tag:theconversation.com,2011:/uk/topics/tobacco-cessation-41676/articlestobacco cessation – The Conversation2024-01-23T19:00:02Ztag:theconversation.com,2011:article/2214122024-01-23T19:00:02Z2024-01-23T19:00:02ZFor the new vape laws to succeed, these 3 things need to happen – or users may look to the illicit market<figure><img src="https://images.theconversation.com/files/570782/original/file-20240123-15-tpau1a.jpg?ixlib=rb-1.1.0&rect=17%2C511%2C5973%2C3476&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/a-woman-sitting-on-a-bench-next-to-a-man-IktGJT61bG4">Ernst Gunther Krause/Unsplash</a></span></figcaption></figure><p>This year, the Australian government will progressively <a href="https://theconversation.com/from-today-new-regulations-make-it-harder-to-access-vapes-heres-whats-changing-218816">ban</a> the retail sale of all e-cigarettes, known as vapes. Vapers will <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/next-steps-on-vaping-reforms?language=en">only be allowed</a> to use nicotine vapes that comply with <a href="https://www.tga.gov.au/products/unapproved-therapeutic-goods/vaping-hub/reforms-regulation-vapes">Therapeutic Goods Administration</a> (TGA) product requirements – and only to help them quit or manage their nicotine dependence, if prescribed by a doctor and dispensed by a pharmacy.</p>
<p>This will be <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/next-steps-on-vaping-reforms?language=en">accompanied by</a> increased funding for law enforcement to prevent illegal importation of vapes, a public education campaign about the risks of vaping, and greater efforts to encourage smokers to only obtain their vapes on prescription.</p>
<p>But for the scheme to be successful, three things need to happen: vaping products that vapers will use need to be available, GPs need to be willing to write prescriptions, and pharmacies need to be able to meet the demand. None of these are guaranteed. </p>
<p>Failure to do so could see some people continue to use the illicit market for vapes, or to switch to traditional cigarettes. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/from-today-new-regulations-make-it-harder-to-access-vapes-heres-whats-changing-218816">From today, new regulations make it harder to access vapes. Here's what's changing</a>
</strong>
</em>
</p>
<hr>
<h2>The previous vape policy failed</h2>
<p>The new policy tightens the enforcement of a <a href="https://link.springer.com/chapter/10.1007/978-3-031-23658-7_1#Sec5">retail sales ban on vapes containing nicotine</a> first introduced in <a href="https://www.aph.gov.au/DocumentStore.ashx?id=b57abf1c-0e4f-49a5-a3a3-2bb02ea76bf3&subId=401164">2011</a>. This only allowed smokers to use nicotine vapes if they had been approved for smoking cessation (quitting) by the TGA and were prescribed by a doctor to help them quit smoking. </p>
<p>The TGA’s expectation was that nicotine vapes would eventually be produced that would be approved for prescription. When no vapes had been approved by 2021, the TGA <a href="https://www.tga.gov.au/resources/publication/scheduling-decisions-final/notice-final-decision-amend-current-poisons-standard-nicotine">reclassified nicotine</a> to allow doctors to prescribe unapproved nicotine vapes.</p>
<p>But these policies didn’t meet their objectives. <a href="https://oia.pmc.gov.au/sites/default/files/posts/2024/01/Impact%20Analysis%20-%20Proposed%20reforms%20to%20the%20regulation%20of%20vapes.PDF">Fewer than 10% of vapers</a> obtained a prescription.</p>
<p>The TGA’s <a href="https://oia.pmc.gov.au/sites/default/files/posts/2024/01/Impact%20Analysis%20-%20Proposed%20reforms%20to%20the%20regulation%20of%20vapes.PDF">impact assessment</a> of the 2021 policy shows it failed to prevent vaping among Australian youth or give smokers legal access to vapes. This was in large part because vape retailers illegally sold nicotine vapes as nicotine-free products (which were not banned) and sold colourful, flavoured disposable vapes that appealed to young people.</p>
<figure class="align-center ">
<img alt="Colourful vapes in a shop" src="https://images.theconversation.com/files/570790/original/file-20240123-27-bz731n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/570790/original/file-20240123-27-bz731n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/570790/original/file-20240123-27-bz731n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/570790/original/file-20240123-27-bz731n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/570790/original/file-20240123-27-bz731n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/570790/original/file-20240123-27-bz731n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/570790/original/file-20240123-27-bz731n.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">Retailers illegally sold nicotine vapes as ‘nicotine-free’ products.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/man-in-black-long-sleeve-shirt-holding-black-dslr-camera-hVcmxpYg1Gc">e Liquids UK/Unsplash</a></span>
