, as they do with “light” cigarettes. However, dozens of research studies have shown that with very low-nicotine-content cigarettes, smokers <a href="https://doi.org/10.1016%2Fj.drugpo.2021.103436">do not increase their smoke intake</a>. </p>
<p>Instead, over a short period of time, smokers learn that the very low-nicotine cigarette is not very satisfying, and <a href="https://doi.org/10.1001/jama.2018.11473">they gradually reduce their smoking</a>. In randomized trials, those using very low-nicotine-content cigarettes are also <a href="https://doi.org/10.1101/2022.05.24.22275536">more likely to quit</a>. </p>
<h2>A role for e-cigarettes</h2>
<p>When nicotine reduction in cigarettes was initially proposed under the Trump administration, Zeller and former FDA director Scott Gottlieb recognized that one of the main challenges to the success of this plan was the possibility that the regulation might give rise to an illicit market for high-nicotine cigarettes. </p>
<p>Zeller and Gottlieb understood that one critical way to keep that from happening is to allow nonsmoked nicotine products – like electronic cigarettes – to remain on the market. E-cigarettes deliver a satisfying amount of nicotine for smokers while exposing the user to significantly <a href="https://nap.nationalacademies.org/resource/24952/012318ecigaretteConclusionsbyEvidence.pdf">lower amounts of toxic substances</a> than regular cigarettes. As a result, e-cigarettes are likely to be significantly less harmful. </p>
<p>New research by our team, along with colleagues at Virginia Commonwealth University, recently found that when smokers with no plans to quit use <a href="https://doi.org/10.1093/ntr/ntab247">electronic cigarettes</a> with cigarettelike nicotine delivery, a greater proportion completely quit smoking than those using zero-nicotine e-cigarettes or no e-cigarette.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/6OZehKDHsj0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Exercise and support from family and friends – along with the nicotine patch – are a few of the strategies this smoker used to quit.</span></figcaption>
</figure>
<h2>The controversy over e-cigarettes</h2>
<p>The potential for e-cigarettes to help replace smoking explains why it came as a surprise to many when – two days after the Biden-Harris announcement in June to drastically reduce the permissible nicotine content in cigarettes – the FDA then announced that it was <a href="https://www.fda.gov/news-events/press-announcements/fda-denies-authorization-market-juul-products">effectively banning all sales</a> of Juul, the enormously popular e-cigarette that has been the biggest selling e-cigarette brand over the past five years. When Juul appealed the decision, the <a href="https://www.statnews.com/2022/06/24/court-rules-juul-can-sell-e-cig-while-challenges-fda-ban/">FDA suspended the denial order until an additional review is completed</a>, which is expected to take months. </p>
<p>And Juul is not the only e-cigarette to be threatened with a ban. Of the millions of e-cigarette applications submitted to the FDA by the deadline in September 2020, more than 99% <a href="https://www.fda.gov/tobacco-products/ctp-newsroom/fda-issues-marketing-denial-orders-fontem-us-myblu-products">have been denied</a>. </p>
<p>The reason the FDA’s e-cigarette ban is so puzzling and counterintuitive in the context of the FDA’s nicotine-reduction efforts in cigarettes is that the availability of e-cigarettes is critical to the feasibility of that plan.
Many researchers, including me, believe that having a variety of legal, regulated high-nicotine e-cigarettes on the market is a critical element in <a href="https://doi.org/10.2105%2FAJPH.2019.305067">reducing consumer demand</a> for illegal high-nicotine smoked products. </p>
<p>Health authorities in other parts of the world, including <a href="https://www.gov.uk/government/publications/the-khan-review-making-smoking-obsolete/making-smoking-obsolete-summary">the United Kingdom</a> and New Zealand, have recognized the important role that e-cigarettes can play in reducing cigarette smoking. New Zealand’s <a href="https://blogs.otago.ac.nz/pubhealthexpert/removing-the-nicotine-from-tobacco-the-key-component-of-the-current-smokefree-bill/">nicotine-reduction plan</a> explicitly includes providing access to alternative nicotine products like e-cigarettes. </p>
<p>Research shows that e-cigarettes are <a href="https://nap.nationalacademies.org/resource/24952/012318ecigaretteConclusionsbyEvidence.pdf">much less harmful</a> than cigarettes, and they are proved to <a href="https://www.cochrane.org/CD010216/TOBACCO_can-electronic-cigarettes-help-people-stop-smoking-and-do-they-have-any-unwanted-effects-when-used">help smokers transition</a> from highly toxic cigarettes. It is therefore highly likely to be appropriate for the protection of public health to keep a variety of e-cigarette brands on the market until after the nicotine reduction plan for cigarettes has been successfully implemented. </p>
<p>As we pass <a href="https://lcfamerica.org/get-involved/events/world-lung-cancer-day/">World Lung Cancer Day</a>, quietly as usual, I believe we now have a plan that could do more than anything else to reduce the number of deaths each year from that horrible disease. It is a plan that has been proposed by Republican and Democratic administrations alike and is supported by the best available science. In my view, implementation of a reduced-nicotine standard for combustible tobacco represents the possibility of finally bringing an end to cigarette addiction within our lifetimes.</p><img src="https://counter.theconversation.com/content/186704/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jonathan Foulds receives research funding from the U.S. National Institutes of Health, and has previously done consulting for pharmaceutical companies that manufacture smoking cessation medicines.</span></em></p>The proposed standard would lower the nicotine content in cigarettes and cigars by 95% – a public health proposal that could prevent millions from becoming smokers in the first place.Jonathan Foulds, Professor of Public Health Sciences and Psychiatry, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1862832022-07-26T05:45:54Z2022-07-26T05:45:54ZNew Zealand is introducing law to create a smokefree generation. Here are 6 reasons to support this policy<figure><img src="https://images.theconversation.com/files/475760/original/file-20220724-12-v8c42f.jpg?ixlib=rb-1.1.0&rect=6%2C55%2C4594%2C3007&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock/Pisit Koolplukpol</span></span></figcaption></figure><p>Imagine a society where tobacco does not kill nearly <a href="https://www.health.govt.nz/your-health/healthy-living/addictions/quitting-smoking/health-effects-smoking">5000 people every year</a> in New Zealand, and more than <a href="https://www.who.int/news-room/fact-sheets/detail/tobacco">eight million worldwide</a>. </p>
<p>The New Zealand government’s new legislation, which had its first reading in parliament today, aims to create a smokefree nation by introducing a unique measure to protect young people from the many harms smoking causes. </p>
<p>Smoking eventually kills two thirds of people who smoke long-term, which means tobacco companies face a stark choice. They can either continue to recruit new users or go out of the smoked-tobacco business. To date, they have chosen the former option. </p>
<p>By positioning smoking as a sophisticated adult behaviour and <a href="https://www.tobaccofreekids.org/microsites/cancerno9/">designing youth-oriented brands</a>, tobacco companies have <a href="https://www.who.int/news-room/questions-and-answers/item/tobacco-industry-tactics-to-attract-younger-generations">lured many thousands of young people</a> into a lifelong addiction that most came to regret.</p>
<p>Governments elsewhere have narrowed the pipeline of replacement smokers by increasing the purchase age of tobacco, which is now an R21 product in some <a href="https://www.fda.gov/tobacco-products/retail-sales-tobacco-products/tobacco-21#">jurisdictions</a>. </p>
<p>But Aotearoa plans to adopt a different approach with the <a href="https://legislation.govt.nz/bill/government/2022/0143/latest/LMS708154.html">Smokefree Environments and Regulated Products (Smoked Tobacco) Amendment Bill</a>, which will introduce a <a href="https://pubmed.ncbi.nlm.nih.gov/23591500/">smokefree generation</a>.</p>
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<a href="https://theconversation.com/smoking-age-heres-what-effect-raising-it-to-21-could-have-in-england-184874">Smoking age: here's what effect raising it to 21 could have in England</a>
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<p>The bill proposes disallowing the sale of tobacco products to people born in 2009 or later. Over time, this measure would create a smokefree cohort – a group of young people protected from smoking. </p>
<p>In combination with other proposed policies – reducing the nicotine content in tobacco products and far fewer retail outlets selling tobacco – the smokefree generation would see tobacco use virtually end.</p>
<p>But why move from extending age restrictions to creating a smokefree generation? Here are six key reasons.</p>
<h2>A measure to protect freedoms</h2>
<p>The vast majority of people who smoke <a href="https://pubmed.ncbi.nlm.nih.gov/15799597/">come to regret it</a> and say they would not smoke if they could live their lives again. </p>
<p>The smokefree generation addresses the burden addiction places on people. It puts in place age-appropriate restrictions, in the same way the government restricts other risky activities, such as drink driving. </p>
<p>However, unlike drink driving, tobacco products <a href="https://pubmed.ncbi.nlm.nih.gov/25857449/">cause the premature death</a> of two thirds of the people who smoke long-term. These risks greatly outweigh any potential perceived “benefits” at all ages. </p>
<p>A smokefree generation is a proportionate response to managing a highly dangerous product.</p>
<h2>Smoking is not an ‘informed choice’</h2>
<p>Tobacco companies have conveniently forgotten how strenuously they once <a href="https://news.stanford.edu/pr/2007/pr-proctor-021407.html">denied the harms smoking causes</a>. They now <a href="https://www.batnz.com/group/sites/BAT_9VNKQW.nsf/vwPagesWebLive/DO9T5KJ8?opendocument">acknowledge</a> the health risks associated with tobacco. </p>
<p>This stance enables them to claim smoking is an “informed choice” and thus blame people who smoke for harms they experience later. The smokefree generation challenges this <a href="https://pubmed.ncbi.nlm.nih.gov/25192770/">rhetoric</a> and recognises nobody can willingly embark on a lifelong addiction before they understand and accept the price it will extract.</p>
<h2>Right to protection from lethal products</h2>
<p>Although tobacco companies have done their best to <a href="https://pubmed.ncbi.nlm.nih.gov/35241613/">position smoking as a socially accepted practice</a> and tobacco as a normal consumer product, no other product kills its users when consumed exactly as intended. </p>
<p>The smokefree generation recognises people’s right to protection from a uniquely harmful product and addresses the historical anomalies that have allowed tobacco to be sold.</p>
<h2>Age restrictions do not provide sufficient protection</h2>
<p>Age-restriction policies mean that, as each year passes, some young people “graduate” beyond the age limit, which may inadvertently frame smoking as a rite of passage. </p>
<p>The smokefree generation challenges misperceptions of smoking as a coming-of-age ritual and makes it clear there is never a safe age to start smoking. By clearly signalling that smoking is always harmful, it offers much greater protection than age-restriction measures.</p>
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Read more:
<a href="https://theconversation.com/tobacco-killed-500-000-americans-in-2020-is-it-time-to-control-cigarette-makers-153611">Tobacco killed 500,000 Americans in 2020 – is it time to control cigarette-makers?</a>
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<h2>Reducing inequities caused by smoking</h2>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/28647728/">Modelling studies</a> estimate the smokefree-generation policy could halve smoking prevalence within 14 years among people aged 45 and younger. </p>
<p>Importantly, it is predicted to achieve a more than five-fold health gain to Māori, compared to non-Māori. These estimates mean the smokefree generation will help address disparities in smoking prevalence and reduce the health inequities they cause.</p>
<h2>The public is ready to bring an end to smoking</h2>
<p>Surveys have reported very strong support for the bill’s approach. A <a href="https://itcproject.s3.amazonaws.com/uploads/documents/ITC_Data_Briefing_SF2025__ASAP_support__final.pdf">New Zealand survey</a> of people who smoke or had recently quit found more than three quarters supported this policy. </p>
<p>Support for a smokefree generation was about 10% higher than for increasing the legal purchase age for tobacco from 18 to 21. Support among the general population is likely to be higher still, making the smokefree generation an overwhelmingly popular policy.</p>
<p>The policy will protect young people’s freedoms and safeguard their future wellbeing by removing access to a product engineered to addict them as quickly as possible. By framing smoking as socially unacceptable and preventing youth sales over time, the smokefree generation will help ensure smoking prevalence can never rise again.</p><img src="https://counter.theconversation.com/content/186283/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Janet Hoek receives funding from the Health Research Council of New Zealand and Cancer Society of New Zealand; she has previously held grants from the Royal Society Marsden Fund. She co-directs ASPIRE 2025, A University of Otago Research Centre whose researchers work to support the Government's Smokefree 2025 goal. She has served on government, crown entity and NGO advisory groups to support public health policy goals and is currently a member of the Health Coalition Aotearoa's Smokefree Expert Advisory Group.</span></em></p>Modelling studies estimate the smokefree generation policy could halve smoking prevalence within 14 years among people aged 45 and younger and achieve a more than a five-fold health gain for Māori.Janet Hoek, Professor of Public Health, University of OtagoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1854002022-06-26T19:58:24Z2022-06-26T19:58:24ZYoung non-smokers in NZ are taking up vaping more than ever before. Here are 5 reasons why<figure><img src="https://images.theconversation.com/files/469895/original/file-20220621-11-zt1wyo.jpg?ixlib=rb-1.1.0&rect=13%2C53%2C4479%2C2930&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Getty Images</span></span></figcaption></figure><p>The number of young New Zealanders aged 15 to 17 who vape every day has <a href="https://www.odt.co.nz/news/dunedin/campus/loopholes-seen-factor-youth-vaping-rate-rise">tripled in two years</a>, from 2% in 2018-19 to 6% in 2020-21, according to the most recent <a href="https://www.health.govt.nz/publication/annual-update-key-results-2020-21-new-zealand-health-survey">New Zealand Health Survey</a>. For young adults, aged 18 to 24, daily vaping increased from 5% to 15%. </p>
<p>Another national <a href="https://assets.nationbuilder.com/ashnz/pages/211/attachments/original/1645983761/2021_ASH_Y10_Snapshot_Topline_smoking_and_vaping.pdf">survey</a> focused on Year 10 school students shows these increases are especially high for Māori girls. Around one in five Māori girls aged 14 to 15 reported vaping daily in 2021. </p>
<p>Increases in regular vaping (defined as vaping at least monthly) are also <a href="https://assets.nationbuilder.com/ashnz/pages/326/attachments/original/1650606612/2021_ASH_Y10_Snapshot_Regular_smoking_and_vaping_FINAL.pdf">large</a>, particularly for Māori boys (19% in 2019 to 31% in 2021) and girls (19% to 41%).</p>
<p>While manufacturers claim vapes are lower risk alternatives <a href="https://www.bat.com/ecigarettes">for people who smoke cigarettes</a>, many people who vape have never smoked. </p>
<p>If only smokers took up vaping, we would expect to see increases in vaping to be offset by equivalent decreases in smoking. Instead, the growth in daily vaping <a href="https://blogs.otago.ac.nz/pubhealthexpert/daily-nicotine-use-increases-among-youth-in-aotearoa-nz-the-2021-snapshot-y10-survey/">exceeds the decline in daily smoking</a>. </p>
<p>Had vapes never been introduced, many young non-smokers may not have started using any nicotine products. Our new <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0268449">research</a> helps explain why non-smokers start vaping.</p>
<h2>5 factors that lead young non-smokers to vaping</h2>
<p>The manufacturers and promoters of vapes have been criticised for youth-centric promotions using <a href="https://tobaccocontrol.bmj.com/content/28/e2/e162">social media influencers and music event sponsorship</a>. Some retailers have also <a href="https://tobaccocontrol.bmj.com/content/early/2022/02/27/tobaccocontrol-2021-057123">circumvented recent laws</a> aimed at preventing youth from being exposed to enticing vape products and e-liquid flavours. </p>
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<p>Regulating industry activities to prevent youth vaping should remain an important focus of policy, research and monitoring. But the personal reasons why young non-smokers start vaping could provide additional insights and ways to reduce the problem.</p>
<p>Our <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0268449">research</a>, published in the journal PLOS One, is based on in-depth face-to-face interviews with 16 young adults, aged 18 to 25, who self-identified as regular vapers (from daily to at least a couple of times each month). Using a qualitative approach, we identified five factors that helped explain what had led these young non-smokers to vaping.</p>
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<a href="https://theconversation.com/vape-sellers-are-using-popular-music-videos-to-promote-e-cigarettes-to-young-people-and-its-working-158272">Vape sellers are using popular music videos to promote e-cigarettes to young people – and it's working</a>
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<p>Two of these factors – connection and belonging, and balancing social status and stigma – were psycho-social in nature. Vaping is a highly social activity, taking place predominantly in shared flat settings or at parties. Being part of a peer group where a vape was circling helped reinforce relationships through a collective experience. </p>
<p>The communal nature of vaping also helped provide an entry to social groups where participants had previously felt on the periphery. For instance, one participant enjoyed how his vape piqued others’ interest and acted as a conversation starter, while another explained how vaping helped him “fit in” at parties. </p>
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<p>The second theme, balancing social status and stigma, reflects the way vapes can become a personal fashion statement. One participant described her vape as “sleek and […] just my kind of style”. For others, vaping offered an opportunity to impress with “skills and tricks” they mastered when exhaling aerosol. </p>
<p>These attributes fostered social cachet and helped offset the perceived stigma many participants felt as non-smokers who vaped. That stigma, they believed, did not apply to people who had switched from smoking to vaping, as one participant explained:</p>
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<p>If you make the effort to get off smoking and get onto vaping, you get a lot more respect for it […] compared to people who just do it for the sake of it.</p>
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<h2>The allure of vaping</h2>
<p>Apart from psycho-social factors, vapes attracted non-smokers by providing stimulation and engagement. Unsurprisingly, the wide variety of vape liquids that mimic confectionery or soft drink flavours attracted and maintained young adults’ interest. Participants also experienced blowing clouds as whimsical, and many expressed an almost child-like fascination with the aerosol they exhaled. </p>
<p>Several participants vaped as a means of self-management, to relieve stress or boredom, anxiety or awkwardness. A minority began vaping intentionally to manage their weight, using sweet-flavoured vape liquids as a replacement for “stress eating”. The effectiveness of this approach is not clear.</p>
<p>Lastly, participants used rationalisations about vapes’ costs and benefits relative to smoking to justify their vaping. They believed vapes offered multiple benefits, such as pleasure, connections and social cachet, without the “costs” they associated with smoking cigarettes, including financial and long-term health harms as well as unpleasant odour and nausea. </p>
<p>As one participant explained, vaping “doesn’t seem anywhere near as bad as cigarettes […] I feel less guilty about using it”.</p>
<h2>Study limitations and implications</h2>
<p>One limitation of our work is that data collection took place before higher-strength “pod” devices such as JUUL and Vuse and disposable vapes such as <a href="https://www.podlyfe.co.nz/blogs/best-of-vaping-products/best-disposable-pod-vapes-in-new-zealand">Fruitia and SOLO</a> entered the market. </p>
<p>Pods and disposables are popular with young people and allow high nicotine concentrations in e-liquids, up to 60mg/ml, without causing a harsh sensation in the mouth and throat. Evidence suggests the <a href="https://www.nzherald.co.nz/nz/study-finds-vaping-with-nicotine-more-common-than-smoking-among-teens/LDBXYIOOPCUC7QHMZVPFEICXUM/">majority</a> (at least 80%) of youth and young adults who vape currently use nicotine, whereas a 2019 study suggested only <a href="https://www.nzherald.co.nz/nz/study-finds-vaping-with-nicotine-more-common-than-smoking-among-teens/LDBXYIOOPCUC7QHMZVPFEICXUM/">around a quarter</a> of vaping school students used nicotine. </p>
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Read more:
<a href="https://theconversation.com/a-damning-review-of-e-cigarettes-shows-vaping-leads-to-smoking-the-opposite-of-what-supporters-claim-180675">A damning review of e-cigarettes shows vaping leads to smoking, the opposite of what supporters claim</a>
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<p>This limitation means our study may not have fully captured the role of nicotine addiction in maintaining vaping. </p>
<p>While recent regulations have restricted the widespread, aggressive marketing of vaping products, <a href="https://tobaccocontrol.bmj.com/content/early/2021/07/22/tobaccocontrol-2021-056750.abstract">social media promotion nonetheless continues</a>. Vaping products are available at <a href="https://vuse.co.nz/pages/store-locator">numerous outlets</a> and there are no restrictions on manufacturers or retailers making “reduced-harm” marketing claims. </p>
<p>Easy access and “lower-risk” marketing messages likely normalise vaping and the belief that vaping is a safe activity. Educational efforts aimed at youth, such as the Asthma Foundation’s <a href="https://www.asthmafoundation.org.nz/news-events/2020/dontgetsuckedin-new-youth-vaping-education-campaign-launches">Don’t Get Sucked In</a> campaign, may help counter ideas that vaping is low-risk. </p>
<p>However, educational campaigns will have a limited impact if products remain widely available and appealing, and social marketing is not a substitute for effective policy. In light of rapidly increasing youth vaping, it is time to reconsider the widespread availability of vaping products in convenience stores and supermarkets and the use of eye-catching packaging and flavours that appeal to young people.</p><img src="https://counter.theconversation.com/content/185400/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lindsay Robertson receives funding from the Royal Society Marsden Fund, the National (NZ) Heart Foundation, and Otago Medical School Foundation Trusts. She has previously been supported by funding from: Bloomberg Philanthropies, the Health Research Council of New Zealand, the Cancer Society of New Zealand, Otago University (Department of Preventive and Social Medicine), Lottery NZ Health Research, and the Asthma and Respiratory Society of Aotearoa/ New Zealand. She is a member of ASPIRE 2025, a University of Otago Research Centre whose researchers work to support the government's Smokefree 2025 goal.</span></em></p><p class="fine-print"><em><span>Janet Hoek receives funding from the Health Research Council of New Zealand and Cancer Society of New Zealand; she has previously held grants from the Royal Society Marsden Fund. She co-directs ASPIRE 2025, A University of Otago Research Centre whose researchers work to support the Government's Smokefree 2025 goal. She has served on government, crown entity and NGO advisory groups to support public health policy goals. </span></em></p>Research suggests that if vapes had never been introduced, many young non-smokers may not have started using any nicotine products.Lindsay Robertson, Senior Research Fellow in the Department of Preventive and Social Medicine, University of OtagoJanet Hoek, Professor of Public Health, University of OtagoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1825832022-05-18T12:14:00Z2022-05-18T12:14:00ZWhy is the FDA seeking to ban menthol cigarettes? 4 questions answered<figure><img src="https://images.theconversation.com/files/462846/original/file-20220512-22-4l21fl.jpeg?ixlib=rb-1.1.0&rect=0%2C29%2C4888%2C3635&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Menthol cigarettes were responsible for an estimated 377,000 premature deaths in the U.S. during the past 40 years.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/cigarette-royalty-free-image/465892800">BAKERLY/iStock via Getty Images</a></span></figcaption></figure><p><em>The FDA has opened the <a href="https://www.fda.gov/tobacco-products/products-guidance-regulations/submit-comments-tobacco-products">public comment period</a> for the agency’s <a href="https://www.federalregister.gov/documents/2022/05/04/2022-08994/tobacco-product-standard-for-menthol-in-cigarettes">proposed ban on menthol cigarettes</a>. Epidemiology and global health professor <a href="https://sph.umich.edu/faculty-profiles/meza-rafael.html">Rafael Meza</a> studies data modeling in disease prevention and cancer risk. <a href="https://sph.umich.edu/faculty-profiles/mendez-david.html">David Mendez</a>, who studies smoking cessation and tobacco control policies, is an associate professor of health management and policy. These University of Michigan researchers found that, in a 38-year period, African Americans <a href="http://dx.doi.org/10.1136/tobaccocontrol-2021-056748">suffered most of the harmful effects</a> of menthol cigarettes. Now the researchers have developed a model to simulate the possible benefits of the menthol ban, based on studies of population trends in tobacco use. As experts on the behavioral and public health aspects of smoking, they explain the role of menthol in smoking-related illness and death.</em></p>
<h2>What are menthol cigarettes?</h2>
<p>Menthol is a chemical compound, obtained naturally from peppermint oil or produced synthetically using thymol, a compound in the herb thyme. When added to tobacco cigarettes, menthol produces a cooling sensation in the mouth and throat. Menthol cigarettes have enough of the compound added to give them that characteristic sensation and minty flavor. Instead of tasting like burning tobacco, menthol cigarettes might bring to mind cough drops or strong breath mints.</p>
<h2>Why are menthol cigarettes particularly harmful?</h2>
<p>Menthol reduces the harshness of cigarette smoking, making it more palatable for those new to smoking. Most of the experimenters are teens and young adults, who are vulnerable to long-term effects of <a href="https://doi.org/10.1016/j.pbb.2020.173010">nicotine on still-developing brains</a>. Among youths who are smokers, about <a href="https://doi.org/10.3390/ijerph18157781">60% smoke menthols</a>, with even <a href="https://doi.org/10.1186/s12889-017-4987-z">higher rates among Black adolescents</a>. Every year, menthol cigarettes increase the number of individuals who become regular smokers. Those who start with menthols often continue with them.</p>
<p>Our research shows that the harm of tobacco use continues as well. In addition to providing youths a more palatable introduction to smoking, the menthol flavor appears to keep them smoking. People who smoke menthol cigarettes smoke longer over their lifetimes and are <a href="https://doi.org/10.1136/tobaccocontrol-2020-056256">less likely to quit</a>. That translates into hundreds of thousands of additional premature deaths from lung cancer, emphysema and diseases made worse by smoking, like heart disease. In our study, we estimated that menthol cigarettes were responsible for <a href="http://dx.doi.org/10.1136/tobaccocontrol-2021-056748">377,000 premature deaths</a> among the U.S. population during the past 40 years.</p>
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<a href="https://images.theconversation.com/files/461648/original/file-20220505-12142-tlfryi.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Against a black background, an unidentified hand with dark skin, dirty nails and a generally unhealthy look holds an unlit cigarette between to fingers." src="https://images.theconversation.com/files/461648/original/file-20220505-12142-tlfryi.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/461648/original/file-20220505-12142-tlfryi.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/461648/original/file-20220505-12142-tlfryi.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/461648/original/file-20220505-12142-tlfryi.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/461648/original/file-20220505-12142-tlfryi.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/461648/original/file-20220505-12142-tlfryi.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/461648/original/file-20220505-12142-tlfryi.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Menthol cigarettes have led to particularly high numbers of negative health outcomes among African Americans.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/cigarette-in-unhealthy-hand-man-on-black-background-royalty-free-image/859367676">BAKERYLY/iStock via Getty Images</a></span>
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<h2>Why has there been a backlash to the FDA’s proposed ban?</h2>
<p>Some critics have raised concerns about potential unintended consequences of the proposed ban, particularly for African American menthol smokers. One worry is that banning menthol cigarettes could make Black people subject to arrest for buying or smoking them. Another concern is that a ban might create an illicit market for the cigarettes, particularly in African American neighborhoods.</p>
<p>But the FDA ban is on distributing the cigarettes, not buying, possessing or smoking them. The agency has been clear that it cannot and <a href="https://www.fda.gov/media/158015/download">will not enforce the ban</a> on individual consumers of menthol cigarettes or flavored cigars. And <a href="http://dx.doi.org/10.1136/tobaccocontrol-2021-057227">Canada’s experience with a similar ban</a> suggests that it is unlikely an illegal market would emerge.</p>
<p>Most importantly, any negative consequences would be outweighed by considerable health gains.</p>
<h2>How would a menthol cigarette ban help?</h2>
<p>Cigarette smoking prevalence has <a href="https://doi.org/10.1016/j.pmedr.2020.101227">decreased drastically since the 1960s</a>, thanks to tobacco control interventions like cigarette taxes, smoke-free air laws, marketing restrictions and education campaigns. The prevalence of menthol cigarette smoking, however, has remained <a href="https://doi.org/10.1186/s12889-017-4987-z">relatively constant since 2000</a>, which highlights the need for interventions specifically targeting menthol cigarettes. </p>
<p>We recently estimated that banning menthol cigarettes in the U.S. would translate into a <a href="https://doi.org/10.1136/tobaccocontrol-2021-056604">15% reduction</a> in menthol smoking prevalence and <a href="https://doi.org/10.1136/tobaccocontrol-2021-056604">prevent 650,000 premature deaths</a> by 2060. The gains among the Black population would be particularly considerable, with an estimated <a href="http://dx.doi.org/10.1136/tobaccocontrol-2021-056604">255,000 premature deaths averted</a>.</p>
<p>Under a menthol cigarette ban, it’s important that menthol cigarette smokers have help to quit smoking, and not just switch to nonmenthol cigarettes.</p><img src="https://counter.theconversation.com/content/182583/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Mendez receives funding from the National Institutes of Health</span></em></p><p class="fine-print"><em><span>Rafael Meza receives funding from the National Institutes of Health. </span></em></p>As the comment period begins for the FDA’s proposed ban, public health experts explain the stakes.David Mendez, Associate Professor of Health Management and Policy, University of MichiganRafael Meza, Professor of Global Public Health, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1806752022-04-06T20:00:16Z2022-04-06T20:00:16ZA damning review of e-cigarettes shows vaping leads to smoking, the opposite of what supporters claim<figure><img src="https://images.theconversation.com/files/456469/original/file-20220406-27-dllnff.jpg?ixlib=rb-1.1.0&rect=2%2C0%2C994%2C559&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-male-red-hoodie-vaping-smoking-1509908354">Shutterstock</a></span></figcaption></figure><p>A major review on the health effects of e-cigarettes reflects what public health advocates have feared – escalating use of e-cigarettes <a href="https://www.news.com.au/lifestyle/health/health-problems/the-deadly-effects-for-children-who-are-addicted-to-vaping/news-story/5d10592f82fb6e8703aef24e716e8b87?msclkid=09b86bfdb4a511ecb8218d6a20afd049">in school-aged children</a>, early warning signs of increased smoking rates in young Australians, and direct health harms of vaping in all ages.</p>
<p>The review, which was <a href="https://openresearch-repository.anu.edu.au/handle/1885/262914">released today</a>, was commissioned by the federal health department and conducted by researchers at the Australian National University. </p>
<p>Overall, it found the health risks from e-cigarettes significantly outweighed any potential benefits.</p>
<p>The review should silence lobbyists, who have long used data selectively <a href="https://www.tga.gov.au/sites/default/files/public-submissions-scheduling-matters-referred-acms-29-accs-27-and-joint-acms-accs-24-meetings-held-march-2020-arvia.pdf?msclkid=f0c3f5aeb48c11ec8e4636335b1daa85">to promote the sale of e-cigarettes</a>. This is despite the fact previous <a href="https://cdn.theconversation.com/static_files/files/2066/E-cigarettes-Consolidated-Final-Report240618-pdf.pdf?1649217778">reports</a>, none as comprehensive and rigorous as this latest review, have delivered similar findings.</p>
<h2>What does the review tell us?</h2>
<p>The review looked at the evidence behind the health impacts of e-cigarettes or “vapes” – a diverse group of devices that aerosolise a liquid for inhalation. These are touted as a safer alternative to cigarettes and an aid to quit smoking.</p>
<p>The review found conclusive clinical evidence e-cigarettes cause acute (short-term) lung injury, poisoning, burns, seizures, and their use leads to addiction. They also cause less serious harms, such as throat irritation and nausea.</p>
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Read more:
<a href="https://theconversation.com/vaping-related-lung-disease-now-has-a-name-and-a-likely-cause-5-things-you-need-to-know-about-evali-125730">Vaping-related lung disease now has a name – and a likely cause. 5 things you need to know about EVALI</a>
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<p>Evidence e-cigarettes produce airborne particles in indoor environments (potentially harming non-users) was also conclusive. </p>
<p>Among evidence ranked as strong, the review confirms what has worried tobacco control experts since patterns of e-cigarette use first emerged.</p>
<p>People who have never smoked or are non-smokers are three times as likely to smoke if they use e-cigarettes, compared with people who have never used e-cigarettes.</p>
<p>This is a dream for <a href="https://www.acosh.org/law-policy/australian-tobacco-control-legislation/e-cigarettes/?msclkid=3b7d0179b4af11ecbaf5e91d09febd1a">tobacco companies and their retail allies</a>.</p>
<h2>Weighing up the harms and the benefits</h2>
<p>The review found limited evidence e-cigarettes assist individuals to stop smoking. But this is no stronger than evidence showing e-cigarette use might also cause former smokers to relapse and revert to tobacco. </p>
<p>There is no conclusive or strong evidence in the review for any beneficial outcome from e-cigarettes. </p>
<p>E-cigarettes might help some individuals stop smoking. So they should only be available <a href="https://www.tga.gov.au/media-release/tga-confirms-nicotine-e-cigarette-access-prescription-only#:%7E:text=TGA%20confirms%20nicotine%20e-cigarette%20access%20is%20by%20prescription,law%20for%20them%20to%20buy%20such%20products%20domestically.?msclkid=48a5d2cfb49711ec9596ab5bdb44e5a2">via a prescription</a> from authorised medical professionals trained in helping people to quit. Any access beyond this risks serious harm for no benefit.</p>
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<strong>
Read more:
<a href="https://theconversation.com/its-safest-to-avoid-e-cigarettes-altogether-unless-vaping-is-helping-you-quit-smoking-123274">It's safest to avoid e-cigarettes altogether – unless vaping is helping you quit smoking</a>
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<h2>Young people are vaping</h2>
<p>Australian Institute of Health and Welfare <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/data">data show</a> the age group most likely to use e-cigarettes in their lifetime are 18 to 24-year-olds. This has risen from 19.2% in 2016 to 26.1% in 2019.</p>
<p>Of e-cigarette users who identify as smokers, the second largest user group is 14 to 17-year-olds. Dual use is starting young, from the limited Australian Institute of Health and Welfare data we have.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/456476/original/file-20220406-22-lhnm5k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Teenage girl smoking cigarette" src="https://images.theconversation.com/files/456476/original/file-20220406-22-lhnm5k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/456476/original/file-20220406-22-lhnm5k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/456476/original/file-20220406-22-lhnm5k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/456476/original/file-20220406-22-lhnm5k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/456476/original/file-20220406-22-lhnm5k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/456476/original/file-20220406-22-lhnm5k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/456476/original/file-20220406-22-lhnm5k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">E-cigarette use is most common in people who also smoke.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/teenage-hands-holding-cigarette-108900479">Shutterstock</a></span>
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<p>The Australian Institute of Health and Welfare data precedes increasingly visible use of e-cigarettes in Australian schools, <a href="https://www.news.com.au/lifestyle/health/health-problems/the-deadly-effects-for-children-who-are-addicted-to-vaping/news-story/5d10592f82fb6e8703aef24e716e8b87?msclkid=09b86bfdb4a511ecb8218d6a20afd049">reported in the media</a>.</p>
<p>The review also shows young males are the leading e-cigarette user group by age and sex. Australian males aged 18-24 are also the only age group which, on the latest Australian Institute of Health and Welfare data, are smoking at greater rates than they were three years earlier.</p>
<h2>We need to limit access</h2>
<p>Whatever benefits might be delivered by e-cigarettes, such as helping people to quit smoking, would, according to the review, be modest compared with the harms they are likely to cause.</p>
<p>Unfortunately, public policy on the regulation of e-cigarettes is at risk of influence from <a href="https://www.afr.com/policy/health-and-education/senators-claim-retail-lobby-group-misled-e-cigarette-inquiry-20210303-p577e7?msclkid=574db7dfb48e11ec839a457cfedebdf5">powerful commercial interests</a>. In the interests of public health, these forces must be resisted.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/vaping-is-glamourised-on-social-media-putting-youth-in-harms-way-159436">Vaping is glamourised on social media, putting youth in harm's way</a>
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<h2>What should governments do?</h2>
<p>Federal, state and territory <a href="https://www.health.gov.au/sites/default/files/documents/2019/12/policy-and-regulatory-approach-to-electronic-cigarettes-e-cigarettes-in-australia-principles-that-underpin-the-current-policy-and-regulatory-approach-to-electronic-cigarettes-e-cigarettes-in-australia.pdf?msclkid=ff001761b4a911ec8f1396f96f88ce8f">governments</a> have enacted policies aimed at providing <a href="https://www.tga.gov.au/nicotine-vaping-products?msclkid=a0393136b4aa11ecad0234c992620faf">e-cigarette access</a> to individuals who might benefit from them to quit smoking, while protecting everyone else. </p>
<p>But the evidence on how widely e-cigarettes are used shows these policies need to be more tightly <a href="https://www.tga.gov.au/testing-nicotine-vaping-products">enforced</a>.</p>
<p>It’s still easy to buy e-cigarettes online, they are available without prescription from petrol stations, tobacconists, specialty “vape” stores and are on-sold by entrepreneurs – all of them acting unlawfully. Heavy fines will end their cash incentive.</p>
<p>The review shows the risks to public health posed by e-cigarettes will only grow unless governments enforce their laws.</p>
<p>This is to protect young Australians from becoming the first generation <a href="https://www.tobaccoinaustralia.org.au/chapter-1-prevalence/1-4-prevalence-of-smoking-young-adults">since trend data was collected</a> to smoke and use nicotine at higher rates than their predecessors.</p>
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Read more:
<a href="https://theconversation.com/twelve-myths-about-e-cigarettes-that-failed-to-impress-the-tga-72408">Twelve myths about e-cigarettes that failed to impress the TGA</a>
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<img src="https://counter.theconversation.com/content/180675/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Grogan is employed by Cancer Council NSW (not-for-profit) and is a Senior Strategic Adviser, Daffodil Centre, a joint venture between Cancer Council NSW and the University of Sydney. Cancer Council NSW has extensively analysed the evidence on e-cigarettes and has taken a public position consistent with the comments in this article.