</figcaption>
</figure>
<p>By the end of 2023, an <a href="https://oia.pmc.gov.au/sites/default/files/posts/2024/01/Impact%20Analysis%20-%20Proposed%20reforms%20to%20the%20regulation%20of%20vapes.PDF">estimated</a> 1.3 million Australian adults were using vapes containing nicotine. The largest uptake was among young adults aged 18 to 24 and there was a worrying uptake among young people aged 14 to 17. More than <a href="https://oia.pmc.gov.au/sites/default/files/posts/2024/01/Impact%20Analysis%20-%20Proposed%20reforms%20to%20the%20regulation%20of%20vapes.PDF">90% of vapes</a> were obtained illegally from retail vape stores and via internet sales.</p>
<h2>What are the new rules, and what are their aims?</h2>
<p>From January 1, the importation of disposable vapes <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/next-steps-on-vaping-reforms?language=en">is banned</a>. </p>
<p>From March, there will be a <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/next-steps-on-vaping-reforms?language=en">complete ban</a> on the import of non-therapeutic vape products. Importers of therapeutic vapes will need a licence and permit from the government’s Office of Drug Control to import them. </p>
<p>The government will <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/next-steps-on-vaping-reforms?language=en">later set product standards</a> that limit flavours, reduce permissible nicotine concentrations and require pharmaceutical packaging of therapeutic vapes.</p>
<hr>
<p>
<em>
<strong>
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>
</strong>
</em>
</p>
<hr>
<p>The policy <a href="https://oia.pmc.gov.au/sites/default/files/posts/2024/01/Impact%20Analysis%20-%20Proposed%20reforms%20to%20the%20regulation%20of%20vapes.PDF">aims</a> to reduce adolescent vaping by 2026 while allowing adult smokers to use vapes for quitting and managing nicotine dependence, by making them easier to access. </p>
<p>But there are major challenges in achieving these goals. </p>
<h2>1. Enough therapeutic products</h2>
<p>The TGA will need to ensure there are enough products that meet their product standards and that vapers will use. </p>
<p>It’s unclear how vape producers will be encouraged to notify the TGA that their device meets standards and whether vapers will be interested in using them. </p>
<p>However, vapes exist with specified nicotine levels that could be plain-packaged, if required.</p>
<h2>2. Doctors will need to prescribe them</h2>
<p>The new regulations allow any medical or nurse practitioner to prescribe nicotine vapes for smoking cessation and to manage nicotine addiction. </p>
<p>Given the existing <a href="https://oia.pmc.gov.au/sites/default/files/posts/2024/01/Impact%20Analysis%20-%20Proposed%20reforms%20to%20the%20regulation%20of%20vapes.PDF">low uptake of vape prescribing</a> and strong discouragement from the <a href="https://www.ama.com.au/qld/news/Vaping-package-good-step-in-nicotine-control#:%7E:text=%E2%80%9CThere%20is%20little%20evidence%20to,use%20as%20a%20cessation%20aid">Australian Medical Association</a> and <a href="https://www.racp.edu.au/docs/default-source/advocacy-library/policy-on-electronic-cigarettes.pdf">medical colleges</a>, more medical practitioners will need to be persuaded to prescribe vapes. </p>
<figure class="align-center ">
<img alt="Doctor writes prescription" src="https://images.theconversation.com/files/570792/original/file-20240123-17-qtktw9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/570792/original/file-20240123-17-qtktw9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/570792/original/file-20240123-17-qtktw9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/570792/original/file-20240123-17-qtktw9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/570792/original/file-20240123-17-qtktw9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/570792/original/file-20240123-17-qtktw9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/570792/original/file-20240123-17-qtktw9.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">Uptake of vape prescribing has been low.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-patient-consulting-room-gp-surgery-2367985555">Stephen Barnes/Shutterstock</a></span>