Paul Grogan is a co-author on separate/unrelated journal articles on tobacco control and cancer care with Professor Emily Banks.</span></em></p><p class="fine-print"><em><span>Guy Marks is President and (interim) Executive Director of the International Union Against Tuberculosis and Lung Disease. This organisation implements a tobacco control program, mainly in low-middle income countries, with funding received from Bloomberg Philanthropies, via Vital Strategies.</span></em></p>The health risks of e-cigarettes outweigh any benefits, a comprehensive review of the evidence shows.Paul Grogan, Adjunct Senior Lecturer, The Daffodil Centre, University of SydneyGuy B. Marks, Professor of Respiratory Medicine, South Western Sydney Clinical School, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1517332021-01-04T14:50:18Z2021-01-04T14:50:18ZEight ways to quit smoking in 2021 – what the science says<figure><img src="https://images.theconversation.com/files/376972/original/file-20210104-13-1ot6y52.jpg?ixlib=rb-1.1.0&rect=0%2C25%2C5607%2C3707&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/smoking-treatment-man-174166523">Image Point Fr/Shutterstock</a></span></figcaption></figure><p>Lots of people are greeting the new year with plans to quit smoking. The good news is, there is more evidence than ever on the best ways to boost your chances of success. Below we cover the different methods that science suggests are worth a shot. </p>
<p>1. <strong>Behavioural counselling</strong>. The science shows that support for quitting smoking makes you more likely to quit and stay quit than going it alone. Counselling on how to stop smoking is widely available from healthcare professionals and stop-smoking advisers. High-quality evidence from <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013229.pub2/full">over 300 studies in over 250,000 people</a> shows that receiving stop-smoking counselling increases long-term quit rates. </p>
<p>2. <strong>Remote support</strong>. There are many reasons – particularly this year – why you might not be able to see someone face to face for behavioural support. The good news is that <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013229.pub2/full">studies haven’t found any clear difference</a> between the effects of support delivered face to face versus remotely – for example, counselling delivered by telephone or video calls. There is also <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006611.pub5/full">growing evidence</a> that stop-smoking support delivered via text messages can boost quit rates.</p>
<p>3. <strong>Monetary rewards for quitting</strong>. There is <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013229.pub2/full">new high-quality evidence</a> that programmes that reward people for successfully quitting smoking increase long-term success. These rewards can include money or vouchers for goods or services. These programmes can be offered by workplaces and in some areas of the world are also available via local governments. They offer the benefit of an <a href="https://theconversation.com/helping-smokers-quit-financial-incentives-work-118488">immediate positive outcome</a> of stopping smoking, as many people find it difficult to think about the longer-term health benefits of quitting.</p>
<p>4. <strong>Nicotine replacement therapy</strong>, known as NRT, has been used safely to help people quit smoking for decades. It can be prescribed by healthcare professionals, but in many countries is available to buy without a prescription from grocery stores and pharmacies. <a href="https://theconversation.com/nicotine-replacement-when-quitting-cigarettes-consider-using-more-nicotine-not-less-115008">Evidence shows</a> that using two forms of NRT rather than one increases your chances of quitting – in particular, using a patch and another form such as gum, sprays or lozenges.</p>
<p>5. <strong>Varenicline</strong>, <a href="https://patient.info/healthy-living/quit-smoking-cessation/varenicline-champix">commonly known as Champix or Chantix</a>, is a medicine for stopping smoking that works by reducing the pleasure people experience from smoking. It also eases withdrawal symptoms when people quit. <a href="http://dx.doi.org/10.1002/14651858.CD006103.pub7">Studies show</a> that varenicline approximately doubles the chances of successful long-term quitting. Varenicline is available on prescription from healthcare providers.</p>
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<img alt="A box of Champix tablets." src="https://images.theconversation.com/files/376974/original/file-20210104-19-snju6x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/376974/original/file-20210104-19-snju6x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/376974/original/file-20210104-19-snju6x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/376974/original/file-20210104-19-snju6x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/376974/original/file-20210104-19-snju6x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/376974/original/file-20210104-19-snju6x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/376974/original/file-20210104-19-snju6x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Champix reduces the pleasure people experience from smoking.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/st-albans-england-10-january-2020-1611713578">Thomas Holt/Shutterstock</a></span>
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<p>6. <strong>Electronic cigarettes</strong> (or e-cigarettes). A <a href="http://dx.doi.org/10.1002/14651858.CD010216.pub4">recent review</a> covering 50 studies and over 12,000 participants found that nicotine e-cigarettes probably do help people to stop smoking for at least six months, and probably work better than NRT and nicotine‑free e-cigarettes. The review didn’t find an association with serious harms. However, <a href="https://theconversation.com/new-evidence-shows-e-cigarettes-can-help-people-quit-smoking-146418">we still need more</a>, reliable evidence to be confident about the effects of e-cigarettes. The good news is, more evidence is <a href="https://podcasts.ox.ac.uk/series/lets-talk-e-cigarettes">on its way</a>.</p>
<p>7. <strong>Combining medication and behavioural support</strong>. <a href="http://dx.doi.org/10.1002/14651858.CD009670.pub4">Studies show</a> that using both behavioural support, such as counselling, and a medicine, such as nicotine replacement therapy, increases quit rates more than using either alone. So for your best shot, try a combination of some of the methods above.</p>
<p>8. <strong>Cut down on how much you smoke</strong>. If you feel like you can’t quit, then try reducing your smoking. <a href="https://academic.oup.com/ntr/article-abstract/8/6/739/1086705">Evidence shows</a> that if you reduce how much you smoke, you are more likely to successfully quit in the long term. When you’re ready to try quitting completely, consider using one or more of the methods listed above.</p>
<h2>A few things to remember</h2>
<p>First, try not to worry about becoming addicted to stop-smoking medication. Most people can stop these medications without problems (if you end up using NRT long-term, remember that the harm from cigarettes <a href="https://theconversation.com/nicotine-replacement-when-quitting-cigarettes-consider-using-more-nicotine-not-less-115008">comes from the tar and not the nicotine</a>). Second, if you have a slip, don’t give up. <a href="https://www.webmd.com/smoking-cessation/features/smoking-relapse#1">This happens to many people</a>, and you should continue your quit attempt. </p>
<p>Finally, don’t be discouraged if you have tried to quit smoking before and it didn’t stick. Lots of people who have tried unsuccessfully to stop smoking eventually manage to quit. It can take a <a href="https://www.nhs.uk/live-well/quit-smoking/what-to-do-if-you-start-smoking-again/">few times to try</a> to stop smoking for good, and there are more ways than ever to help you quit.</p><img src="https://counter.theconversation.com/content/151733/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jamie Hartmann-Boyce receives funding from the National Institute for Health Research and Cancer Research UK for research to support quitting smoking. The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the NIHR or other organisations from which the authors receive research funding. </span></em></p><p class="fine-print"><em><span>Nicola Lindson receives funding from the National Institute for Health Research and Cancer Research UK for research to support quitting smoking. The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the NIHR or other organisations from which the authors receive research funding.</span></em></p>Experts at Oxford University’s Centre for Evidence Based Medicine review the latest evidence on how to quit smoking.Jamie Hartmann-Boyce, Senior Research Fellow, Departmental Lecturer and Co-Director of Evidence-Based Healthcare DPhil programme, Centre for Evidence-Based Medicine, University of OxfordNicola Lindson, University Research Lecturer, Nuffield Department of Primary Care Health Sciences, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1467472020-09-24T20:01:01Z2020-09-24T20:01:01ZCOVID-19 has offered us an unexpected opportunity to help more people quit smoking<figure><img src="https://images.theconversation.com/files/359705/original/file-20200924-21-rj9vg0.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6114%2C4064&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Smokers are worried. A respiratory disease is running rampant across the globe and people with unhealthy lifestyle habits appear to be especially vulnerable. </p>
<p>We know smokers hospitalised with COVID-19 are more likely to become <a href="https://www.who.int/news-room/commentaries/detail/smoking-and-covid-19">severely unwell and die</a> than non-smokers with the disease. </p>
<p>At any point in time, most smokers <a href="https://www.quit.org.au/news/8-10-victorian-smokers-want-quit-survey/">want to quit</a>. But COVID-19 provides the impetus to do it sooner rather than later. </p>
<p>In our <a href="https://journals.lww.com/journaladdictionmedicine/Abstract/9000/Preferences_for_Tobacco_Cessation_Information_and.99161.aspx">new study</a>, we surveyed 1,204 adult smokers across Australia and the United Kingdom. We found the proportion intending to quit within the next two weeks almost tripled from around 10% of smokers before COVID-19 to 29% in April.</p>
<p>Many more were thinking about quitting some time soon, and most wanted help to do so.</p>
<p>Our research shows many people who smoke understand they can reduce their COVID-19 related risk by addressing their smoking. Given this, and the broader health gains associated with stopping smoking, we must ensure people who want to quit in the face of COVID-19 are supported.</p>
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Read more:
<a href="https://theconversation.com/smoking-increases-your-coronavirus-risk-theres-never-been-a-better-time-to-quit-135294">Smoking increases your coronavirus risk. There's never been a better time to quit</a>
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<h2>Information and support</h2>
<p>When asked whether they’d like to receive information about the risks of COVID-19 for smokers, almost half (45%) of our respondents said they would. This was especially the case among those wanting to quit very soon. </p>
<p>As for where they wanted to get this information, participants most commonly chose government representatives (59%) and doctors (47%) as their preferred sources. </p>
<p>Television news was the most favoured information delivery channel (61%), followed by online news (36%), social media (31%) and email (31%).</p>
<figure class="align-center ">
<img alt="A man smokes a cigarette outdoors." src="https://images.theconversation.com/files/359704/original/file-20200924-16-4olx77.jpg?ixlib=rb-1.1.0&rect=8%2C0%2C5742%2C3828&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/359704/original/file-20200924-16-4olx77.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/359704/original/file-20200924-16-4olx77.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/359704/original/file-20200924-16-4olx77.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/359704/original/file-20200924-16-4olx77.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/359704/original/file-20200924-16-4olx77.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/359704/original/file-20200924-16-4olx77.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">We surveyed about 1,200 smokers in Australia and the UK.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>As well as being receptive to information, our participants were keen for support to help them quit.</p>
<p><a href="https://www.cdc.gov/tobacco/data_statistics/sgr/2020-smoking-cessation/index.html">Evidence-based</a> forms of smoking cessation assistance include nicotine replacement therapy (for example, gum, patches and inhalers) and counselling.</p>
<p>Almost two-thirds (61%) of our respondents expressed an interest in receiving nicotine replacement therapy to help them quit, which rose to more than three-quarters (77%) if it could be home-delivered and provided free of charge. </p>
<p>Half (51%) wanted access to personal advice and support, such as that provided by <a href="https://www.health.gov.au/contacts/quitline">Quitline</a>. A similar number (49%) were receptive to being part of a text support program for smokers.</p>
<p>These results show us smokers are interested in forms of quitting assistance that can be delivered remotely. Making sure smokers know these sorts of things are available in lockdown could increase uptake, and in turn reduce smoking rates.</p>
<p>It’s also important to note the <a href="https://www.acpjournals.org/doi/10.7326/M20-1212">social isolation</a> associated with the pandemic may make people more vulnerable to the addictive effects of nicotine. So they may need extra support during this time.</p>
<h2>Two big risks to our health</h2>
<p>Strong groundwork in the form of anti-smoking campaigns, tobacco taxes, and smoke-free environment legislation has reduced smoking levels in Australia to a record low of <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/contents/summary">11%</a>. But even at this rate, smoking remains Australia’s <a href="https://www.aihw.gov.au/getmedia/953dcb20-b369-4c6b-b20f-526bdead14cb/aihw-bod-20.pdf.aspx?inline=true">number-one avoidable killer</a>.</p>
<p>Smoking eventually kills up to <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-015-0281-z">two-thirds of regular users</a>, and the number of people dying from smoking-related diseases still dwarfs COVID-19 deaths. </p>
<p>Roughly <a href="https://www.who.int/news-room/fact-sheets/detail/tobacco">eight million people</a> around the world die each year from tobacco-related diseases (such as cancer, stroke and heart disease), compared to the almost <a href="https://www.worldometers.info/coronavirus/">one million</a> deaths attributed to COVID-19 so far. </p>
<p>Of course, the infectious nature of COVID-19 brings its own set of challenges. But combined, we have a potent reason to prioritise encouraging and helping smokers to quit as soon as possible.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/does-nicotine-protect-us-against-coronavirus-137488">Does nicotine protect us against coronavirus?</a>
</strong>
</em>
</p>
<hr>
<p>There has been <a href="https://theconversation.com/does-nicotine-protect-us-against-coronavirus-137488">speculation</a> about whether smoking increases the risk of contracting COVID-19, or whether nicotine might actually protect against the disease. The evidence remains unclear. </p>
<p>Regardless of whether smoking affects the risk of contracting COVID-19 in the first place, we know it increases the risk of dying from it. Providing intensive quit support during the pandemic could facilitate a substantial boost to cessation rates and bring us closer to the day when smoking becomes history.</p>
<h2>Capitalising on this opportunity</h2>
<p>Smokers’ increased risk from COVID-19 and the importance of encouraging smokers to quit to reduce their risk of a range of non-communicable diseases means <a href="https://infogram.com/ama-covid-19-factsheet-tobacco-1hd12y0rovwm6km?live">health agencies</a> <a href="https://www.gov.uk/government/news/smokers-at-greater-risk-of-severe-respiratory-disease-from-covid-19">around the world</a> are sending messages about the importance of quitting now. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1308392004653658112"}"></div></p>
<p>Our results suggest these statements should ideally be accompanied by explicit offers of help to quit in the form of nicotine replacement therapy and counselling. Investment in these is <a href="https://pubmed.ncbi.nlm.nih.gov/26031929/">cost-effective</a>, and now is an ideal time to make them as widely available and affordable as possible. </p>
<p>Many smokers would also likely benefit from the use of mass media to provide more information about their greater risk if infected with COVID-19.</p>
<p>This heightened interest in quitting in the face of COVID-19 — reflected not only in our research, <a href="https://news.sky.com/story/number-of-people-quitting-smoking-at-ten-year-high-thanks-to-change-in-attitudes-during-covid-19-pandemic-12077840">but elsewhere</a> — represents a unique opportunity for governments and health agencies to help smokers quit, and stay off smoking for good.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/smoking-at-record-low-in-australia-but-the-grim-harvest-of-preventable-heart-disease-continues-119169">Smoking at record low in Australia, but the grim harvest of preventable heart disease continues</a>
</strong>
</em>
</p>
<hr>
<p><em>Readers around Australia can call Quitline on 13 7848 or visit <a href="https://www.quit.org.au/">www.quit.org.au</a> to access a free multi-session quit assistance program.</em></p><img src="https://counter.theconversation.com/content/146747/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simone Pettigrew has received funding from the National Health and Medical Research Council, the Australian Research Council, Cancer Council Australia, and the National Heart Foundation. </span></em></p>During the COVID-19 pandemic, more smokers are wanting to quit. So how can we best support them?Simone Pettigrew, Professorial fellow, George Institute for Global HealthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1419862020-07-13T06:06:39Z2020-07-13T06:06:39ZMaking it harder to import e-cigarettes is good news for our health, especially young people’s<figure><img src="https://images.theconversation.com/files/346250/original/file-20200708-3974-1t0zycd.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C685&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/ecig-addiction-young-people-electronic-cigarette-1346973122">Shutterstock</a></span></figcaption></figure><p><a href="https://www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/prescription-nicotine-based-vaping">From next year</a>, access to e-cigarettes and related products containing liquid nicotine will require a doctor’s prescription. This is to ensure liquid nicotine is handled like the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4561260/">poisonous, addictive</a> substance it is and not promoted to young people. It’s good news for public health and bad news for the tobacco and e-cigarette industries.</p>
<p>This restriction comes into effect <a href="https://www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/prescription-nicotine-based-vaping">from January 1 2021</a>, six months later than <a href="https://www.odc.gov.au/news-media/news/australian-government-proposes-strengthening-its-stance-against-e-cigarettes">originally proposed</a>. </p>
<p>It’s not a ban on importing e-cigarettes. But it will <a href="https://www.tga.gov.au/behind-news/prohibition-importing-e-cigarettes-containing-vaporiser-nicotine">close loopholes</a> between established prohibitions on the supply and sale of nicotine at the federal level, and state and territory laws restricting access to nicotine.</p>
<p>Here’s the evidence to show why closing the loophole between health regulations, customs regulations and state and territory laws is good news for the nation’s health.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/twelve-myths-about-e-cigarettes-that-failed-to-impress-the-tga-72408">Twelve myths about e-cigarettes that failed to impress the TGA</a>
</strong>
</em>
</p>
<hr>
<h2>The so-called benefits of e-cigs don’t stand up</h2>
<p>There have only been a small number of quality reviews on the harms and benefits of
e-cigarettes for the whole population (rather than for individual people). They draw the same conclusions. </p>
<p><a href="https://www.csiro.au/en/Research/BF/Areas/Nutrition-and-health/Public-health-and-wellbeing/Case-studies/E-cigarettes-report">CSIRO</a> and the US <a href="https://www.nationalacademies.org/news/2018/01/new-report-one-of-most-comprehensive-studies-on-health-effects-of-e-cigarettes-finds-that-using-e-cigarettes-may-lead-youth-to-start-smoking-adults-to-stop-smoking">National Academies of Science, Engineering and Medicine</a> reviews found the evidence for e-cigarettes helping people quit smoking is inconclusive. The reviews also found e-cigarettes are harmful in their own right and associated with increased smoking and nicotine use in young people.</p>
<p>A 2017 review from Australia’s National Health and Medical Research Council drew <a href="https://www.nhmrc.gov.au/health-advice/all-topics/electronic-cigarettes">similar conclusions</a>.</p>
<p>Australian regulator, the <a href="https://www.tga.gov.au/community-qa/electronic-cigarettes">Therapeutic Goods Administration</a> or TGA, found no evidence to support the sale of e-cigarettes as a “therapeutic good”; the evidence of therapeutic benefit was inconclusive. Nor has the TGA found evidence to relax existing poison safety controls that require liquid nicotine access to be authorised by a doctor.</p>
<p>Despite the e-cigarette industry’s <a href="http://eprints.lse.ac.uk/56631/1/__lse.ac.uk_storage_LIBRARY_Secondary_libfile_shared_repository_Content_Phillips,%20L%20D_Estimating%20harms_Phillips%20_Estimating%20harms_2014.pdf">claims</a> and further promotion that “<a href="https://www.gov.uk/government/news/e-cigarettes-around-95-less-harmful-than-tobacco-estimates-landmark-review">e-cigarettes are 95% less harmful</a>” than smoking traditional cigarettes, there is <a href="https://ajph.aphapublications.org/doi/10.2105/AJPH.2019.305424">no scientific basis</a> for this either.</p>
<h2>Protecting young people</h2>
<p>Tobacco companies and retailers <a href="https://www.reuters.com/article/us-philipmorris-ecigs-instagram-exclusiv/exclusive-philip-morris-suspends-social-media-campaign-after-reuters-exposes-young-influencers-idUSKCN1SH02K">claim</a> e-cigarettes are an effective quit aid and are targeted at adult smokers who need them.</p>
<p>However, the tobacco industry and retail sector <a href="https://tobaccocontrol.bmj.com/content/28/e2/e162">promote</a> e-cigarettes through youth-friendly events, such as music festivals, and through social media by using influencers and celebrities, including singer <a href="https://www.bbc.com/news/technology-50821476">Lily Allen</a>.</p>
<p>And the promotion of flavoured e-cigarette products — strawberry, doughnut or banana, for instance — could create a generation of nicotine addicts.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/UKZIcRSFJaU?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Flavoured e-cigarettes can be appealing to children.</span></figcaption>
</figure>
<p>So, Australia’s latest move will protect young people and avoid the fate of countries like the US, where e-cigarette use in secondary school children has <a href="https://www.cdc.gov/tobacco/basic_information/e-cigarettes/surgeon-general-advisory/index.html">increased 78% in just 12 months</a>. </p>
<p>Parents and teachers are now seeing <a href="https://www.smh.com.au/lifestyle/health-and-wellness/principals-sound-alarm-as-students-take-up-vaping-become-black-market-dealers-20200703-p558vv.html">more e-cigarette use in Australian schools</a>. It is telling that the <a href="https://www.smh.com.au/politics/federal/vaping-a-harmless-alternative-or-a-dangerous-gateway-to-smoking-20200702-p558e7.html">largest growing segment</a> in e-cigarette use in Australia is in 18 to 24-year-old non-smokers and use has <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/ndshs-2016-detailed/contents/table-of-contents">also risen</a> among 12 to 17-year-olds.</p>
<h2>What about quitters?</h2>
<p>There are individuals who feel e-cigarettes help reduce the harms of smoked tobacco, and doctors who agree with them. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-the-ban-on-nicotine-vape-fluid-will-do-more-harm-than-good-141365">Why the ban on nicotine vape fluid will do more harm than good</a>
</strong>
</em>
</p>
<hr>
<p>Given the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4561260/">toxicity and addictiveness</a> of liquid nicotine, it is entirely appropriate to close loopholes that until now have enabled it to be acquired with no medical authority.</p>
<p>This is no different from controls around other harmful substances, such as methadone for treating heroin addiction.</p>
<p>There are two key differences with e-cigarettes. One, the case has not been made within an evidence-based framework that the products are safe and effective for widespread distribution; and two, they are being pushed through retailers operating outside the health system.</p>
<h2>Is this the end of the line for e-cigarettes in Australia?</h2>
<p>The government’s proposal is not closing the door to evidence or to options that may work for some individuals with a legitimate need to access these products. It is closing a door that exploits a disconnect between the poison and import laws to protect young Australians.</p>
<p>The restrictions will also prevent profiteers from addicting young Australians to harmful, novel products. Evidence on the benefits of e-cigarettes remains inconclusive but the risks to young Australians are increasingly clear.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/australias-decisive-win-on-plain-packaging-paves-way-for-other-countries-to-follow-suit-140553">Australia's decisive win on plain packaging paves way for other countries to follow suit</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/141986/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Becky Freeman has received funding from NHMRC, WHO, the Australian Government, Australian National Preventive Health Agency, NSW Health, Cancer Council Australia, Cancer Council NSW, NSW National Heart Foundation, Cancer Council Victoria, Healthway WA, Cancer Institute New South Wales, and the Australia-Indonesia Centre. She is a member of the NHMRC Electronic Cigarettes Working Committee.</span></em></p><p class="fine-print"><em><span>Matthew Peters is a member of the NHMRC Electronic Cigarettes Working Committee, is Co-Chair of the Thoracic Society of Australia and New Zealand Working Party on Electronic Cigarettes and also a member of the RACGP Smoking Cessation Guidelines Advisory Committee. </span></em></p><p class="fine-print"><em><span>Paul Grogan is a Senior Strategic Adviser, Cancer Research Division, Cancer Council NSW; While not politically active in any partisan sense, Cancer Council advocates for evidence-based cancer control public policy. I have represented Cancer Council as an independent/not-for-profit delegate on a number of government bodies, though none specifically focused on tobacco control. </span></em></p>From 2021, it will be harder to import e-cigarettes. That protects young people, in particular, who are increasingly being lured into nicotine and tobacco addiction.Becky Freeman, Senior Research Fellow, University of SydneyMatthew Peters, Professor of Respiratory Medicine, Macquarie UniversityPaul Grogan, Adjunct Senior Lecturer, School of Public Health, University of Sydney, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1293182020-01-29T13:20:28Z2020-01-29T13:20:28ZE-cig flavors may be more than alluring; they could cause damage themselves<figure><img src="https://images.theconversation.com/files/312168/original/file-20200128-81336-phd8ra.jpg?ixlib=rb-1.1.0&rect=63%2C120%2C4669%2C2963&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A vape shop in New York City shows a line of flavorings on Jan. 2, 2020.</span> <span class="attribution"><a class="source" href="https://theconversation.com/drafts/129424/edit">Mary Altaffer/AP Photo</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p><a href="https://news.gallup.com/poll/267413/percentage-americans-vape.aspx">Millions of Americans</a> are vaping, and some are getting sick. Since June 2019, <a href="https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html">2,711 have been hospitalized and 60 have died</a> due to <a href="https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html">EVALI</a> (e-cigarette-associated lung injury), the devastating lung disease linked to e-cigarettes.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/31688912">Five million</a> users are middle and high school students. Some are as young as 11, although it’s illegal to sell vaping products to anyone under 21. </p>
<p>Especially for kids, much of the lure is <a href="https://doi.org/10.1371/journal.pone.0194145">flavor</a>. E-cigarettes offer attractive smells and tastes. Fruit, mint, candy and dessert flavors are the favorites, and <a href="https://doi.org/10.1001/jama.2019.18387">studies suggest</a> they ignite the desire to vape. That’s why the Trump administration <a href="https://www.fda.gov/consumers/consumer-updates/facts-fdas-new-tobacco-rule">just banned</a> the sale of those sweet flavors from cartridge-based e-cigs, the delivery method most popular with teens. </p>
<p>One of us (<a href="https://biology.umbc.edu/directory/faculty/person/SA20601/">Weihong</a>) is a chemosensory neurobiologist, and the other (Rakaia) is a research assistant in <a href="https://linlab.umbc.edu/">my lab</a>. Put simply, we study how the sensory systems and brain react to chemical stimulation. With e-cigarettes, we are focusing on how the enticing flavors ensnare our children. </p>
<p>But our studies have shown that the effect of flavor goes beyond the pleasure they may bring – the flavorings themselves may actually harm tissue. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/uyCl3BdlICY?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">These ads extol the virtues of flavored cigarettes.</span></figcaption>
</figure>
<h2>Flavors enhance e-cig appeal</h2>
<p>The tobacco industry <a href="http://dx.doi.org/10.1136/tobaccocontrol-2014-051830">has long been using</a> flavorings make their products more palatable; it <a href="https://www.ncbi.nlm.nih.gov/pubmed/14507484">added menthol</a> to cigarettes nearly a century ago. </p>
<p>Today, the allure of flavors in e-cigarettes bring potential health consequences, and kids are particularly vulnerable. E-cigarettes can put adolescents at risk for respiratory, cardiopulmonary diseases, brain disorders and cancers.</p>
<p>About <a href="http://dx.doi.org/10.1136/tobaccocontrol-2019-055303">20,000 flavored e-liquids</a> are on the market – countless combinations of hundreds of flavoring molecules extracted from natural ingredients or artificially made. The vast majority are volatile odor chemicals, perceived not by taste, but by smell.</p>
<p>Your olfactory system, with far more sensitivity than your taste buds, can distinguish more than 10,000 smells. During vaping, a flavoring enters our nose, and like any agreeable scent, immediately evokes the <a href="https://doi.org/10.3758/BF03193837">fond memories</a> and <a href="https://www.livescience.com/why-smells-trigger-memories.html">pleasant emotions</a> associated with the aroma. Vanillin, a popular e-cigarette flavoring, smells like dessert; <a href="https://pubchem.ncbi.nlm.nih.gov/compound/Ethyl-maltol">ethyl maltol</a>, a flavoring used in many foods, has a candy-like odor. The user, comforted and calmed, savors the moment – then goes back for more. </p>
<p>But e-cigarette vapor also contains nicotine, heavy metals and formaldehyde, as pungent as they are <a href="https://www.ncbi.nlm.nih.gov/books/NBK507184/">harmful</a>. Mixing in delectable flavorings disguises their unpleasantness, much like the cherry additive that camouflages the otherwise medicinal taste of children’s cough syrup. </p>
<p>Yet perceptions of irritation and pain in the nose, mouth, and throat serve as warning signals, the body’s cautionary bells and whistles evolved over millions of years. A <a href="https://scholarblogs.emory.edu/evolutionshorts/2014/05/01/the-evolution-of-bitter-taste/">bitter taste</a> might originate from a toxic plant; irritation in the nose or respiratory tract indicates the inhaled substance is potentially harmful. </p>
<p>But now that flavorings in e-cigarette mask the warning signals, many consumers have been lulled into believing vaping is benign. They rate <a href="https://doi.org/10.18001/TRS.5.6.4:10.18001/">mint flavors as safer</a>, though they are not. And instead of irritation from the e-cigarette prompting a cough – an action that removes harmful stimuli from the airway – the flavorings instead dampen the user’s sensory alarms and protective reactions. The risk of chemically induced injury, along with nicotine abuse, is increased.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/312349/original/file-20200128-81362-i84vlg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/312349/original/file-20200128-81362-i84vlg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=485&fit=crop&dpr=1 600w, https://images.theconversation.com/files/312349/original/file-20200128-81362-i84vlg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=485&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/312349/original/file-20200128-81362-i84vlg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=485&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/312349/original/file-20200128-81362-i84vlg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=609&fit=crop&dpr=1 754w, https://images.theconversation.com/files/312349/original/file-20200128-81362-i84vlg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=609&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/312349/original/file-20200128-81362-i84vlg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=609&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Flavorings themselves, and not just e-cigarettes, could lead to chronic coughing.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/coughing-senior-man-sitting-on-sofa-615311849">Africa Studios/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>How flavors themselves may be toxic</h2>
<p>Although the U.S. Food and Drug Administration has acknowledged some flavorings as “safe for consumption,” its label dodges a critical distinction. Safe for consumption does not mean safe for inhalation. While scientists still haven’t confirmed the <a href="https://doi.org/10.1016/j.jaci.2019.11.001">inhalation toxicity</a> for all flavorings, the latest research reveals some disturbing evidence.</p>
<p>Many of the most common flavorings when present at high levels can cause <a href="https://doi.org/10.1016/j.toxlet.2018.02.025">inflammation</a>, cell death, <a href="https://doi.org/10.1016/j.toxlet.2018.02.025">free radical formation</a> and DNA damage. One class of compounds, known as furfurals, trigger <a href="https://doi.org/10.1016/j.toxlet.2018.02.025">tumor growth in mice</a>. </p>
<p>Flavor molecules, reacting <a href="https://doi.org/10.1093/ntr/nty192">with the propylene glycol</a> in the e-liquid, can produce <a href="https://www.news-medical.net/life-sciences/What-are-Metabolites.aspx">metabolites</a>, or intermediate substances that are part of metabolic reactions, that are irritating to the respiratory system. Long-term exposure to irritants can lead to chronic cough; inflammation; hyper-reactive airway (wheezing, shortness of breath); edema (swelling in the arms, hands, legs or feet); and acute lung damage.</p>
<p>Some flavorings, inhaled chronically or at high levels, are already known to cause serious and sometimes deadly respiratory illnesses. Diacetyl, a buttery flavor used in processed foods – notably some popcorn products – causes “<a href="https://www.lung.org/about-us/blog/2016/07/popcorn-lung-risk-ecigs.html">popcorn lung,</a>” an irreversible disease that affects factory workers exposed daily to the compound. </p>
<p>Many e-liquids contain diacetyl; <a href="https://www.ncbi.nlm.nih.gov/pubmed/26642857#">an analysis</a> found the substance in 39 out of 51 tested e-cigarette samples. In about half the samples, the estimated daily consumption was above safety limits. </p>
<p>Patients with EVALI exhibit a significant number of these symptoms, and all were attributed to vaping. <a href="https://doi.org/10.1016/j.drugalcdep.2018.11.030">In one survey</a>, users reported cough (40.0%); dry or irritated mouth or throat (31.0%); dizziness or lightheadedness (27.1%); headache or migraine (21.9%); or shortness of breath (18.1%). </p>
<p>Similar health problems have been reported by patients with chemically induced <a href="https://doi.org/10.1016/0378-4274(96)03673-9">sick building syndrome</a>. This implies that e-cigarette users share common health problems with those suffering from chemical exposure.</p>
<h2>What about long-term vaping?</h2>
<p>Ongoing chemical exposure, especially at high doses, can cause olfactory dysfunction, including a reduced sense of smell. This encourages chronic e-cigarette users to choose stronger-flavored e-liquids to receive a sufficient buzz. In turn, more potent e-liquids generate more irritation and damage to the nose, lungs and lower airway. </p>
<p>The health effects of e-cigarette exposure go beyond the sensory and respiratory systems. Mint and candy flavors are more than chemical accessories that enhance a harmless experience. They shape our behavior, perhaps for a lifetime. </p>
<p>Our government is making progress towards keeping teens away from e-cigarettes. Now, long-term research is needed to fully comprehend the adverse health effects and toxicity of flavorings and other chemical substances in the e-cigarette vapor to prevent the potentially catastrophic effects of vaping.</p>
<p>[ <em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/129318/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Weihong Lin receives research funding from NIH NIDA/TRSP.</span></em></p><p class="fine-print"><em><span>Rakaia Kenney does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The FDA has banned flavored e-cigarettes that appeal to kids. But new research shows that the danger of flavors could go beyond their appeal to kids. The flavorings themselves could cause damage.Weihong Lin, Professor of Biological Sciences, University of Maryland, Baltimore CountyRakaia Kenney, Research assistant, University of Maryland, Baltimore CountyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1271632019-11-20T21:53:06Z2019-11-20T21:53:06ZSome smokers credit e-cigarettes with saving their lives – does that matter?<figure><img src="https://images.theconversation.com/files/302701/original/file-20191120-474-k89gbo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Smoking is the number one cause of preventable death in the U.S., and most smokers say they want to quit.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/New-Jersey-Tobacco-Settlement/be6c6bac884f481d865bc14344306561/13/0">Mel Evans/AP File Photo</a></span></figcaption></figure><p>In a major blow to the vaping industry, the American Medical Association has called for a <a href="https://www.nytimes.com/2019/11/19/health/juul-lawsuit-ny-california.html">ban on e-cigarettes and vaping products</a> that the FDA doesn’t deem tobacco cessation devices. </p>
<p>As a <a href="https://www.uvm.edu/cas/psychology/profiles/allison-kurti">tobacco researcher</a> and former smoker, I don’t care much about the health of the vaping and e-cigarette industry. But I do care about the health of smokers, and I wonder whether policy makers may now be reacting too strongly to e-cigarettes. </p>
<p>Although e-cigarettes in the U.S. are not regulated or approved by the FDA as smoking cessation devices, they <a href="https://doi.org/10.1136/bmj.j3262">may have helped thousands quit cigarettes</a>.</p>
<p>I also wonder to what degree fear and hysteria, rather than evidence, might be informing this crucial public health topic. Smoking is the nation’s number one cause of preventable death, claiming close to half a million lives a year. </p>
<h2>Info overlooked, left out?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/302277/original/file-20191118-66941-8loxhv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/302277/original/file-20191118-66941-8loxhv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=343&fit=crop&dpr=1 600w, https://images.theconversation.com/files/302277/original/file-20191118-66941-8loxhv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=343&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/302277/original/file-20191118-66941-8loxhv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=343&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/302277/original/file-20191118-66941-8loxhv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=431&fit=crop&dpr=1 754w, https://images.theconversation.com/files/302277/original/file-20191118-66941-8loxhv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=431&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/302277/original/file-20191118-66941-8loxhv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=431&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">When comparing the dangers of e-cigarettes to cigarettes, some experts believe the health risks of e-cigs are not as serious as those from cigarettes.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-businessperson-holding-electronic-cigarette-hand-272625431">Andrey_Popov/Shutterstock.com</a></span>
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<p>As of Nov. 20, 42 people have died, and more than 2,000 have been sickened from vaping-related illnesses. The New York Times reported last month on the <a href="https://www.nytimes.com/2019/10/08/nyregion/vaping-death.html">youngest person to die</a> from vaping, a 17-year old boy from the Bronx. </p>
<p>If your reaction to this story is to call for comprehensive vaping bans, you are not alone. The outbreak of vaping-related pulmonary illnesses has generated substantial news coverage, with stories of <a href="https://www.nytimes.com/2019/10/14/us/vaping-victim.html">vaping-related deaths</a> emerging frequently, and likely contributing to several states implementing <a href="https://time.com/5685936/state-vaping-bans/">vaping bans</a>. </p>
<p>Reporting and public discourse often leave important data out of conversations, however. </p>
<p>For example, the <a href="http://nationalacademies.org/hmd/reports/2018/public-health-consequences-of-e-cigarettes.aspx">National Academies of Sciences’ report</a>, published in January 2018, reviewed all of the evidence to date on e-cigarettes, and found that, except for nicotine, toxicant exposure from e-cigarettes is lower than from combustible cigarettes. </p>
<p>Although “less harmful” does not mean “harmless,” harm minimization is likely the <a href="https://www.annualreviews.org/doi/10.1146/annurev-publhealth-040617-013849">most productive approach</a> for persistent smokers. That is, although <a href="https://doi.org/10.1038/nrcardio.2017.36">nicotine itself poses risks</a> to some vulnerable groups, there is <a href="https://truthinitiative.org/research-resources/harmful-effects-tobacco/re-thinking-nicotine-and-its-effects">little evidence that nicotine alone</a> causes cardiovascular disease, cancer and pulmonary diseases when decoupled from smoke.</p>
<p>The National Academies’ conclusion about e-cigarettes being less harmful than cigarettes presumes that vaping products are being used as intended. This <a href="https://www.cdc.gov/mmwr/volumes/68/wr/mm6845e1.htm?s_cid=mm6845e1_e&deliveryName=USCDC_921-DM13074">is not always the case</a>. In fact, recent findings indicate that most lung injury cases have involved <a href="https://www.nejm.org/doi/10.1056/NEJMoa1911614">vaping THC products</a>, and/or products obtained from <a href="https://www.cdc.gov/mmwr/volumes/68/wr/mm6839e2.htm?s_cid=mm6839e2_w">informal and poorly regulated markets</a>, with as few as <a href="https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#map-cases">10% of cases</a> involving nicotine alone. </p>
<p>Although some evidence suggests that laws legalizing medical and recreational <a href="https://doi.org/10.1016/j.drugalcdep.2019.107730">cannabis are associated with youth THC vaping</a>, the potential relationship between vaping injuries and marijuana legalization is sparsely acknowledged. </p>
<h2>An issue unique to the US?</h2>
<p>Reports on vaping also tend to leave out that vaping illnesses are a uniquely American problem. In the U.K., where e-cigarettes are regulated as cessation devices, comparable lung illnesses <a href="https://www.reuters.com/article/us-health-vaping-britain/vaping-illness-deaths-likely-very-rare-beyond-u-s-experts-say-idUSKBN1WT1XP">are not occurring</a>. In fact, clinical trials conducted outside the U.S. have found e-cigarettes to be <a href="https://doi.org/10.1371/annotation/e12c22d3-a42b-455d-9100-6c7ee45d58d0">as effective as</a>, or <a href="https://doi.org/10.3310/hta23430">more effective</a> than, nicotine replacement therapy at promoting cessation.</p>
<p>In the U.S., where e-cigarettes are regulated as tobacco products rather than cessation devices, comparable trials are lacking. </p>
<p>However, <a href="https://doi.org/10.1093/ntr/ntz114">recent findings</a> from one nationally representative survey indicated that smokers who used e-cigarettes daily were significantly more likely to stop smoking for at least two years compared to non-e-cigarette users – 11% versus 6%. </p>
<p>These results were consistent with <a href="https://doi.org/10.1136/tobaccocontrol-2017-054108">another national study</a> of about 5,000 adults. In that study, 337 (6.90%) quit smoking cigarettes and 778 (16.69%) substantially reduced their smoking rate, with about 14% of quitters and 15% of reducers reporting e-cigarette use. </p>
<p>One caveat is that officials and scholars cannot determine whether using e-cigarettes specifically facilitated quitting smoking, as some may have quit over time anyway even without e-cigarettes. </p>
<h2>Undermining gains?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/302280/original/file-20191118-66979-2vksob.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/302280/original/file-20191118-66979-2vksob.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=365&fit=crop&dpr=1 600w, https://images.theconversation.com/files/302280/original/file-20191118-66979-2vksob.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=365&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/302280/original/file-20191118-66979-2vksob.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=365&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/302280/original/file-20191118-66979-2vksob.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=459&fit=crop&dpr=1 754w, https://images.theconversation.com/files/302280/original/file-20191118-66979-2vksob.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=459&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/302280/original/file-20191118-66979-2vksob.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=459&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A woman smokes a cigarette at a homeless encampment in Oakland, California, in May 2019.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Oakland-Homeless/3d045cf10cf94defbd865342a14c8bb7/107/0">Ben Margot/AP Photo</a></span>
</figcaption>
</figure>
<p>One significant risk of vaping alarmism is undermining the gains the nation has made in reducing cigarette smoking, including youth smoking. National data among middle and high school students show that cigarette smoking has <a href="http://dx.doi.org/10.15585/mmwr.mm6722a3">continued to decline even as vaping explodes</a>. </p>
<p>Some studies have suggested that e-cigarettes <a href="https://doi.org/10.1542/peds.2017-3594">serve as a gateway</a> to cigarettes for some teens. However, the most recent study of the gateway question found that among 12,000 U.S. youth, those who vaped were more likely to try cigarettes, but <a href="https://academic.oup.com/ntr/advance-article/doi/10.1093/ntr/ntz157/5570011">not more likely to become regular smokers</a>. In simpler terms, the relationship between vaping and smoking is likely explained by shared risk factors – that is, the same characteristics that predict teen vaping also predict teen smoking.</p>
<p>The group most often neglected in our conversations about vaping is current cigarette smokers. Although <a href="https://www.cdc.gov/mmwr/volumes/68/wr/mm6845a2.htm">smoking prevalence today</a> is at an all-time low of 13.7%, smoking is increasingly concentrated among <a href="https://www.lung.org/our-initiatives/tobacco/reports-resources/sotc/by-the-numbers/top-10-populations.html">the most vulnerable</a> – those with mental illness, substance use disorders or living in poverty. </p>
<p>It is exceedingly difficult to promote cessation among these “hardened” smokers. That’s why health professionals and policy makers should be open to allowing, or even encouraging, these smokers to manage their nicotine addiction by transitioning from combusted to non-combusted sources of nicotine. </p>
<p>Just as opioid maintenance therapy is the standard of care for individuals with opioid use disorder, long-term nicotine maintenance should be an option for those addicted to nicotine. I have been “nicotine-maintained” for about five years, primarily with nicotine replacement therapy, but at one point with a “cig-a-like” vaping product. Five years is longer than the recommended 8-12 weeks of nicotine replacement therapy, but the prolonged therapy has allowed me to function effectively as a nonsmoker. </p>
<p>Today’s often economically disadvantaged smokers likely cannot afford five years of nicotine replacement therapy. Although Medicaid recipients smoke at <a href="https://www.cdc.gov/mmwr/volumes/67/wr/mm6702a1.htm?s_cid=mm6702a1_w">higher rates</a> than those with private health insurance, most states have limited coverage for tobacco cessation treatment. Until nicotine replacement therapy is more affordable, we ought to consider the implications of decisions that dramatically limit smokers’ access to alternative, less harmful sources of nicotine, such as <a href="https://www.theatlantic.com/ideas/archive/2019/10/danger-vaping-bans/600451/?fbclid=IwAR3KL3MJ-ODz1qqOn3XCrs3ZjyKG9FwUT65QxZ5OMmwo6qGrE1tPjndzFMY">comprehensive vaping bans</a>. </p>
<p>In fact, one effect of Massachusetts’ statewide vaping ban is <a href="https://tobaccoanalysis.blogspot.com/2019/10/sales-data-show-that-massachuetts.html">a rise in cigarettes sales</a> as former smokers reliant on e-cigarettes return to the most toxic, dependence-producing tobacco product available.</p>
<p>To be clear: The scientific evidence to date does not suggest that we should all be advocates for vaping. However, I believe we should have more reasoned conversations about vaping that are grounded in science, and acknowledge that while 39 deaths is 39 too many, there are <a href="https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm">half a million smoking-associated deaths</a> each year in the U.S. Advocating for these smokers having easy and affordable access to less harmful sources of nicotine is imperative to improving U.S. public health.</p>