</figcaption>
</figure>
<p>GP guidelines for quitting recommend prescribing nicotine gum and patches, and vapes only if these products are unsuccessful. However, a <a href="https://pubmed.ncbi.nlm.nih.gov/38189560/">Cochrane review</a> of clinical trials found vapes were more effective for smoking cessation than nicotine gum and patches.</p>
<h2>3. Pharmacies need to dispense them</h2>
<p>There must be enough pharmacies prepared to dispense vapes. Pharmacy organisations are <a href="https://www.psa.org.au/nicotine-vaping-product-access-changes-coming/">cautiously supportive of the new regulations</a> but it’s unclear how many pharmacies will provide vapes. This may depend, in part, on demand for these products. </p>
<h2>Risks of the illicit market</h2>
<p>All of these challenges need to be met in two years. Failure to achieve these aims will sustain the illicit market for vapes. </p>
<p>Vapers who are unconcerned about the possibility of arrest for possessing vapes without a prescription (a <a href="https://www.criminaldefencelawyers.com.au/blog/is-vaping-illegal-in-australia/?utm_source=Mondaq&utm_medium=syndication&utm_campaign=LinkedIn-integration">criminal offence</a> in most states) may continue to use the illicit market.</p>
<p>Australian Border Force officials <a href="https://www.smh.com.au/politics/federal/smoke-alarm-warning-to-border-force-it-won-t-stop-vape-black-market-20240101-p5eujs.html">have conceded</a> they will not be able to prevent the illicit importation of vaping devices. </p>
<hr>
<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>
</strong>
</em>
</p>
<hr>
<p>There is also a risk some vapers will switch to cigarettes which, while expensive, are readily available. Vapes are not without harm, but toxicological analyses <a href="https://respiratory-research.biomedcentral.com/articles/10.1186/s12931-021-01737-5">conclude</a> they are <a href="https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html">less harmful</a> than conventional cigarettes.</p>
<h2>What if the vape regulations fail?</h2>
<p>If the vape laws aren’t successful, regulators must find another way to meet the policy’s goals of minimising youth vaping and reducing the size of the illicit vaping market. </p>
<p>One way would be to allow the sale of approved vapes to adult smokers under much tighter regulations than apply to cigarettes. This could mean banning disposable vapes and restricting sales of other vapes to licensed tobacconists on the condition that they will lose their licence if they sell to youth. This could be enforced by requiring the installation of CCTV in stores, as occurs in US cannabis retail outlets. </p>
<p>This alternative model could include many of the other regulations proposed: only allowing approved vaping devices, plain packaging, flavour restrictions and no advertising. But this <a href="https://onlinelibrary.wiley.com/doi/10.1111/dar.13663">model</a> wouldn’t require a doctor’s prescription or restrict dispensing to pharmacies.</p><img src="https://counter.theconversation.com/content/221412/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Wayne Hall has been a paid advisor to the Therapeutic Goods Administration on the safety and effectiveness of medical cannabis (2017-2019) and was a member of Australian Advisory Council on Medicinal Uses of Cannabis, Commonwealth Department of Health, February 2017-2021. He has advised the World Health Organization on the health effects of cannabis, 2019-2023. He has not received any funding from the alcohol, pharmaceutical, tobacco or e-cigarette industries. His past research on tobacco related topics was funded by the National Health and Medical Research Council. The opinions expressed in this article are those of the author and do not necessarily reflect the view of the organisation where he works or its funders.</span></em></p>If the scheme isn’t successful, some people may continue using illicit vapes, or to switch to traditional cigarettes.Wayne Hall, Emeritus Professor, The National Centre for Youth Substance Use Research, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1396902020-05-30T08:46:21Z2020-05-30T08:46:21ZTobacco bans during lockdown should encourage renewed anti-smoking drives<figure><img src="https://images.theconversation.com/files/338542/original/file-20200529-96713-qo3omb.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">Christian Ohde/McPhoto/ullstein bild via Getty Images</span></span></figcaption></figure><p>The 2020 World No Tobacco Day is unique and historic as it comes at the time when countries across the world are on lockdown due to the COVID-19 pandemic. </p>