<p>[ <em>You’re smart and curious about the world. So are The Conversation’s authors and editors.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=youresmart">You can read us daily by subscribing to our newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/127163/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Allison Kurti receives funding from: Tobacco Centers of Regulatory Science award from the National Institute on Drug Abuse (NIDA) and Food and Drug Administration (FDA), and Centers of Biomedical Research Excellence award from the National Institute on General Medical Sciences.</span></em></p>Concerns about e-cigarettes are growing, with the AMA calling for a ban. With the Great American Smokeout on Nov. 21, it’s worth asking: What do smokers think?Allison Kurti, Assistant Professor of Psychiatry, University of VermontLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1259762019-11-12T10:01:44Z2019-11-12T10:01:44ZWhy you shouldn’t write off e-cigarettes, despite the headlines<figure><img src="https://images.theconversation.com/files/300114/original/file-20191104-88368-1qxph91.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1520285939?src=74a4d59c-3dca-4531-87de-e429644eaa6f-5-49&size=medium_jpg">Leszek Glasner/Shutterstock</a></span></figcaption></figure><p>Vaping has been getting something of a bad name of late. Countries worldwide are considering restrictions and bans. But, as a way to help smokers quit, e-cigarettes are an important tool that we shouldn’t dismiss.</p>
<p>In the US, the Centers for Disease Control and Prevention (CDC) recently reported over a thousand cases of a <a href="https://www.cdc.gov/mmwr/volumes/68/wr/mm6843e1.htm">vaping-related lung disease called EVALI, and 34 deaths</a>. This is catastrophic for the families involved, but must be compared with the <a href="https://www.who.int/news-room/fact-sheets/detail/tobacco">8m smokers who die every year</a> as a result of smoking tobacco. Any potential harms of using e-cigarettes must always be considered in comparison to the many known harms of continuing to smoke tobacco.</p>
<p>The <a href="https://www.cdc.gov/mmwr/volumes/68/wr/mm6843e1.htm">CDC report</a> stated that 86% of the people who became ill from vaping had used THC (cannabis) products in the previous three months. THC is illegal in most countries, which may be why EVALI outbreaks are not being reported elsewhere.</p>
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Read more:
<a href="https://theconversation.com/e-cigarettes-nearly-twice-as-effective-as-other-nicotine-replacement-therapies-at-helping-smokers-quit-110739">E-cigarettes nearly twice as effective as other nicotine replacement therapies at helping smokers quit</a>
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<p>The latest news from the CDC reveals that vitamin E acetate (found in THC oil) <a href="https://www.statnews.com/2019/11/08/vaping-illnesses-vitamin-e-acetate/?utm_source=STAT+Newsletters&utm_campaign=0e14f28907-Daily_Recap&utm_medium=email&utm_term=0_8cab1d7961-0e14f28907-149899525">may be to blame for vaping-related illness</a>. Although vitamin E acetate seems to be the most likely culprit behind EVALI, health officials are still saying it’s too soon to rule out other possible causes.</p>
<h2>Smoking still kills</h2>
<p>Smokers are likely to <a href="https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm">die ten years earlier than non-smokers</a>. Quitting at a young age gives people the best chance of living a normal life, but <a href="https://www.who.int/tobacco/quitting/benefits/en/">quitting at any age has great benefits</a>. Smokers who quit will notice improved breathing, a better sense of taste and smell, and being financially better off.</p>
<p>One way to quit is e-cigarettes. Most smokers want to quit, but they also enjoy smoking. E-cigarettes offer a similar sensory experience to smoking regular cigarettes and flavours are an important part of <a href="https://www.ncbi.nlm.nih.gov/pubmed/29921278">that experience</a>.</p>
<p>E-cigarettes are unlikely to be completely safe, but exposure to harmful toxins from vaping is similar to <a href="https://www.ncbi.nlm.nih.gov/pubmed/28166548">exposure to toxins and carcinogens from nicotine replacement therapy</a>, a licensed drug to help people stop smoking that is available on prescription and over-the-counter. </p>
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Read more:
<a href="https://theconversation.com/e-cigarettes-why-im-optimistic-they-will-stub-smoking-out-for-good-119831">E-cigarettes: why I'm optimistic they will stub smoking out for good</a>
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<p>By using an e-liquid containing nicotine, addiction to nicotine will also continue, but a <a href="https://www.gov.uk/government/publications/e-cigarettes-and-heated-tobacco-products-evidence-review/evidence-review-of-e-cigarettes-and-heated-tobacco-products-2018-executive-summary">review from Public Health England</a> suggests that vaping is much safer than smoking tobacco. The best thing that smokers can do to improve their health is to stop smoking completely. Using an e-cigarette really can help people to do this.</p>
<p>Other countries have regulated vaping products for smokers wanting to quit. In these countries, there have not been the same reports of lung disease or death. As e-cigarettes have been widely used in many countries for <a href="https://www.ncbi.nlm.nih.gov/pubmed/25156991">over a decade</a>, if adverse effects were related to the long-term use of regulated e-cigarettes we would also be seeing these outcomes in other countries by now, just as we did when we realised the population-level link between tobacco smoking and lung cancer. We are not seeing this pattern of harm emerging.</p>
<h2>Vaping for smoking cessation</h2>
<p>It is important to pay attention to research evidence about the <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1808779">effectiveness of e-cigarettes for smoking cessation</a> and avoid a moral panic. A ban may have the unintended consequence of discouraging smokers from trying vaping to help them stop smoking, or may result in ex-smokers stopping vaping and returning to smoking tobacco. </p>
<p>Experience tells us that prohibition is not the answer. Banning products and flavours fuels the illicit economy, leaving more people vulnerable to the ill effects of adulterated, unregulated products. Instead, we need to take a measured view, assessing the benefits of regulated e-cigarettes for helping people stop smoking. </p>
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Read more:
<a href="https://theconversation.com/vaping-smokers-who-switch-could-be-less-likely-to-use-cigarettes-again-109098">Vaping: smokers who switch could be less likely to use cigarettes again</a>
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<p>Recent observational evidence suggests that in the UK alone <a href="https://onlinelibrary.wiley.com/doi/10.1111/add.14851">around 50,000 smokers who take up e-cigarettes quit smoking every year</a>. It is also clear from the data that, since the <a href="https://ash.org.uk/information-and-resources/fact-sheets/statistical/use-of-e-cigarettes-among-adults-in-great-britain-2019/">use of e-cigarettes took off</a>, the prevalence of <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2018#main-points">tobacco smoking in the UK has declined</a>. </p>
<h2>What’s in them?</h2>
<p>E-cigarette liquid contains propylene glycol, glycerin, nicotine and flavourings. Around <a href="https://www.rcgp.org.uk/clinical-and-research/about/clinical-news/2018/september/ecigarettes-is-vaping-safe.aspx">42 chemicals have been found in different e-liquids</a>. But a Canadian study found that a sample of e-liquids purchased contained an average of only <a href="https://www.ncbi.nlm.nih.gov/pubmed/31025300">six chemicals</a>. The study also found that 70% of products contained chemicals that may present some risk, including some carcinogenic nitrosamines. </p>
<p>E-cigarettes are unlikely to be risk free, but we need more research to find out if the chemicals in e-liquid are of sufficient level to be a significant health risk. It is clear that the risks are much lower than continuing to smoke tobacco. <a href="https://www.ncbi.nlm.nih.gov/books/NBK53017/">Tobacco smoke contains around 7,000 chemicals</a>, at least 70 of which are directly and conclusively linked to developing cancer.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/300911/original/file-20191108-194675-ybhvxf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/300911/original/file-20191108-194675-ybhvxf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/300911/original/file-20191108-194675-ybhvxf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/300911/original/file-20191108-194675-ybhvxf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/300911/original/file-20191108-194675-ybhvxf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/300911/original/file-20191108-194675-ybhvxf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/300911/original/file-20191108-194675-ybhvxf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Cigarette smoke contains around 7,000 chemicals.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cigarette-557423590">Billion Photos/Shutterstock</a></span>
</figcaption>
</figure>
<p>Although a precautionary approach might suggest that we should ban e-cigarettes as we don’t know the long-term effects of inhaling the chemicals in flavours, this would be a travesty for public health. It would be effectively denying hundreds of thousands of smokers the opportunity to successfully stop smoking, as robust evidence has demonstrated that e-cigarettes are <a href="https://www.nejm.org/doi/10.1056/NEJMoa1808779">more effective</a> for smoking cessation than nicotine replacement therapy. </p>
<p>There are other effective ways to give up smoking – using nicotine in the form of patches or gum, taking medication (neither of which are risk free, <a href="https://cancerpreventionresearch.aacrjournals.org/content/4/11/1719">although also much less risky than continuing to smoke</a>. When these methods haven’t worked, or for people that don’t want to use these methods, e-cigarettes are an <a href="https://www.nejm.org/doi/10.1056/NEJMoa1808779">effective</a>, <a href="https://www.ncbi.nlm.nih.gov/pubmed/29921278">attractive</a> and <a href="https://www.gov.uk/government/publications/e-cigarettes-and-heated-tobacco-products-evidence-review/evidence-review-of-e-cigarettes-and-heated-tobacco-products-2018-executive-summary">safer</a> alternative to smoking.</p><img src="https://counter.theconversation.com/content/125976/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Caitlin Notley receives funding from The National Institute for Health Research and Cancer Research UK</span></em></p>Governments around the world are banning e-cigarettes. This is very bad news for public health.Caitlin Notley, Senior Lecturer in Mental Health, University of East AngliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1235002019-09-16T12:01:43Z2019-09-16T12:01:43ZFlavored e-cigarettes sweetly lure kids into vaping and also mislead them to dismiss danger, studies suggest<figure><img src="https://images.theconversation.com/files/292326/original/file-20190912-190065-l5fzzp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Vaping flavors in a store in Biddeford, Maine, Sept. 3, 2019. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Vaping-Flavor-Bans/688e481ad1f04499b3904c3f08795620/18/0">Robert F. Bukaty/AP Photo</a></span></figcaption></figure><p>New York Gov. Andrew M. Cuomo announced Sept. 15, 2019 that he plans to <a href="https://www.nytimes.com/2019/09/15/nyregion/vaping-ban-ny.html?action=click&module=Top%20Stories&pgtype=Homepage">pursue emergency regulations </a>to quickly ban the sale of flavored e-cigarettes, making New York the second state to consider such a ban. Cuomo’s action came only days after the Trump administration called for a <a href="https://www.nytimes.com/2019/09/11/health/trump-vaping.html">ban on flavored e-cigarettes</a> in an effort to address six recent vaping deaths and <a href="https://www.cdc.gov/media/releases/2019/s0912-update-cases-vaping.html">380 cases</a> of confirmed or probable lung diseases in the U.S. </p>
<p>On Sept. 4, Michigan <a href="https://beta.washingtonpost.com/health/michigan-becomes-first-state-to-ban-flavored-e-cigarettes/2019/09/03/34f234c6-ce4c-11e9-8c1c-7c8ee785b855_story.html">announced a ban</a> on the sale of flavored cigarettes that is expected to go into effect within 30 days of the announcement. </p>
<p>There’s ample reason for concern. The Centers for Disease Control and Prevention reported a significant increase in use of any tobacco product among youth from 2017 to 2018, the most recent year for which data are available. In 2018, more than 4 million high schools students and 840,000 middle schools students used any tobacco product, with e-cigarettes driving the surge. The increase among high school students represented a <a href="https://www.fda.gov/tobacco-products/youth-and-tobacco/2018-nyts-data-startling-rise-youth-e-cigarette-use">78% increase</a>, according to the Food and Drug Administration.</p>
<p>The upsurge started in 2011, when <a href="https://www.cdc.gov/mmwr/volumes/67/wr/mm6745a5.htm?s_cid=mm6745a5_w#contribAff">1.5 percent of high school students, or 220,000,</a> reported e-cigaratte usage in the past 30 days. In 2018, <a href="https://www.cdc.gov/mmwr/volumes/67/wr/mm6745a5.htm?s_cid=mm6745a5_w#contribAff">20.8 percent,</a> or 3.01 million, high school students surveyed reported e-cigarette use in the past 30 days. </p>
<p>There is strong reason to believe that flavoring, such as mango, cucumber, strawberry lemonade, and others are a factor in the increase. <a href="https://www.med.unc.edu/fammed/tobacco/directory/leah-ranney-phd-ma/">I work in the field of tobacco control</a> and have conducted studies that show that flavors lead kids to underestimate the risk of tobacco products. Research shows that flavored tobacco products have the potential to undermine progress gained to reduce youth tobacco use in the U.S.</p>
<h2>Strategic flavoring</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/292473/original/file-20190913-8668-1snz9cv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/292473/original/file-20190913-8668-1snz9cv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/292473/original/file-20190913-8668-1snz9cv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/292473/original/file-20190913-8668-1snz9cv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/292473/original/file-20190913-8668-1snz9cv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/292473/original/file-20190913-8668-1snz9cv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/292473/original/file-20190913-8668-1snz9cv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A Juul vaping device, on right. The company uses an array of flavors.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/vaping360/43812201594/">Vaping360/Flckr.com</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>The increase in e-cigarette usage by youth is not by chance. Tobacco companies have spent billions of dollars annually on tobacco product advertisement, <a href="https://www.ftc.gov/system/files/documents/reports/federal-trade-commission-cigarette-report-2016-federal-trade-commission-smokeless-tobacco-report/ftc_cigarette_report_for_2016_0.pdf">according to a Federal Trade Commission</a> report, and have used appealing packaging, culturally tailored brand names and advertisements <a href="https://www.sciencedirect.com/science/article/pii/S003335061830283X?via%3Dihub">that appear to target specific minorities and youth</a>.</p>
<p>The colorful packaging and other strategies employed by the tobacco and e-cigarette industry contribute to lower harm perceptions of these products and increase susceptibility to use among young people, according to <a href="https://tobaccocontrol.bmj.com/content/24/e4/e233.long">researchers at the Center for Global Tobacco Control</a>, Harvard School of Public Health and <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0196236">recent research on cigarillo packaging I conducted with my research team</a>.</p>
<p>While tobacco companies spend billions on their own research, those of us who study public health, specifically tobacco control and prevention have conducted our own research.</p>
<p>Using a survey of young adults aged 18 to 26 recruited through an online crowd-sourcing tool, our group of researchers at the University of North Carolina School of Medicine found in a study <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0196236">published in PLOS ONE</a> that cigarillo pack flavor descriptors, such as grape and sweet, and colors such as pink and purple, resulted in more favorable product perceptions among young adults. These pack attributes had a greater impact on how people who had never used cigarillos perceived product flavor and taste, compared to current cigarillo users, and people who have previously used them.</p>
<p>Further, we conducted a systematic review of all the scientific literature through April 2016 examining the impact of flavors on tobacco product perceptions and use behaviors. Important findings from this study, published in <a href="https://tobaccocontrol.bmj.com/content/26/6/709">Tobacco Control,</a> suggested that flavored tobacco products have a strong appeal to youth and young adults because of the variety and availability of flavors; that flavors are a reason for use; and that flavors play a primary role in the use of e-cigarettes, little cigars and cigarillos, and hookah among younger people. An update of this review, “The Impact of Non-Menthol Flavors in E-Cigarettes on Perceptions and Use: An Updated Systematic Review”, will be published in BMJ Open by the end of the year. </p>
<p>Two studies within our <a href="https://www.ncbi.nlm.nih.gov/pubmed/26650455">systematic review</a> found packs containing flavor descriptions were more likely to be rated by youth as having a lower health risk. </p>
<p>Another <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3942180/">study</a> of smokeless tobacco packs in the U.S. found that young adults were more likely than older adults to report that packs without flavor descriptions would contain more dangerous chemicals.</p>
<h2>Why this is dangerous</h2>
<p>Research and survey data have shown that tobacco habits in this age group are changing. Youth cigarette smoking rates have declined substantially in recent years, with the <a href="https://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm">National Youth Tobacco Survey</a> showing current use of cigarettes declining from 15.8% in 2011 to 7.6% in 2017 among high school students, <a href="https://www.cdc.gov/mmwr/volumes/67/wr/mm6722a3.htm">according to data from experts at the CDC and FDA</a>. Meanwhile, e-cigarettes were the most commonly used product in that population in both middle and high school students in the survey data. </p>
<p>But while traditional cigarette smoking has declined, patterns of dual (that is, use of two or more tobacco products in 30 days) and poly tobacco use (or the use of three or more tobacco products in 30 days) have emerged. In 2013, in a survey of North Carolina high school students, almost 30% reported use of any tobacco product, according to a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4661661/">study</a> from our team published in 2015 in the International Journal of Environmental Research and Public Health. </p>
<p>Within this sample, 19.1% used multiple tobacco products, compared with just 10.6% of the sample who were single product tobacco users. Youth predominately used cigarettes in combination with little cigars and cigarillos, or cigarettes with e-cigarettes. </p>
<p>Using data from the 2015 <a href="https://www.tobaccopreventionandcontrol.ncdhhs.gov/data/yts/index.htm">North Carolina Youth Tobacco Survey</a>, we found that among survey respondents who were not susceptible to smoking cigarettes, <a href="https://www.cdc.gov/pcd/issues/2018/17_0368.htm">26% were at “high risk”</a> for future e-cigarette use; 11.3% were classified as “susceptible” to using e-cigarettes; 10.4% had already tried an e-cigarette; and 4.5% were current e-cigarette users. </p>
<p>Using school enrollment figures, we estimated that 55,725 high school students in our home state of North Carolina were at low risk of smoking cigarettes, but at high risk for e-cigarette use – which meant that they were susceptible to using e-cigarettes, had experimented with e-cigarettes, or currently used e-cigarettes. On a national scale, these findings are a considerable public health problem.</p>
<p>Specifically, high school students who believed that e-cigarettes and secondhand e-cigarette vapor were not harmful, or only somewhat harmful, were more likely to be susceptible to using e-cigarettes than students who thought e-cigarettes and secondhand e-cigarette vapor were harmful, <a href="https://www.cdc.gov/pcd/issues/2018/17_0368.htm">our study found</a>. </p>
<p>Moreover, exposure to e-cigarette vapor in indoor or outdoor public places was associated with greater odds of being susceptible to using e-cigarettes. This could mean that restricting secondhand exposure to vapor of e-cigarettes in public places, such as in school buildings, stores, restaurants, school grounds and parks, and mass media efforts to educate youth about the harms of e-cigarette use could be just as necessary as restricting access to these products.</p>
<p><a href="https://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/factsheet.html">We know</a> that teenagers are very vulnerable to the influence of tobacco marketing. The use of appealing packages and flavors has a significant impact on young people, causing them to perceive these tobacco products as less harmful and, in turn, making them more likely to experiment and continue using tobacco products. As research on the impact of flavored tobacco products builds, I look forward to increased action to help prevent youth tobacco use.</p>
<p><em>Editor’s Note: This article is an updated version of an article that was published originally Dec. 21, 2018.</em></p>
<p>[ <em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/123500/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Leah Ranney receives funding from NIH/FDA. I was part of the UNC Tobacco Centers of Regulatory Science award. </span></em></p>It’s not just that e-cigarettes have fruity, fun-evoking flavors added to them. There’s danger in the mere fact that the flavors lead kids to dismiss risk.Leah Ranney, Director of Tobacco Prevention and Evaluation, University of North Carolina at Chapel HillLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1225272019-09-13T11:36:24Z2019-09-13T11:36:24ZHow a person vapes, not just what a person vapes, could also play a big role in vaping harm<figure><img src="https://images.theconversation.com/files/291839/original/file-20190910-190021-zhg4f9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A smoking machine in the author's lab. Smoking by a machine is not the same as smoking by a person, the author and others have found.</span> <span class="attribution"><span class="source">Katie DiFrancesco</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>In the wake of six deaths and <a href="https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html">380 cases of confirmed and probable</a> lung disease across the U.S., the Trump administration has called for <a href="https://www.nytimes.com/2019/09/11/health/trump-vaping.html">banning most flavored e-cigarettes </a> because of their huge appeal to young people. </p>
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Read more:
<a href="https://theconversation.com/flavored-e-cigarettes-are-fueling-a-dangerous-increase-in-vaping-use-107998">Flavored e-cigarettes are fueling a dangerous increase in vaping use</a>
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<p>The Centers for Disease Control and Prevention is <a href="https://www.cdc.gov/media/releases/2019/s0823-vaping-related-death.html">looking closely at the different flavored nicotine juices</a> and other substances users may be vaping in e-cigarettes to determine how the aerosol might be affecting users’ lungs. </p>
<p>On Sept. 12, 2019, the CDC lowered the number of confirmed and probable cases from more than 400 to 380. The number was lower, the agency said, because it is no longer reporting “possible cases.”</p>
<p>The mystery and concern remain. And, many smokers who use these devices to quit are concerned that a valuable tool may be taken away from them. </p>
<p>There’s much more that researchers need to know. These devices have a short history. As an engineer who studies how people use tobacco products, I believe that users’ behavior is key to understanding the positive and negative health effects resulting from e-cigarettes. After all, their intent was to help people stop smoking, the number one cause of preventable death in the U.S. </p>
<p>The way users puff, how long they puff and what they puff all play a role. We do not yet know how this behavior affects how much of each substance vapers consume over the course of their daily lives, but we have reason to believe it is significant.</p>
<h2>The failed promise of alternative nicotine products</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/292272/original/file-20190912-190007-80htcl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/292272/original/file-20190912-190007-80htcl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/292272/original/file-20190912-190007-80htcl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/292272/original/file-20190912-190007-80htcl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/292272/original/file-20190912-190007-80htcl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/292272/original/file-20190912-190007-80htcl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/292272/original/file-20190912-190007-80htcl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Tens of thousands of people who smoked low-tar cigarettes still developed lung cancer.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-shows-results-old-patient-xray-543601138?src=nHlgfSkF_0PA5Ryr91OwZA-1-51">didesign021/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Many are skeptical that e-cigarettes will reduce death rates related to smoking. Historically safer cigarettes have not delivered on a similar promise. After the U.S. surgeon general <a href="https://www.fda.gov/media/127853/download">declared smoking harmful</a> in 1964, smokers who could not quit migrated to what were then considered <a href="https://cancercontrol.cancer.gov/brp/tcrb/monographs/13/m13_complete.pdf">low-yield cigarettes</a>, marketed as safer and having less tar than regular cigarettes. </p>
<p>But the wide use of low-yield cigarettes did not lower death rates for smokers.