<p>For Botswana the day is particularly poignant. The country has banned imports and sales of tobacco or tobacco-related products along with other emergency regulations during the country’s declared six-month <a href="https://iharare.com/botswana-national-lockdown/">state of public emergency</a>. </p>
<p>To the best of my knowledge <a href="https://africanbusinessmagazine.com/sectors/commodities/covid-19-threatens-southern-africas-tobacco-industry/">Botswana</a> and neighbouring <a href="https://www.bbc.com/news/world-africa-52772186">South Africa</a> are the only countries to have done so. Governments in both countries have faced a massive backlash, with smokers expressing their <a href="https://mg.co.za/coronavirus-essentials/2020-05-15-those-who-zol-dangerous-discourses-in-a-time-of-crisis/">unhappiness</a>. The prohibition and the response have attracted global <a href="https://www.bbc.com/news/world-africa-52772186">headlines</a>.</p>
<p>The motivation to ban the sales of tobacco and tobacco related products in Botswana was informed by <a href="http://www.tobaccoinduceddiseases.org/COVID-19-and-smoking-A-systematic-review-of-the-evidence,119324,0,2.html">scientific evidence</a> that smoking damages human lungs and other body organs. As COVID-19 is primarily a disease affecting the respiratory system, smokers are therefore <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7103991/">more vulnerable</a>.</p>
<p>Another motivation has been the actions of tobacco companies. In recent months, the industry has stooped to new lows to target youth by exploiting the pandemic to sell <a href="https://www.tobaccofreekids.org/media/2020/2020_05_covid-marketing">more products</a>. In more than 28 countries, tobacco and e-cigarette companies have used social media and other marketing tactics to launch <a href="https://www.tobaccofreekids.org/media/2020/2020_05_covid-marketing">pandemic-themed</a> promotions, undermine minimum age purchase restrictions meant to protect youth and make unproven and illegal health claims.</p>
<p>Botswana has a very high smoking rate of <a href="https://www.who.int/tobacco/surveillance/policy/country_profile/bwa.pdf?ua=1">18%</a> – <a href="https://www.afro.who.int/sites/default/files/2019-01/Botswana_GATS_2017_FactSheet_Final.pdf">27% of males and 9% of females currently use tobacco</a>. This is similar to South Africa, where the national smoking <a href="https://pubmed.ncbi.nlm.nih.gov/26449697">prevalence</a> is about 18%: 29% of males and 6.8% of females.</p>
<p>These figures are higher than the rest of the continent, where <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0132401">about</a> 14% of men and 2% of women smoke. According to the estimates by the <a href="https://www.who.int/gho/tobacco/use/en/">World Health Organisation (WHO)</a>, Africa is one of two regions – along with the Eastern Mediterranean region – where smoking rates are on the rise.</p>
<p>At a time when COVID-19 is gripping the world, the pandemic should encourage countries to kickstart programmes and policies that encourage smokers to quit. The justifications behind the bans should be used in other countries to encourage smokers to quit. Along with the measures to ban tobacco imports and sales, governments have the opportunity to provide smokers with treatments to help them. </p>
<h2>The evidence</h2>
<p>On account of the devastating impact of smoking on COVID-19, the WHO has put out a scientific <a href="https://www.who.int/news-room/detail/11-05-2020-who-statement-tobacco-use-and-covid-19">brief</a> based on a review of 32 studies. It notes that</p>
<blockquote>
<p>smoking is associated with increased severity of disease and death in hospitalised COVID-19 patients.</p>
</blockquote>
<p>The WHO’s recommendation based on the review is that given the well-established harm associated with tobacco use and second-hand smoke exposure, “tobacco users stop using tobacco”. </p>
<p>Botswana needs to jump on to this opportunity. Never before have smokers had this kind of opportunity to quit. The government must facilitate quitting by providing smoking cessation programmes. </p>
<p>The WHO <a href="https://www.who.int/tobacco/quitting/summary_data/en/">advises</a> governments to support users wanting to quit. Interventions it recommends include toll-free quit lines, mobile text-messaging cessation programmes, nicotine replacement therapies and other approved medications.</p>