Cases of squamous cell lung cancer did decrease after the surgeon general’s warning, but another type, <a href="https://cancercontrol.cancer.gov/brp/tcrb/monographs/13/m13_complete.pdf">adenocarcinoma, increased</a>. </p>
<p>Engineering models suggest that changes in smoke characteristics combined with smokers’ compensating behaviors <a href="https://www.tandfonline.com/doi/pdf/10.1080/027868201300034844">changed where the particles deposited in the lung</a> played a role. Smokers may have consumed more smoke to maintain their addiction. Different cancer types originate in different lung locations. The thought is that smokers changed their behavior, and in doing so, may have traded one type of cancer for another. </p>
<p>How did we miss this?</p>
<p>Traditionally, cigarettes were tested in a laboratory, using smoking machines – not a smoker – <a href="https://tobaccocontrol.bmj.com/content/10/2/96">using an industry standard protocol established in 1966</a>. <a href="https://cancercontrol.cancer.gov/brp/tcrb/monographs/13/m13_complete.pdf">Research later revealed</a> that this “mechanized smoking” <a href="https://www.hri.global/files/2011/07/13/Hammond_-_Secret_Science_-_No_Copyright.pdf">does not represent realistic behavior</a> and so did not represent realistic exposure to harmful constituents. The former standard (<a href="https://tobaccocontrol.bmj.com/content/10/2/96">FTC/ISO puffing protocol) was repealed in 2008</a>, with the hope that a new, more realistic standard would take its place.</p>
<p>Now, thanks to a <a href="https://www.congress.gov/bill/111th-congress/house-bill/1256">law passed in 2009</a>, tobacco product manufacturers cannot claim reduced risk without scientific evidence. Researchers like me are applying lessons learned from the low-tar debacle and generating scientific evidence to understand the true health impact of e-cigarettes. </p>
<h2>Regulatory authority over e-cigarettes</h2>
<p>Since e-cigarettes entered the market in Europe in 2006, demand increased from those hoping to quit cigarettes to those who have never smoked, including an <a href="https://www.fda.gov/tobacco-products/youth-and-tobacco/2018-nyts-data-startling-rise-youth-e-cigarette-use">unusually high number of young people</a>. This has raised concerns. Is vaping a gateway for youth to start smoking? Do young people use e-cigarettes in a different way than adults?</p>
<p>In June, 2019 the FDA <a href="https://www.fda.gov/media/127853/download">released guidelines</a> for e-cigarette manufacturers, recognizing the significant role behavior plays in determining whether or not a product poses a health threat. The guidelines call for an assessment of how individual users consume the product, including such things as the number of puffs, puff duration, puff intensity, puff duration and the frequency of use.</p>
<p>This behavior data is very important for many reasons. Users may adopt a behavior that nullifies any anticipated health effect based on lab tests. A puff generated in the lab may contain less nicotine, but the user may simply take more puffs during the day to achieve their nicotine addiction, and so consume more toxins than expected.</p>
<h2>Other potential dangers</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/292275/original/file-20190912-190065-panpnm.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/292275/original/file-20190912-190065-panpnm.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=455&fit=crop&dpr=1 600w, https://images.theconversation.com/files/292275/original/file-20190912-190065-panpnm.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=455&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/292275/original/file-20190912-190065-panpnm.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=455&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/292275/original/file-20190912-190065-panpnm.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=572&fit=crop&dpr=1 754w, https://images.theconversation.com/files/292275/original/file-20190912-190065-panpnm.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=572&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/292275/original/file-20190912-190065-panpnm.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=572&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Designs of vaping devices vary greatly, with some, like Juul, so small they can be concealed by a teen using in a classroom.</span>
<span class="attribution"><span class="source">Katie DiFrancesco</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>Researchers and physicians also need to know what substances are being vaped and also various device designs. The FDA maintains a list called harmful and potentially harmful constituents, or <a href="https://www.federalregister.gov/documents/2012/04/03/2012-7727/harmful-and-potentially-harmful-constituents-in-tobacco-products-and-tobacco-smoke-established-list">HPHCs</a>, based on data related to traditional cigarette smoking, but less is known about the effect of product designs. Users can tamper with the various modular devices, which could change their effects. Teens may be particularly likely to toy with devices. </p>
<p>The FDA is currently updating the list to include <a href="https://www.federalregister.gov/documents/2019/08/05/2019-16658/harmful-and-potentially-harmful-constituents-in-tobacco-products-established-list-proposed-additions">ingredients that might be found in e-cigarettes</a>. Nicotine is already on the list, as well as various metals and other non-nicotine substances. </p>
<p>The liquids used to deliver the nicotine could be a problem. The base [e-liquids], typically made of a combination of vegetable gylcerine and propylene glycol, may alone <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0116732">cause inflammatory response</a> in the lung, even if flavor additives are banned.</p>
<p>And with regard to flavors, it is important to understand that the toxicity of a substance may be different if it is inhaled versus ingested. For example, vanilla flavoring may be deemed safe for eating, but it may not be safe for vaping. Some flavorings <a href="https://www.mdpi.com/1660-4601/15/2/323">decompose when heated</a> and generate molecules that are not in the base e-liquid. </p>
<p>Would reducing the intake of flavorings also reduce harmful effects? And how much of these additives can be consumed before harmful effects materialized? Or, alternatively, how much must be reduced before health benefits can be realized? </p>
<h2>Engineering tools can advance the regulatory process</h2>
<p>By reenacting vaping behavior in the lab, those of us who study design and behavior can better understand the nature of the constituents being consumed.<br>
What have we have found so far? </p>
<ul>
<li><p>Puff flow rate <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0206341">alters the nature of the aerosol</a>, so users can control the strength of each puff simply by altering the way they puff.</p></li>
<li><p>E-cigarette users change their puffing flow rate when they switch flavors or nicotine levels and are <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0196640">altering their exposure to harmful or potentially harmful</a> constituents. </p></li>
<li><p>For a given e-cigarette brand and flavor, there is a <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0129296">wide range of use behaviors</a>, <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0164038">such as</a> puff flow rates and puff durations. </p></li>
<li><p><a href="https://www.nature.com/articles/s41598-019-44983-w">Machine replays</a> of vapor behaviors show exposure varies over a wide range for any given product. </p></li>
<li><p>Some e-cigarette users puff all day long, whereas others puff in more discrete time intervals, similar to smoking. </p></li>
<li><p>Even if there is less nicotine per puff in some cases for e-cigarettes compared to cigarettes, e-cigarette users can indeed consume the same amount or more nicotine in a day compared to smoking. </p></li>
</ul>
<p>We and other researchers aim to continue studying how new e-cigarette products are being used so manufacturers can develop safer products, and the FDA can develop meaningful regulations, so the consumer, in consultation with their physician, can make informed decisions. </p>
<p>[ <em>You’re smart and curious about the world. So are The Conversation’s authors and editors.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=youresmart">You can read us daily by subscribing to our newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/122527/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Risa Robinson receives funding from National Institution of Health.</span></em></p>Vaping is under heavy scrutiny in the wake of six deaths and hundreds of illnesses. A product engineer who studies how people puff explains why the way users vape could be a clue.Risa Robinson, Professor and Department Chair, Mechanical Engineering, Rochester Institute of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1230512019-09-11T12:21:36Z2019-09-11T12:21:36ZVaping likely has dangers that could take years for scientists to even know about<figure><img src="https://images.theconversation.com/files/291811/original/file-20190910-190002-er0msm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A man exhales after vaping Aug. 28, 2019 in Portland, Maine.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Oregon-Vaping-Death/a4569cf21ab648e79ff69c573d226725/4/0">Robert F. Bukaty/AP Photo</a></span></figcaption></figure><p>The rise in cases of otherwise healthy young adults who have been hospitalized or even died from <a href="https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html">vaping-associated lung injury</a> is alarming. </p>
<p>Many people don’t know what is contained in these vaping devices, what the reported health effects actually mean, and, most importantly, why all of this developed so quickly, considering that e-cigarettes have only been popular for fewer than 10 years.</p>
<p>Vaping describes the process of inhaling aerosols generated by devices such as e-cigarettes. </p>
<p>When <a href="http://www.casaa.org/historical-timeline-of-electronic-cigarettes/">e-cigarettes first came to the U.S.</a> in 2006, many smoking cessation experts were optimistic. They viewed the delivery of nicotine through e-cigarettes to be a useful alternative to traditional cigarettes. That is because e-cigarettes did not have all of the other harmful combustion products inhaled through cigarette smoke. Since there is no doubt that smoking traditional cigarettes is harmful to your health – and the number one cause of preventable death in the U.S. – e-cigarettes were marketed as a “safer” alternative. </p>
<p>As an <a href="https://www.med.unc.edu/childrensresearch/directory/ilona-jaspers-phd/">inhalation toxicologist</a>, I study how inhaled chemicals, particles and other agents affect human health. Since e-cigarettes were introduced, I have been concerned about how the scientific community could possibly know the full spectrum of their dangers. After all, it took decades for epidemiologists to discover that regularly inhaling the smoke from burning plant material, tobacco, caused lung cancer. Why would the scientific community be so quick to assume e-cigarettes would not have hidden dangers that might take years to manifest too?</p>
<h2>Do e-cigarettes even work as a cessation tool?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/291814/original/file-20190910-190026-1cgrnnd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/291814/original/file-20190910-190026-1cgrnnd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/291814/original/file-20190910-190026-1cgrnnd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/291814/original/file-20190910-190026-1cgrnnd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/291814/original/file-20190910-190026-1cgrnnd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/291814/original/file-20190910-190026-1cgrnnd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/291814/original/file-20190910-190026-1cgrnnd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Smoking is notoriously hard to quit, and tobacco companies have been ruthless in concealing its dangers. Some public health officials thus hailed e-cigarettes as a tool to help people stop.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/closeup-view-woman-breaking-cigarette-hands-606932273?src=K8Fa4BRp7UTW1BPf5B98iA-1-0">Africa Studios/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Many smokers have reported that switching from cigarettes to e-cigarettes has helped their physical well-being, including <a href="https://doi.org/10.3310/hta23430">reduced coughing</a>. </p>
<p>But a few randomized clinical trials examining the use of e-cigarettes as a cessation tool have shown mixed results. While some trials <a href="https://doi.org/10.1016/j.drugalcdep.2019.01.043">demonstrate a significant increase</a> in cessation success (from 9.9% to 18%), people using e-cigarettes were much more likely to remain dependent on nicotine as compared to those randomized for more traditional nicotine replacement products, such as nicotine patch, gum and nasal spray. Or, they were more likely to <a href="https://DOI.org/10.1016/j.drugalcdep.2019.01.043">relapse to using cigarettes</a>.</p>
<p>In short, whether, how, and to what extent e-cigarettes have potential as a cessation tool is not yet settled, especially considering that more than 80% of smokers randomized to use e-cigarettes <a href="https://doi.org/10.1056/NEJMoa1808779">continued to smoke</a> after the cessation trial.</p>
<h2>Safer than a spitting cobra</h2>
<p>Cessation claims aside, the messaging of e-cigarettes as a <a href="https://www.cdc.gov/tobacco/basic_information/e-cigarettes/surgeon-general-advisory/index.html">“safer” alternative</a> may have led many of the 3.6 million teenagers in the U.S. who use e-cigarettes today to believe these devices are “safe.” <a href="https://truthinitiative.org/research-resources/emerging-tobacco-products/e-cigarettes-facts-stats-and-regulations">“Safer” does not equal “safe,”</a> and the messaging of “safer” was based on comparisons to cigarettes. </p>
<p>Public Health England, the equivalent of the FDA in the U.K., stated in 2015 that “while vaping may not be 100% safe, <a href="https://www.thelancet.com/action/showPdf?pii=S0140-6736%2815%2900042-2">most of the chemicals causing smoking-related disease are absent</a> and the chemicals that are present pose limited danger.” </p>
<p>This statement did not consider the fact that health effects of inhaling flavoring chemicals contained in popular e-cigarettes are completely unknown, or that heating liquids in these devices causes thermal decomposition of those e-cigarette chemicals that “pose limited danger” into <a href="https://pubs.acs.org/doi/10.1021/acsomega.6b00489">known toxicants</a>. It also did not consider that e-cigarettes are a fast evolving consumer product with ever-changing devices and chemicals, creating mixtures and exposures of unknown health consequences.</p>
<p>This mistake was further advanced by assessing the adverse health effects caused by using e-cigarettes as a comparison to what occurs when someone smokes cigarettes for several years. It is well established that smoking cigarettes causes diseases such as <a href="https://www.lung.org/our-initiatives/tobacco/reports-resources/sotc/by-the-numbers/10-worst-diseases-smoking-causes.html">chronic obstructive pulmonary disease, chronic bronchitis, emphysema and cancer</a>. Many of these diseases <a href="https://www.hhs.gov/surgeongeneral/reports-and-publications/tobacco/index.html">do not manifest clinically until many years</a> after the first cigarette has been smoked. </p>
<p>No controlled studies were ever conducted assessing whether using e-cigarettes causes any adverse health effects in people who never smoke. To this day, scientists do not know the potential long-term health consequences of using e-cigarettes for decades. </p>
<h2>E-cigarettes cause very different health effects than cigarettes</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/291849/original/file-20190910-190012-1q0oykr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/291849/original/file-20190910-190012-1q0oykr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=387&fit=crop&dpr=1 600w, https://images.theconversation.com/files/291849/original/file-20190910-190012-1q0oykr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=387&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/291849/original/file-20190910-190012-1q0oykr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=387&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/291849/original/file-20190910-190012-1q0oykr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=486&fit=crop&dpr=1 754w, https://images.theconversation.com/files/291849/original/file-20190910-190012-1q0oykr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=486&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/291849/original/file-20190910-190012-1q0oykr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=486&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Cigarette smoking-related diseases such as lung cancer and emphysema took years to develop. The same may not be true for diseases from e-cigarettes.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/lung-patient-senior-oxygen-glasses-respiratory-1254214531?src=hlVLhBqcygUD7hCAquV0GQ-1-76">Robert Kneschke/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>I think that scientists and policymakers should completely stop comparing vaping outcomes to smoking outcomes. The now 380-plus cases of vaping-associated lung injuries <a href="https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html">prove this point</a>. The <a href="https://emcrit.org/ibcc/vaping-associated-pulmonary-injury/">clinical manifestations</a> in these patients are <a href="https://doi.org/10.1056/NEJMoa1911614">not something a doctor would ever see</a> in somebody who has been smoking cigarettes for a few months. </p>
<p>Similarly, these clinical outcomes have not been reported in marijuana users, even though THC, the psychoactive ingredient in marijuana, has now been associated with a large percentage of these cases. </p>
<p>Furthermore, the onset of these significant health problems is much faster than one would anticipate from smoking-related diseases. Since doctors are seeing severe diseases after relatively short exposures, does that make vaping more harmful than cigarettes? </p>
<p>Considering that the compounds inhaled through cigarette smoke are very different from those inhaled through the vast number of different flavored e-cigarettes and vaping devices, wouldn’t that be like comparing apples and oranges? Nobody would consider it reasonable to compare health effects caused by smoking cigarettes to those induced by smoking crack. </p>
<p>A lot of attention is now being placed on identifying the <a href="https://www.cdc.gov/media/releases/2019/p0906-vaping-related-illness.html">potential “culprit”</a> for the observed health effects in the more than 450 cases of vaping-induced lung injury. Additives contained in THC liquids have emerged as a <a href="https://khn.org/morning-breakout/as-deaths-related-to-mysterious-vaping-linked-lung-illness-continue-to-climb-heres-what-you-need-to-know/">potential cause</a>. </p>
<p>However, not all cases identified by the CDC have a documented history of vaping THC, and some have only reported a <a href="https://doi.org/10.1056/NEJMoa1911614">history of using nicotine products</a>. Furthermore, case reports of vaping-associated lung injury with symptoms similar to those reported by the Centers for Disease Control and Prevention but no history of THC use <a href="https://doi.org/10.1542/peds.2016-3927">have been documented</a> before, suggesting that vaping-associated lung injury has been detected before this recent rise in reported cases. </p>
<p>In addition, other <a href="https://doi.org/10.1080/02770903.2019.1643361">vaping-associated clinical outcomes</a> have been reported as well, indicating that <a href="https://www.hindawi.com/journals/cripu/2018/9724530/">vaping-induced</a> adverse health effects can vary. Hence, it is premature to draw any conclusions regarding which compounds – and there are likely several – inhaled by vaping nicotine or THC containing products are causing specific types of lung injury.</p>
<p>While it is too early to say whether or to what extent e-cigarettes can be used to support smoking cessation, one conclusion can already be drawn: Vaping is not without health effects.</p>
<p>[ <em><a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=expertise">Expertise in your inbox. Sign up for The Conversation’s newsletter and get a digest of academic takes on today’s news, every day.</a></em> ]</p><img src="https://counter.theconversation.com/content/123051/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ilona Jaspers receives funding from the NIH, EPA, and DoD</span></em></p>As vaping-related illnesses increase and deaths reported, an inhalation toxicologist explains why comparing the dangers of vaping to the dangers from cigarettes doesn’t make sense.Ilona Jaspers, Professor of pediatrics, microbiology and immunology, and environmental sciences and engineering, University of North Carolina at Chapel HillLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1184882019-07-17T10:39:12Z2019-07-17T10:39:12ZHelping smokers quit: financial incentives work<figure><img src="https://images.theconversation.com/files/281194/original/file-20190625-81745-rmse3h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/416970880?src=PnNoW5Xl4NxI59Tk7EstvQ-1-17&studio=1&size=medium_jpg">Bokeh Blur Background/Shutterstock</a></span></figcaption></figure><p>Smoking <a href="http://ash.org.uk/wp-content/uploads/2019/06/Smoking-Statistics-ASH-fact-sheet-November-2018-v2.pdf">kills one in two regular smokers</a>, but quitting at any point in life leads to big improvements in health, increased life expectancy and savings in healthcare costs. That’s why we need a range of ways to help people quit – and <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004307.pub6/full">new evidence</a> shows that paying people to quit is one way to boost quit rates.</p>
<p>Our recently updated <a href="https://www.cochrane.org/">Cochrane review</a> looked at the evidence from 33 trials and found strong evidence that <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004307.pub6/full">incentive programmes help people to quit smoking</a>, increasing quit rates at six months or longer by about 50%. In these programmes, smokers who could prove they’d quit smoking were rewarded financially. Some have expressed concern that smokers would return to smoking once the financial rewards ended, but the studies showed that people stayed smoke free, even after the rewards finished. </p>
<p>Financial incentives can come in all shapes and sizes. In our review, they ranged from vouchers for goods or services, to actual money. We didn’t find any evidence that success varied based on the amount of the reward, but more studies are needed to investigate this. Some studies paid people money, others were deposit programmes where people deposited their own money at the start and then had the chance to earn it back by staying smoke free. </p>
<p>There was no evidence that the success rates were different when it was a deposit programme. It might be harder to attract smokers to take part in a deposit programme, but they might be more attractive for programme providers worried about the cost or <a href="https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2014.418">potential backlash</a> of paying smokers to quit.</p>
<h2>Immediate reward</h2>
<p>There are compelling reasons why paying people to quit might help them. Financial incentives can reward the desired behaviour of being smoke free. Paying people may also offer the benefit of an immediate positive outcome of stopping smoking, providing instant gratification, as many find it difficult to think about the longer-term health benefits of stopping smoking.</p>
<p>That’s why it’s encouraging that more and more programmes do this – including <a href="https://www.nhs.uk/news/heart-and-lungs/gift-vouchers-can-help-pregnant-smokers-quit/">programmes that help pregnant women stop smoking</a> and programmes for people with a history of substance misuse.</p>
<p>Providing incentives as a way to help people quit, however, presents different challenges to offering support through, say, <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002850.pub4/full">quitlines</a> or <a href="http://dx.doi.org/10.1002/14651858.CD001292.pub3">counselling</a>. Though quit rates among these different approaches appear broadly similar, some people worry that non-smokers will enrol on the financial-reward programmes just to get paid.</p>