<p>Countries should take their lead from the global health body. The ban on the sale of tobacco products and any calls by governments for smokers to quit during the COVID-19 pandemic need to be accompanied by initiatives that aid smokers in this course of action.</p>
<p>Additionally, and in line with the ideals of the 2020 World No Tobacco Day, the government of Botswana must strictly enforce the provisions of its Control of Smoking Act. Section 13 of the act bans the advertisement of tobacco products by the tobacco industry. </p>
<p>Recently there has been an upsurge in advertisements, especially banners posted by tobacco companies or individuals that boldly advertise and promote tobacco products in the face of COVID-19. These actions disregard existing law prohibiting the advertising and promotion of tobacco products in Botswana.</p>
<p>A survey done in South Africa of how <a href="http://www.reep.uct.ac.za/sites/default/files/image_tool/images/405/Publications/reports/Lockdown%20Survey%20Final.pdf">smokers</a> are coping with the ban on cigarette sales during lockdown confirms how difficult it is for smokers once they are caught in addiction. Governments should recognise this and accept that smokers need help to quit. This should includes counselling and nicotine replacement therapies. </p>
<p>Such strategies will counter the tobacco industry’s strategies to negate government tobacco control efforts.</p><img src="https://counter.theconversation.com/content/139690/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bontle Mbongwe 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>According to the estimates by the World Health Organisation, Africa is one of two regions – along with the Eastern Mediterranean region – where smoking rates are on the rise.Bontle Mbongwe, Associate Professor, University of BotswanaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1071852018-11-26T11:37:52Z2018-11-26T11:37:52ZSmoking rates in US have fallen to all-time low, but how did they ever get so high?<figure><img src="https://images.theconversation.com/files/247093/original/file-20181124-149326-1smreuf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">This ad featuring then-actor Ronald Reagan is an example of industry advertising that made smoking so popular.</span> <span class="attribution"><a class="source" href="https://www.industrydocumentslibrary.ucsf.edu/tobacco/docs/nhvd0050">University of California San Francisco Tobacco Archives</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>The Centers for Disease Control and Prevention <a href="https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm">calls cigarette smoking</a> “the leading cause of preventable disease and death in the U.S., accounting for over 480,000 deaths per year.” The CDC just announced that smoking rates among U.S. adults have fallen to the <a href="https://www.cdc.gov/media/releases/2018/p1108-cigarette-smoking-adults.html">lowest level ever recorded</a> – only 14 percent, <a href="https://profiles.nlm.nih.gov/ps/access/nnbcph.pdf">less than a third</a> the rate just 70 years ago. While this decline is remarkable, it also points to a puzzle: How did smoking rates ever get so high in the first place?</p>
<p>November is <a href="https://lcam.org/">Lung Cancer Awareness Month</a>, which provides a timely opportunity to review the history of tobacco smoking and its promotion.</p>
<h2>Getting cigarettes rolling</h2>
<p>Tobacco smoking originated in America around 3,000 B.C. Seafaring traders introduced it to Europe and Asia in the 17th century. One of the first anti-tobacco publications ever issued was King James I’s 1604 “<a href="http://www.laits.utexas.edu/poltheory/james/blaste/">Counterblaste to Tobacco</a>,” in which he condemns the practice as “loathsome to the eye, hatefull to the nose, harmefull to the braine, and dangerous to the lungs.”</p>
<p>Smoking has several appeals. First, tobacco naturally <a href="https://www.scientificamerican.com/article/is-nicotine-all-bad/">contains nicotine</a>, an insecticide, which raises alertness, speeds reaction times, and stimulates the release of neurotransmitters such as dopamine, which are associated with pleasure. Second, smoking may <a href="https://www.sciencedaily.com/releases/2017/08/170821102718.htm">provide opportunities</a> to flout authority and fit in with peer groups. Third, once someone has started smoking, attempts to stop may <a href="https://www.healthline.com/health/smoking/nicotine-withdrawal">precipitate</a> withdrawal symptoms such as headaches, nausea, anxiety and weight gain.</p>