<p>But most programmes test the levels of smoking-related chemicals in participants’ blood, breath or urine before allowing them on the programme, so this is unlikely to happen. Also, there’s no evidence of this kind of deception regularly occurring.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/281158/original/file-20190625-81770-14n9r9u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/281158/original/file-20190625-81770-14n9r9u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/281158/original/file-20190625-81770-14n9r9u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/281158/original/file-20190625-81770-14n9r9u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/281158/original/file-20190625-81770-14n9r9u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/281158/original/file-20190625-81770-14n9r9u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/281158/original/file-20190625-81770-14n9r9u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Most programmes test levels of smoking-related chemicals.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/773586904?src=6kgE1k9mo7fLp3QPW1F4Bg-1-59&studio=1&size=medium_jpg">Kom_Pornnarong/Shutterstock</a></span>
</figcaption>
</figure>
<p>In other cases, there are concerns about how certain programmes reward quitting. For example, the tobacco firm Philip Morris <a href="https://www.independent.co.uk/news/health/tobacco-life-insurance-discount-philip-morris-quit-smoking-a8885956.html">recently launched</a> an <a href="https://www.revitilife.com/life-insurance/">insurance company that includes financial benefits</a> for smokers who quit. The amount of the benefit depends on how they quit and whether they use other Philip Morris products to do so. </p>
<p>Some people object, in principle, to paying people to quit as it may be seen as unfair that non-smokers receive nothing in comparison. After all, people who’ve never smoked aren’t eligible for such programmes. This is an important point to address because public acceptance of public health interventions is key to their success. </p>
<p>Of course, on some level, these programmes are rewarding smokers, but it is difficult to conceive that anyone would start smoking just to enter such a programme. The vast majority of smokers start young, influenced by <a href="http://ash.org.uk/wp-content/uploads/2019/02/Tobacco-Advertising-and-Promotion-download.pdf">billions spent on advertising</a> directly targeting them. In this scenario, smoking is not a free choice; it’s a behaviour constrained by social influence that can become an addiction. </p>
<p>Most smokers want to quit. They know smoking is bad for their health; they know it is costing them and society dearly, but cigarettes have been designed to make quitting really difficult. As a society, if there’s anything we can do to make this easier, shouldn’t we?</p><img src="https://counter.theconversation.com/content/118488/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Paying people to quit smoking seems unfair, but that doesn’t mean we shouldn’t do it.Jamie Hartmann-Boyce, Senior Researcher, Health Behaviours, University of OxfordCaitlin Notley, Senior Lecturer in Mental Health, University of East AngliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1191692019-07-03T19:58:29Z2019-07-03T19:58:29ZSmoking at record low in Australia, but the grim harvest of preventable heart disease continues<figure><img src="https://images.theconversation.com/files/281531/original/file-20190627-76734-htbpzo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The latest statistics show smoking's legacy when it comes to preventable deaths from cardiovascular diseases like heart attack and stroke.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/82970389?src=Xy6ZiUaaPKINAH02Ov3M_Q-1-24&studio=1&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>Smoking rates in Australia are at an all-time low. And yet, nearly 11,500 people are hospitalised from smoking-related cardiovascular (heart and blood vessel) disease each year, while almost 6,500 die as a result.</p>
<p>And it’s not just older people dying from their addiction. More than one-third of deaths from cardiovascular disease, such as heart attack or stroke, in people under the age of 65 in Australia can be attributed to smoking.</p>
<p>A recent publication of the largest and most comprehensive <a href="https://doi.org/10.1186/s12916-019-1351-4">study of smoking and cardiovascular disease</a> in Australia is a reminder we can’t be complacent.</p>
<p>The study, published this week in BMC Medicine, found current smokers have a five-fold increase in the risk of peripheral vascular disease, such as gangrene. Smoking also doubles the risk of heart attack, stroke and heart failure and triples the risk of dying from these diseases. This is compared to people who have never smoked.</p>
<p>The study’s authors said the findings suggest that if a smoker has a heart attack or a stroke, it’s highly probable smoking caused it. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-australians-die-cause-1-heart-diseases-and-stroke-57423">How Australians Die: cause #1 – heart diseases and stroke</a>
</strong>
</em>
</p>
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<h2>Our smoking rates</h2>
<p>The table below shows how <a href="https://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4364.0.55.0012017-18?OpenDocument">Australia’s smoking rates</a> compare with four other nations with which we are often benchmarked: <a href="https://www.cdc.gov/mmwr/volumes/67/wr/mm6744a2.htm#T1_down">USA</a>, <a href="https://www150.statcan.gc.ca/n1/pub/82-625-x/2018001/article/54974-eng.htm">Canada</a>, <a href="https://minhealthnz.shinyapps.io/nz-health-survey-2016-17-annual-data-explorer/_w_fa9587ac/#!/download-data-sets">New</a> <a href="https://minhealthnz.shinyapps.io/nz-health-survey-2016-17-annual-data-explorer/_w_fa9587ac/_w_90d53eb9/#!/explore-topics">Zealand</a> and the <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2017#the-proportion-who-are-current-smokers-in-the-uk-its-constituent-countries-and-local-areas-2011-to-2017">UK</a>.</p>
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<p>So at 15.1%, we are level with the UK. But we are almost certainly ahead of them because their 15.1% only includes people who smoke cigarettes (including rollies). It excludes people who only smoke other tobacco products, such as cigars or pipes.</p>
<p>The <a href="https://www.cancervic.org.au/downloads/cbrc/2019_Brief_1_daily_smoking_15to18_subgrps.pdf">very latest data</a> from Victoria are even more promising with only 10.7% smoking daily, down from 13.5% in 2015.</p>
<p>But the new research shows the impacts of past decades of smoking.</p>
<h2>What the researchers did and found</h2>
<p>Researchers followed 188,167 people aged 45 and over for an average of 7.2 years. </p>
<p>At the start of the study, none had been diagnosed with cardiovascular disease, 8% smoked and 34% had given up smoking. </p>
<p>The researchers used questionnaires, as well as hospitalisation and death data, to the end of 2015 and examined 36 sub-types of cardiovascular disease.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/women-have-heart-attacks-too-but-their-symptoms-are-often-dismissed-as-something-else-76083">Women have heart attacks too, but their symptoms are often dismissed as something else</a>
</strong>
</em>
</p>
<hr>
<p>Current smokers were significantly more likely to have a diagnosis or an event (a heart attack or stroke) in 29 out of the 36 cardiovascular disease types.</p>
<p>The new paper estimates that every year, smoking-related cardiovascular disease results in 11,400 people being sent to hospital and 6,400 people dying. This translates to 17 preventable deaths and 31 preventable hospitalisations a day.</p>
<p>The authors report one-third of premature cardiovascular deaths are attributable to smoking. The same researchers earlier calculated long-term smokers have a <a href="https://theconversation.com/smoking-new-australian-data-to-die-or-live-for-37962">two in three chance of dying from a smoking-caused disease</a>.</p>
<h2>How about those who cut back smoking?</h2>
<p>Australians who smoke daily smoke <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4364.0.55.001%7E2017-18%7EMain%20Features%7ESmoking%7E85">an average 12.3 cigarettes a day</a>. Many smokers believe cutting back instead of quitting will reduce much of the health risk.</p>
<p>But in this study, people who smoked four to six cigarettes a day had double the risk of dying from cardiovascular disease compared to people who had never smoked.</p>
<p>These results are similar to those found in smokers followed for years who had cut back rather than quit.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/ten-myths-about-smoking-that-will-not-die-56076">Ten myths about smoking that will not die</a>
</strong>
</em>
</p>
<hr>
<p>For example, a <a href="http://tobaccocontrol.bmj.com/content/15/6/472.full.pdf+html">Norwegian cohort</a> of 51,210 people followed from the 1970s until 2003 found “no evidence that smokers who cut down their daily cigarette consumption by >50% reduce their risk of premature death significantly”.</p>
<p>Another study from <a href="http://jco.ascopubs.org/content/26/31/5101.full.pdf">Korea</a>, involving nearly half a million men followed for 11 years, found no link between smoking less and the risk of all types of cancer. While there was a significant decrease in the risk of lung cancer, this was “disproportionately smaller than that expected”.</p>
<h2>And now, the good news</h2>
<p>Finally, some good news for <a href="https://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.83.2.215">smokers who think the damage may have already been done</a>. Quitting smoking dramatically reduces the risk of cardiovascular disease compared with continuing to smoke: the earlier the better. </p>
<p>People who quit smoking by age 45 avoid more than 95% of the cardiovascular disease risks related to smoking. Quitting at any age reduced their risk.</p>
<h2>Looking to the future</h2>
<p>Health minister Greg Hunt’s recently announced <a href="https://croakey.org/calls-for-national-preventive-health-strategy-to-address-poverty-and-other-determinants-of-health/">national prevention strategy</a> must give high priority to tobacco control. </p>
<p>The <a href="https://www.directory.gov.au/portfolios/health/australian-national-preventive-health-agency">Australian National Preventive Health Agency</a>, set up by Labor’s health minister Nicola Roxon in the Rudd government and then axed by the Abbott government, <a href="https://www.researchgate.net/publication/329234114_A_PRIORITY-DRIVEN_RESEARCH_AGENDA_FOR_TOBACCO_CONTROL_IN_AUSTRALIA">produced a report</a> on how best to drive tobacco control in Australia, which I co-authored. This followed a lengthy national and international evidence-based assessment and consultation on how to best accelerate the historical decline in smoking. </p>
<p>This report can be used to drive research and action to get smoking in Australia well below 10%.</p><img src="https://counter.theconversation.com/content/119169/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Chapman does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Smoking-related cardiovascular disease like heart attack and stroke results in 11,400 people being sent to hospital and 6,400 people dying in Australia each year, new research shows.Simon Chapman, Emeritus Professor in Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1152742019-04-15T10:54:32Z2019-04-15T10:54:32ZApril 15 is the day tobacco companies pay $9 billion for tobacco illnesses, but is it enough?<figure><img src="https://images.theconversation.com/files/269086/original/file-20190412-76850-16syt0z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Cigarettes have been known for years to cause many diseases. Tobacco companies now have to pay $9 billion each year to help states pay for the costs of treatment to people they sickened.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/xray-human-thorax-effects-cigarette-smoking-154687589?src=bZjtI7tpzuwcNcpfkNljdA-1-4">Protosav-AN/Shutterstock.com</a></span></figcaption></figure><p>April 15 is Tax Day in the U.S., and it is a bitter pill for many.</p>
<p>For state Medicaid plans, though, which pay a heavy price for tobacco-related illnesses, it can be a shot in the arm of sorts. April 15 is also the day when the five largest tobacco companies pay US$9 billion dollars to state <a href="https://www.publichealthlawcenter.org/sites/default/files/resources/MSA-Overview-2018.pdf">governments</a>, each and every year, forever, because of a <a href="https://publichealthlawcenter.org/topics/tobacco-control/tobacco-control-litigation/master-settlement-agreement">1998 legal settlement</a> meant to compensate states for the costs of tobacco-related illness such as cancer, emphysema and heart disease. Actual payments made by the tobacco companies vary year to year because of adjustment factors written into the settlement; each of the states’ payments varies as well. </p>
<p>Payments from tobacco companies, as well as tobacco taxes, help to support health care and other services for low-income people served by state Medicaid programs. Even though the federal government supports each state’s Medicaid program by paying at least half the costs, many states have <a href="https://www.governing.com/topics/health-human-services/gov-medicaid-expansion-funding-states.html">difficulty finding revenues</a> to pay the remaining share.</p>
<p>Determining how much tobacco use costs states’ Medicaid programs puts the payments from tobacco companies into perspective. One estimate found <a href="https://doi.org/10.1016/j.amepre.2014.10.012">15% of nationwide Medicaid costs</a> were caused by tobacco use. But such estimates based on national surveys may not account for which tobacco-related diseases are most prevalent in a particular state. How many of the state’s Medicaid participants smoke, and how hospitals and doctors are paid, also affect a state’s Medicaid costs. </p>
<p>The <a href="https://mshealthpolicy.com/">Center for Mississippi Health Policy</a> was interested in estimating the actual costs to Mississippi Medicaid for treating tobacco-related disease. The center wanted a price tag that more accurately reflected the health-related behaviors of people in Mississippi and health care services available in the state. Our team of researchers from <a href="https://hilltopinstitute.org/">The Hilltop Institute</a> at the University of Maryland, Baltimore County (UMBC) conducted the study. We think our study is the first to focus on Medicaid costs using actual state Medicaid data. </p>
<h2>Getting a truer picture</h2>
<p>Instead of applying estimates of total costs of smoking from national surveys to individual states as previous studies have done, our <a href="https://www.hilltopinstitute.org/publication/estimatedcoststomississippimedicaidattributabletotobacco-dec2018/">research</a> assessed how specific, individual smoking-related illnesses create costs for Mississippi. This lets the state better understand how much it differs from nationwide averages for both its total Medicaid costs and the sources of those costs.</p>
<p>First, we reviewed medical literature for studies that identified how tobacco use or exposure changes the risk of acquiring a particular illness. Many studies of how much smoking increases the risk of getting particular diseases have been conducted since the U.S. surgeon general first <a href="https://profiles.nlm.nih.gov/ps/retrieve/Narrative/NN/p-nid/60">reported on the health hazards</a> of smoking in 1964. In 2014, the surgeon general summarized many of these studies in a <a href="https://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf">50th anniversary report</a>. </p>
<p>Some of the diseases we studied, such as prostate cancer, may have many causes in addition to tobacco use. Others, such as lung cancer, are almost always caused by tobacco. Once we found a number specifying how much smoking increased the risk for contracting each disease, we multiplied those risk scores by the percentage of people in Mississippi Medicaid who smoked. That enabled us to estimate what percentage of Mississippi Medicaid spending for each of these diseases was smoking-related. The Mississippi Medicaid program gave us data to determine the cost of each service paid to treat each person with the specific diagnosis. </p>
<p>We then adjusted this initial estimate for other factors that were not captured in the Medicaid payment data. We added adjusted costs for prescription drugs that could be used to treat smoking-related conditions. In addition, many Medicaid participants are in nursing homes because of diseases acquired from smoking. So we added the costs of nursing home stays based on residents’ diagnoses and the same risk scores. </p>
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<p>Tobacco use can also affect the health of nonsmokers exposed to second-hand smoke. Mississippi had <a href="https://mstobaccodata.org/wp-content/uploads/2015/08/medicaid-costs-secondhand-smoke.pdf">estimated the costs of second-hand smoke</a> using national estimates. We updated those numbers based on relative risk of tobacco-related diseases we found in the more recent data.</p>
<h2>An expensive set of illnesses</h2>
<p>In total, we estimated that the cost of tobacco-related illness to Mississippi Medicaid was $388 million in 2016 and $396 million in 2017. This made up about 9% of Mississippi’s annual spending on Medicaid. Our estimates were somewhat lower than the <a href="https://doi.org/10.1016/j.amepre.2014.10.012">national cost estimates of 15%</a>. We believe this is because Mississippi Medicaid covers large numbers of children and younger adults – a tobacco-related disease may appear only after many years of smoking. </p>
<p>Many Mississippi Medicaid participants may still be too young to be diagnosed with tobacco-related illnesses. Furthermore, our estimates only included diseases with measures of increased risks because of smoking that are presented in the medical literature or the 2014 surgeon general’s report. So, our estimates are relatively conservative. </p>
<p>We believe our study results will help policymakers in Mississippi assess the benefits of policies affecting tobacco. These could include increasing tobacco cessation services, raising the minimum age for buying tobacco products, raising taxes on tobacco products and requiring smoke-free public places. Our approach to estimating costs could also be used by other states to conduct their own analyses of tobacco-related costs to Medicaid to inform their policy choices.</p><img src="https://counter.theconversation.com/content/115274/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Charles Betley receives funding from the Center for Mississippi Health Policy.</span></em></p>April 15 is not only a day to pay individual taxes to the IRS. It is also the day that tobacco companies must pay a penalty to help offset states’ costs for the treatment of tobacco-related diseases.Charles Betley, Senior Policy Analyst, University of Maryland, Baltimore CountyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1086362019-01-09T11:45:28Z2019-01-09T11:45:28ZHow to increase your chances of sticking with your resolutions<figure><img src="https://images.theconversation.com/files/252725/original/file-20190107-32148-1nuzl2r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Staying on track with exercise goals can be hard without a plan to deal with stressors that get in the way.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/fit-young-people-doing-pushups-gym-420708367?src=LCKRXixDVt06aE6ALEzF4w-1-6">Flamingo Images/Shutterstock.com</a></span></figcaption></figure><p>The beginning of every new year comes with resolutions and plans for behavior change. Often the quest to improve health behaviors, such as losing weight, increasing physical activity or quitting tobacco is short-lived. Estimates vary, but by some accounts, as many as <a href="https://health.usnews.com/health-news/blogs/eat-run/articles/2015-12-29/why-80-percent-of-new-years-resolutions-fail">80 percent</a> of people fail to meet their resolution by mid-February. <a href="https://www.ncbi.nlm.nih.gov/pubmed/2980864">One study</a> followed 200 people with New Year’s resolutions and reported that 81 percent of them failed to maintain their health behaviors after two years. </p>
<p>The reasons vary. With the case of cigarettes, people are dealing with a highly addictive product. For example, about <a href="https://www.ncbi.nlm.nih.gov/pubmed/14678060">95 percent of people relapse</a> after six to 12 months of abstinence when they try to quit smoking on their own.</p>
<p>Regardless of the severity of your addiction or even if you do not have an addiction, change is very hard. People often have not explored their reasons for making the change or how ready they are. They also may not have come up with a plan. And, they may simply not realize how hard it is to change behavior. </p>
<p>I am a counseling psychologist who studies and works with people trying to change their behavior. Those who succeed have certain things in common. They are usually motivated to change, and they believe in their ability to engage in positive health behaviors. They also track their health behaviors and set goals. </p>
<h2>What psychologists know about behavior change</h2>
<p>Biological, psychological, social and environmental processes influence behavior change. One of the popular theories used to explain health behaviors is something called <a href="http://psycnet.apa.org/record/1984-26566-001">the transtheoretical model</a>. This theory states that there are five stages of behavior change. </p>
<ul>
<li>Pre-contemplation. In this stage, the person is not thinking about making the change. Those who fall in this stage may be unwilling to admit they have a problem in the first place. They are unlikely to respond to nagging from others to stop smoking, for example. This could be attributed to the fact that the <a href="http://psycnet.apa.org/record/1994-26988-001">cons for changing their unhealthy behavior outweighs the pros</a>.</li>
</ul>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/252728/original/file-20190107-32136-ii0vzv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/252728/original/file-20190107-32136-ii0vzv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/252728/original/file-20190107-32136-ii0vzv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/252728/original/file-20190107-32136-ii0vzv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/252728/original/file-20190107-32136-ii0vzv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/252728/original/file-20190107-32136-ii0vzv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/252728/original/file-20190107-32136-ii0vzv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">In the contemplation stage of behavior change, a person begins to think about making a change.</span>
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</figure>
<ul>
<li><p>Contemplation. This happens when a person acknowledges that he or she has a problematic behavior but is not ready to adopt a healthier lifestyle. Successful behavior change even during this stage is unlikely. However, people in this stage are thinking about making a change within the next six months. </p></li>
<li><p>Preparation. In this stage, an individual starts making plans for the change. For example, a person who wishes to quit smoking may set a quit date and plan to purchase their last pack of cigarettes the week before the quit date.</p></li>
<li><p>Action. This is when behavior change starts to occur. In this stage, a person who wishes to stop smoking quits using cigarettes and may start using smoking cessation aids. Or someone who wants to lose weight will start eating fewer calories or start going to the gym. This stage requires the most effort and commitment.</p></li>
<li><p>Maintenance. This usually occurs after six months of uninterrupted continuous efforts to sustain the changes they have made and to prevent a relapse. It is not uncommon for relapse to occur after a person has been successful with incorporating the new behavior. This usually happens during the action stage and can also happen after maintenance given that it is difficult to sustain behavior change. Most people are not successful with behavior change after a first attempt, especially when changing an addictive behavior. People with New Year’s resolutions <a href="https://www.ncbi.nlm.nih.gov/pubmed/2980864">can make about five or more years of continuous attempts to change a behavior before they are successful</a>. Unanticipated barriers such as stressful life events can cause a relapse. </p></li>
</ul>
<p>While it is normal to experience negative emotions such as guilt and embarrassment after a failed attempt, these feelings can make a person lose hope in their ability to change if they persist for too long. The good news is that after a relapse you can learn from your mistakes and try again. <a href="http://psycnet.apa.org/fulltext/1993-09955-001.html">Research</a> shows that a person’s odds of success with positive behavior change increase gradually with time, after unsuccessful attempts. </p>
<h2>Why do you want to make a change?</h2>
<p>It helps to start with a thorough understanding of why you want to change. Without that, it is hard to stay motivated, especially when barriers arise, such as getting stuck in traffic on the way to the gym, or a family member getting sick and needing your care. State of readiness also affects behavior change. </p>
<p>Part of your preparation stage should be developing a realistic plan. It should incorporate the reality that behavior change is hard.