<p>Cigarette smoking in the U.S. really caught fire in the first half of the 20th century. <a href="https://books.google.com/books?id=yybaN6j4IpEC&pg=PA592&lpg=PA592&dq=the+cigarette+century+bennett&source=bl&ots=KWUsAHGJh4&sig=HhloH37soOITSBpVx5sniS546Vo&hl=en&sa=X&ved=2ahUKEwi66sfN1tveAhWQG3wKHVERBvsQ6AEwB3oECAEQAQ#v=onepage&q=bonsack&f=false">Technology played</a> an important role. Through most of the 19th century, each cigarette had to be rolled by hand, which took about 15 seconds. But in 1875, a Richmond, Virginia, company offered a US$75,000 prize for the invention of an automatic rolling machine. The prize was claimed by James Bonsack, whose machine could roll 200 cigarettes per minute, dramatically increasing capacity and lowering production costs.</p>
<h2>Wartime promotion</h2>
<p>Over the course of World War I, <a href="https://pointsadhsblog.wordpress.com/2014/06/27/wwi-part-5-tobacco-in-the-trenches/">cigarettes supplanted pipes</a> as the most popular means of tobacco consumption. Soldiers who smoked pipes had to keep their loose tobacco dry, take time to fill their pipes, and relight them frequently, which could attract enemy attention. By contrast, cigarettes were quick and easy to consume. Free cigarettes were distributed to the troops, and they soon began serving as a unit of currency, with the price of a haircut, for instance, set at two cigarettes. During the war, rates of smoking tripled.</p>
<p>During World War II, free cigarettes were again <a href="https://smokingjacketmagazine.com/2014/11/11/smokes-for-the-boys-a-history-of-smoking-and-the-military/">distributed to soldiers</a> and even included with ration kits. Soldiers were encouraged to smoke to relieve boredom and improve morale, and in 1943 their demand helped U.S. companies manufacture 290 billion cigarettes. Some tobacco ads showed patriotic wives and mothers shipping cartons of cigarettes to their loved ones on the front. At home, rationing made cigarettes scarcer, and on days they were available, people often lined up to buy them.</p>
<p>U.S. tobacco companies <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2352989/pdf/bmj00571-0040.pdf">received an unexpected boost</a> during WWII when Germany’s Nazi Party introduced a variety of initiatives aimed to reduce smoking among both the general public and physicians. Perhaps augmented by Hitler’s personal distaste for the habit, smoking was banned in many public places, the tobacco tax was raised and educational initiatives were launched. After the war, U.S. cigarette firms were able to undermine anti-smoking campaigns by linking them to Nazi tactics.</p>
<h2>Cigarettes’ health effects</h2>
<p>For decades, cigarette companies strenuously denied that smoking is linked to human disease. A 1954 ad that appeared in over 400 U.S. dailies was entitled “<a href="https://www.tobaccofreekids.org/assets/factsheets/0268.pdf">A Frank Statement to Cigarette Smokers</a>.” It declared that “interest in people’s health is a basic responsibility, paramount to every other consideration in business.” Yet it also added, “We believe the products we make are not injurious to health,” claiming that “one by one” charges that cigarettes are injurious “have been abandoned for lack of evidence.”</p>
<p>Tobacco companies were not content merely to deny that cigarettes are harmful. They also used print, radio, and television ads to argue that they are positively healthful. Many ads featured physicians and dentists endorsing particular brands because they were filtered or mentholated. <a href="http://americanhistory.si.edu/blog/2014/03/smoke-gets-in-your-eyes-20th-century-tobacco-advertisements.html">One 1930 Lucky Strike ad claimed</a> that “20,679 physicians say Luckies are less irritating,” calling them “Your throat protection against cough.”</p>
<h2>Madison Avenue psychology</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/247094/original/file-20181124-149320-3m4rcj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/247094/original/file-20181124-149320-3m4rcj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=425&fit=crop&dpr=1 600w, https://images.theconversation.com/files/247094/original/file-20181124-149320-3m4rcj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=425&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/247094/original/file-20181124-149320-3m4rcj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=425&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/247094/original/file-20181124-149320-3m4rcj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=534&fit=crop&dpr=1 754w, https://images.theconversation.com/files/247094/original/file-20181124-149320-3m4rcj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=534&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/247094/original/file-20181124-149320-3m4rcj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=534&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">This ad from the World War II era encouraged people to send Chesterfields to men in the armed forces.</span>