Studies have shown that just <a href="https://selfdeterminationtheory.org/SDT/documents/2002_KoestnerLekesPowersChicoine_JPSP.pdf">setting a goal does not lead</a> to the desired results. Ambiguous goals, such as saying you want to lose weight in the coming year but not thinking of specific health goals are associated with unsuccessful results. </p>
<p>Setting goals that are too challenging, such as going from complete inactivity to trying to exercise seven times a week, often results in failure. Setting several goals also can be overwhelming and result in failure. </p>
<h2>Factors that affect behavior change</h2>
<p>Even with good goals in place, stress lowers a person’s ability to achieve successful change. Stress lowers our inhibitions, making it more difficult to achieve one’s goals. For example, the stress of the loss of a job would likely challenge a smoker’s ability to abstain from cigarettes. Depression and anxiety, when unmanaged, can have a negative effect on a person’s motivation and derail efforts to change. A lack of <a href="https://www.ncbi.nlm.nih.gov/pubmed/1192069">self-efficacy</a>, a person’s belief in their ability to exercise successful change, has been associated with unsuccessful behavior change.</p>
<p>Biological processes can also affect behavior change. One of the difficulties associated with weight loss is that we <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/nbu.12002">inherited traits</a> from our ancestors that cause our bodies to store fat. This was good for our ancestors when food was scarce, but it is bad for our current well-being, given that food is easier to access. </p>
<p>Also, <a href="https://www.ncbi.nlm.nih.gov/pubmed/2253845">studies suggest that our bodies have a certain set-point</a> at which they are most comfortable and have a natural weight thermostat that adjusts our metabolism and eating. This set-point keeps our weight within a certain genetically determined range. This makes initial weight loss easier given that the individual’s metabolism is higher as a result of having more weight. However, it becomes harder to lose weight over time as one’s metabolism decreases. </p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pubmed/24821503">environment in which we live</a> also influences behavior change. The majority of our foods are highly processed and contain high fats and sugars. Without the appropriate nutritional knowledge and with limited access to healthy foods, successful weight loss becomes challenging. The food environment coupled with a sedentary lifestyle has a negative impact on a person’s health.</p>
<p>People who live in neighborhoods without sidewalks, parks or those who reside in dangerous neighborhoods are less likely to be active. Certain cues in our environment also affect our ability to maintain change. For example, a person’s attempts to stop smoking may be hindered by living with other smokers, especially if they have certain rituals around smoking, such as sitting on the porch together at night to chat and smoke. </p>
<h2>How to improve your odds of success</h2>
<p>While change is hard, there are things you can do to increase your chances of success. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/252729/original/file-20190107-32124-1cy8x0f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/252729/original/file-20190107-32124-1cy8x0f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/252729/original/file-20190107-32124-1cy8x0f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/252729/original/file-20190107-32124-1cy8x0f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/252729/original/file-20190107-32124-1cy8x0f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/252729/original/file-20190107-32124-1cy8x0f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/252729/original/file-20190107-32124-1cy8x0f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Some people make health changes so they can be a good role model for their family.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/dad-son-cooking-together-1071347756?src=uPQHmRlBFZGcQozUdu6rCw-1-6">Rawpixel.com/Shutterstock.com</a></span>
</figcaption>
</figure>
<ul>
<li><p>Change for the right reasons. Change for a desire to improve one’s health, to be a better example for your family or to prolong your life, are more likely to motivate positive change. </p></li>
<li><p>Set both <a href="https://www.ncbi.nlm.nih.gov/pubmed/15559708">short-term and long-term goals</a> when executing change. Researchers have found that these goals should be <a href="https://www.ncbi.nlm.nih.gov/pubmed/29466911">specific, measurable, achievable, realistic and timely</a>, or SMART. Weekly SMART goals help in making progressive steps towards a long-term goal. </p></li>
<li><p>Track and monitor your behavior. This enhances positive behavior change.
You can accomplish this by journaling and note-taking. Many people find that free fitness apps are helpful. </p></li>
<li><p>Get help. In some cases, behavior change may be most successful with the help of a professional such as a licensed clinical health psychologist. Trained professionals can provide services such as <a href="https://www.psychologytoday.com/us/therapy-types/motivational-interviewing">motivational interviewing</a>, <a href="https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral.aspx">cognitive-behavioral therapy</a>, and <a href="https://www.psychologytoday.com/us/therapy-types/acceptance-and-commitment-therapy">acceptance and commitment therapy</a>.</p></li>
</ul><img src="https://counter.theconversation.com/content/108636/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Camilla Nonterah does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Behavior change is very hard. Try as we might to keep those New Year’s resolutions, many have given up by this time. Here are some ways to keep going and stay on track, from a counseling psychologist.Camilla Nonterah, Assistant professor of health psychology, University of RichmondLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1054702018-10-23T13:31:09Z2018-10-23T13:31:09ZPhilip Morris anti-smoking ads slammed for hypocrisy – and it’s easy to see why<figure><img src="https://images.theconversation.com/files/241704/original/file-20181022-105748-1m1ijvw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Away with you.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-attractive-man-breaking-cigarette-221220160?src=UomsT-hXtDcRuBSIE7-3Ug-1-48">Stas Walenga/Shutterstock</a></span></figcaption></figure><p>A new advertising campaign from tobacco giant Philip Morris has drawn <a href="https://www.bbc.co.uk/news/business-45932048">accusations of hypocrisy</a> from official health bodies even though it advocates giving up smoking. ASH (Action on Smoking and Health) echoed the sentiment, describing the company’s press ads – which including a wrap around of a daily newspaper – as a wheeze to enable the manufacturer of the iconic Marlboro brand to get around the UK’s anti-cigarette advertising regulations. </p>
<p>The “Hold My Light” campaign builds on earlier Phillip Morris adverts in which the company claimed <a href="https://www.bbc.co.uk/news/business-42539142">that it wished</a> to stop selling cigarettes in the UK. Of course, it still needs to sell tobacco, and its proposed solution is to replace cigarettes with alternative tobacco “delivery systems” such as Iqos, a tobacco warming system the company launched in 2016, and which <a href="https://www.bbc.co.uk/news/business-38152297">it says</a> may be effective for smokers who can’t give up but want a nicotine fix that is less toxic than combustion. </p>
<p>However, the relative health harms of warmed tobacco against combusted tobacco are <a href="https://www.gov.uk/government/publications/e-cigarettes-and-heated-tobacco-products-evidence-review/evidence-review-of-e-cigarettes-and-heated-tobacco-products-2018-executive-summary">still not fully understood</a> and the <a href="http://theconversation.com/e-cigarettes-are-good-or-bad-depending-on-the-study-so-whats-the-truth-104787">jury is still out</a> on whether vaping is a healthier alternative. Nonetheless, the consensus to date is that both tobacco warming and vaping are much less harmful to health than smoking. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/241843/original/file-20181023-169816-1j6dkqy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/241843/original/file-20181023-169816-1j6dkqy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=386&fit=crop&dpr=1 600w, https://images.theconversation.com/files/241843/original/file-20181023-169816-1j6dkqy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=386&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/241843/original/file-20181023-169816-1j6dkqy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=386&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/241843/original/file-20181023-169816-1j6dkqy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=484&fit=crop&dpr=1 754w, https://images.theconversation.com/files/241843/original/file-20181023-169816-1j6dkqy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=484&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/241843/original/file-20181023-169816-1j6dkqy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=484&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Vaping: big – and growing – market for tobacco companies.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/brutal-bearded-young-man-having-rest-727821652?src=jpJQoRC2TNDaTpP35K6Egg-1-67">Vladee/Shutterstock</a></span>
</figcaption>
</figure>
<p>So is Philip Morris being hypocritical in positioning itself as an anti-smoking advocate? Well, no doubt the company is sincere about wishing to distance itself from the appalling public health toll of cigarettes. More pragmatically, as <a href="https://www.telegraph.co.uk/news/2018/05/31/smoking-declines-around-world-countries-set-miss-targets-report/">smoking rates decline</a> in the <a href="https://ourworldindata.org/smoking">developed world</a>, it needs to find other ways to sell tobacco. Like any other public company, Phillip Morris has a duty to its shareholders, its employees and its manufacturing chain – including tobacco farmers – as well as to its customers. If they simply stopped selling cigarettes the business would collapse, and, they claim, other suppliers would step in to leave the public health issues unchanged. </p>
<p>The conflicting demands on the company could perhaps be reconciled if the whole market switched to non-smoking tobacco delivery products. No doubt the <a href="https://www.independent.co.uk/news/world/americas/canada-marijuana-legal-cannabis-laws-weed-pot-stores-sales-when-a8586116.html">changing climate of marijuana legislation</a> around the world is also a factor in the industry’s calculation. There is huge opportunity there and cigarette companies might be well positioned to move into that space as nicotine loses some of its buzz. Alternative “delivery systems” that can be used for pot as well as tobacco could be a winner. </p>
<h2>Other actions</h2>
<p>However, the tobacco giant cannot move away from cigarettes just yet, and it’s the gap between their claims and their actions around the world that have led to the charge of hypocrisy. Philip Morris’s UK managing director Peter Nixon told the BBC that the company wanted to work alongside government as an anti-smoking campaigner – and this might be stretching credulity too far. After all, the finest legal minds in the tobacco industry <a href="https://www.theguardian.com/society/2017/apr/11/uk-supreme-court-denies-tobacco-firms-permission-for-plain-packaging-appeal?CMP=Share_iOSApp_Other">tried and failed to block</a> the recent legislation banning branding on cigarette packaging. What is more, the tobacco industry has a long record of <a href="https://www.tobaccofreekids.org/press-releases/id_1215">trying to evade</a> anti-smoking legislation where it can’t block it. </p>
<p>Claiming that they want to be partners to government in policies to reduce cigarette smoking is great PR, but putting the fox in charge of the hen house has its dangers. Health bodies <a href="http://www.dldocs.stir.ac.uk/documents/alcoholindustry.pdf">have learned</a> from actions by alcohol and gambling companies that they tend to see this as a great way to take the edge off legislative moves that might damage their business. </p>
<p>Even more damning is the evidence that tobacco companies are perfectly happy to continue aggressively promoting cigarettes in <a href="https://www.theguardian.com/world/2018/mar/09/how-children-around-the-world-are-exposed-to-cigarette-advertising">parts of the world less accessible to regulation</a>.</p>
<p>Big tobacco might be forgiven for continuing to serve markets in the Middle East and Asia with millions of die-hard smokers who are not giving up any time soon, but being active in trying to grow these markets by targeting the very poor and the very young is harder to overlook.</p>
<p>The cigarette industry is well used to the scepticism that greets its PR efforts, and it has done much to deserve that scepticism. As <a href="http://ash.org.uk/media-and-news/press-releases-media-and-news/ash-reaction-to-new-philip-morris-iqos-heat-not-burn-product/">ASH point out</a>, big tobacco may be correct in claiming that non-smoking tobacco delivery is relatively harmless to health in the short term, but, to <a href="https://en.wikipedia.org/wiki/Mandy_Rice-Davies#%22He_would,_wouldn't_he?%22">misquote Mandy-Rice Davies</a>, they would say that wouldn’t they? </p>
<p>Offering to become a government partner in anti-(cigarette) smoking drives looks very much like a tactic straight out of the playbook used by big alcohol. The cigarette industry knows it has to change to retain its huge profits, but the latest initiative looks clumsy. Their product strategy, PR and policy engagement all need a new delivery system to persuade the health lobbies of their sincerity.</p><img src="https://counter.theconversation.com/content/105470/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chris Hackley in the past received funding from the ESRC </span></em></p>Why tobacco giant isn’t a credible partner for anti-cigarette smoking policy just yet, despite what they want you to think.Chris Hackley, Professor of Marketing, Royal Holloway University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1020582018-09-06T09:21:02Z2018-09-06T09:21:02ZShisha addiction may be stronger than cigarette addiction<figure><img src="https://images.theconversation.com/files/234646/original/file-20180903-41726-cndeyn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Not the healthy choice.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1044094318?src=BEOHsvodF9OWVDCRnmioqw-1-47&size=medium_jpg">HelgaBragina/Shutterstock</a></span></figcaption></figure><p>Smoking shisha is <a href="https://tobaccocontrol.bmj.com/content/early/2014/10/08/tobaccocontrol-2014-051903.short">very popular</a>, particularly among young people. And despite what many people believe, it is highly <a href="https://www.ncbi.nlm.nih.gov/pubmed/26054945">addictive</a>. In fact, a drug commonly prescribed to help people quit smoking cigarettes doesn’t seem to work for shisha smokers, our <a href="https://onlinelibrary.wiley.com/toc/13600443/0/ja">latest study</a> shows. </p>
<p>Given that shisha is often smoked with friends and family, its addiction may be more than just physical. This strong social element to the addiction may be the reason the smoking cessation drug, varenicline, which is effective for cigarette smokers, doesn’t have the same effect on daily shisha smokers. </p>
<p>Traditionally smoked by older men in the Middle East and South Asia, shisha has now gained popularity around the globe. Shisha cafes and bars have opened in most cities in Europe and the US in recent years. Flavoured brands, such as fruit shisha, have become particularly popular with young people who are attracted to shisha’s <a href="https://tobaccocontrol.bmj.com/content/24/Suppl_1/i13">romantic allure</a> – it is seen as fashionable and exotic.</p>
<h2>Addictive and harmful</h2>
<p>In a <a href="https://www.ncbi.nlm.nih.gov/pubmed/15564614">shisha</a> (also known as a waterpipe or hookah), tobacco is burned using charcoal. The smoke passes through a water-filled bowl and leaves through a hose. By inhaling at one end of the hose, a vacuum is produced that makes smoke pass through the water to the smoker.</p>
<p>There are two common <a href="https://tobaccocontrol.bmj.com/content/24/Suppl_1/i13">misconceptions</a> about shisha smoking. The first is that it is less harmful than cigarettes as the smoke is believed to be “cleansed” while passing through water. The second is that it is less addictive than cigarettes. </p>
<p>Both assertions are wrong. Shisha smokers inhale large quantities of harmful particles and are at risk of the same diseases as cigarette smokers, including a variety of <a href="https://tobaccocontrol.bmj.com/content/26/1/92">cancers</a>. In fact, during a single session of shisha, one can inhale several times more nicotine, carbon monoxide and cancer-causing chemicals than a single <a href="https://www.ncbi.nlm.nih.gov/pubmed/26054945">cigarette</a>. </p>
<p>Between shisha smoking sessions, smokers show cravings and <a href="https://www.ncbi.nlm.nih.gov/pubmed/27113610">withdrawal symptoms</a> just like cigarette smokers, even with infrequent use. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/234654/original/file-20180903-41720-1ubj98w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/234654/original/file-20180903-41720-1ubj98w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/234654/original/file-20180903-41720-1ubj98w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/234654/original/file-20180903-41720-1ubj98w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/234654/original/file-20180903-41720-1ubj98w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/234654/original/file-20180903-41720-1ubj98w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/234654/original/file-20180903-41720-1ubj98w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Just because the smoke passes through water, doesn’t mean it is cleansed.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/263853425?src=zbR9JDUmzTJHyW1OtneQ_Q-1-7&size=medium_jpg">Lev Savitskiy/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Quitting shisha smoking</h2>
<p>There has been very little research done on ways to help shisha smokers quit successfully. Approaches, such as counselling and medication, are usually successful in getting cigarette smokers to <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008286.pub3/full">quit</a>, but have shown little promise with shisha smokers, <a href="https://www.ncbi.nlm.nih.gov/pubmed/26228266">so far</a>. </p>
<p>For our study, we recruited 500 shisha smokers in Pakistan. For 12 weeks, half the research participants were treated with the drug varenicline, the other half with a placebo. Both groups were also given advice on changing behaviour to help them address some of the psychological aspects of addiction. </p>
<p>Our results showed that varenicline was not more effective than a placebo. This study does not necessarily show that the drug did not work in shisha smokers, but, despite the willingness of participants to quit, only a minority made a serious attempt at quitting. </p>
<p>The study also demonstrated that shisha smokers that took part in the study were highly dependent and many smoked cigarettes as well, reducing the effect of the drug. </p>
<p>There are many layers to addiction, neurological and psychological, and one of the things we found in this study is that the social aspect of smoking shisha played a significant role in its appeal. Almost 90% of the study participants smoked shisha with their family or friends.</p>
<h2>More controls needed</h2>
<p>Strong tobacco control policies are needed to break the social norms of shisha smoking alongside conventional medication and counselling. </p>
<p>The way tobacco is sold and bought for shisha consumption means that standard packaging with graphic health warnings either doesn’t exist or doesn’t have an impact. </p>
<p>Inconsistent policies for tobacco price and taxation mean that smoking shisha is still fairly cheap for most people. Shisha smokers may have a better chance of quitting if shisha smoking is less affordable and not served in cafes, bars and restaurants. </p>
<p>An approach, similar to that taken against cigarette smoking, to raise awareness of the risks, particularly with young people, and control its use in public spaces would be a step forward, alongside traditional quitting approaches.</p><img src="https://counter.theconversation.com/content/102058/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kamran Siddiqi receives funding from National Institute of Health Research, Medical Research Council, Cancer Research UK, European Commission and Pfizer. </span></em></p>A common smoking cessation drug doesn’t appear to work for shisha smokers.Kamran Siddiqi, Professor Global Public Health, University of YorkLicensed as Creative Commons – attribution, no derivatives.