<span class="attribution"><a class="source" href="https://www.industrydocumentslibrary.ucsf.edu/tobacco/docs/syvd0050">University of California Tobacco Archives</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>Many campaigns <a href="http://americanhistory.si.edu/blog/2014/03/smoke-gets-in-your-eyes-20th-century-tobacco-advertisements.html">featured celebrity endorsements</a>. One 1947 Chesterfield ad featured popular comedian Bob Hope, saying “Dorothy Lamour is my favorite brunette. Chesterfield is my favorite cigarette.” A 1950 Chesterfield holiday campaign showcased actor and future U.S. President Ronald Reagan, a cigarette dangling from his lips, saying “I’m sending Chesterfields to all my friends. That’s the merriest Christmas any smoker can have.”</p>
<p>To promote sales to men, campaigns linked cigarettes to masculinity. The Marlboro Man, conceived by advertising executive Leo Burnett in 1954, <a href="https://adage.com/article/special-report-the-advertising-century/marlboro-man/140170/">aimed to enhance the male appeal</a> of filtered cigarettes, which had a feminine connotation. Running from 1954 to 1999, Marlboro ads featured rugged cowboys on the open range, often backed by bold music, such as the theme from the film, “The Magnificent Seven.” Ironically, many of the Marlboro Men eventually succumbed to tobacco-related diseases.</p>
<p>In the years following World War I, cigarette companies had been disappointed to find that smoking was much less popular among women than men. They soon turned to advertising to stoke demand. One campaign, “torches of freedom,” <a href="https://tobaccocontrol.bmj.com/content/9/1/3">was developed</a> by Sigmund Freud’s nephew <a href="https://theconversation.com/the-manipulation-of-the-american-mind-edward-bernays-and-the-birth-of-public-relations-44393">Edward Bernays</a>, who paid young women to light cigarettes during a 1929 Easter parade, symbolizing their emancipation. By 1935, cigarette purchases by women had more than tripled.</p>
<p>By the 1970s, women’s cigarette marketing often focused on themes of liberation. For example, Virginia Slims, which sponsored the women’s professional tennis tour, often promoted images of irrepressible young women with the tag line “<a href="https://flashbak.com/youve-come-a-long-way-baby-virginia-slims-advertising-year-by-year-365664/">You’ve come a long way, baby</a>.” The implication? By lighting up, women could strike a blow for an oppressed minority, announce their independence, and cast their lot with a svelte cadre of role models.</p>
<h2>Where are we now?</h2>
<p>Cigarette use has fallen to an all-time low in part because the last television cigarette ad appeared at 11:59 p.m. on Dec. 31, 1970, just one minute before a federal ban went into effect. But cigarette marketing is not dead. For example, many point-of-sale campaigns can be found in convenience stores, gas stations and even pharmacies. <a href="https://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/marketing/index.htm">Such promotions now account</a> for most of the $8.7 billion U.S. cigarette marketing budget.</p>
<p>Although cigarette marketing has declined considerably since its heyday, the timeliness of its lessons remains undiminished. Americans today are still subjected to marketing for a variety of hazardous products, from <a href="https://www.businessinsider.com/heres-how-guns-are-advertised-in-america-2012-12">firearms</a> and <a href="https://www.researchgate.net/publication/46302105_Impact_of_Gambling_Advertisements_and_Marketing_on_Children_and_Adolescents_Policy_Recommendations_to_Minimise_Harm">gambling</a> to less obvious threats such as social media, the excessive use of which is <a href="https://www.forbes.com/sites/alicegwalton/2018/11/16/new-research-shows-just-how-bad-social-media-can-be-for-mental-health/#68254c157af4">linked to depression</a>. So long as there is money to be made in moving such merchandise, it seems, someone will be on hand with a battery of techniques to promote sales.</p><img src="https://counter.theconversation.com/content/107185/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Gunderman 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>Smoking rates are at their lowest, but it has been a long and expensive struggle. Promoters of cigarette smoking have included not only tobacco companies but advertisers and even the US government.Richard Gunderman, Chancellor's Professor of Medicine, Liberal Arts, and Philanthropy, Indiana UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1052732018-11-01T10:50:28Z2018-11-01T10:50:28ZA vaccine to stop lung cancer? It’s made from tobacco taxes and legislation<figure><img src="https://images.theconversation.com/files/242783/original/file-20181029-76384-pryjy9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Anti-smoking ads such as this one can help curb smoking, but studies are suggesting that raising the tax on cigarettes may be most effective to help deter poor people.</span> <span class="attribution"><span class="source">California Department of Public Health</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Lung cancer is the <a href="https://www.cancer.gov/types/common-cancers">biggest cancer killer</a> in the country, and almost <a href="https://www.cdc.gov/cancer/lung/basic_info/mortality-infographic.htm">90 percent of deaths</a> from this disease are directly attributable to cigarette smoking. Many cancers, such as breast cancer, that were once a death sentence are <a href="https://progressreport.cancer.gov/after/survival">now treatable</a>, yet lung cancer survival rates remain <a href="https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/lung-cancer/resource-library/lung-cancer-fact-sheet.html">below 20 percent</a>. A cure may be elusive, but the medical community can stop this disease and eliminate most future lung cancer deaths. </p>
<p><a href="https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/lung-cancer/resource-library/lung-cancer-fact-sheet.html">Most lung cancer deaths are caused by smoking</a>, and smoking is a socially influenced behavior. People tend to catch it from tobacco marketing and by modeling smokers. Tobacco companies spend <a href="https://www.ftc.gov/news-events/press-releases/2017/10/ftc-releases-reports-2015-cigarette-smokeless-tobacco-sales">more than a million dollars an hour</a> to market their products in order to <a href="http://publichealthlawcenter.org/topics/tobacco-control/tobacco-control-litigation/united-states-v-philip-morris-doj-lawsuit">recruit new smokers</a>. </p>
<p>I am a tobacco control researcher who has studied ways to stop the disease. There is a vaccine to smoking, and you don’t even have to get a shot. Scientists have more than 60 years of research on how to get people to quit smoking and prevent teens from starting to smoke. Evidence compiled over many years shows that a combination of hard-hitting media prevention campaigns, strict laws and higher taxes can reduce the numbers of teens who start smoking and nudge adults smokers toward quitting.</p>
<h2>Smoking rates drop by more than half</h2>
<p>Cigarettes were a common part of American life for most of the 20th century. Smoking peaked mid century; more than <a href="https://www.lung.org/our-initiatives/research/monitoring-trends-in-lung-disease/smoking-trends/index.html">40 percent of Americans smoked cigarettes in 1965</a>. </p>
<p>The prior year, the <a href="https://www.cdc.gov/tobacco/data_statistics/sgr/history/index.htm">surgeon general’s warning</a> about the dangers of smoking launched a massive effort to end smoking. Media campaigns about the newly established dangers of smoking led to the first sustained dip in smoking prevalence in the United States. Subsequent smoke-free policies beginning in the 1980s, age restrictions and other regulatory constraints on smoking and the tobacco industry led to further declines in smoking. Today fewer than 15 percent of adults are <a href="https://www.cdc.gov/nchs/data/nhis/earlyrelease/EarlyRelease201803_08.pdf">smokers</a>.</p>
<p>And yet, while fewer and fewer Americans smoke, smoking rates remain persistently high among <a href="https://www.cdc.gov/tobacco/disparities/low-ses/index.htm">poorer Americans</a>. Most families with higher socioeconomic status live, work and play in places where smoking is not allowed and in fact frowned upon. </p>
<p>The social climate around tobacco is very different for poorer Americans. <a href="https://www.cdc.gov/tobacco/disparities/low-ses/index.htm">More of their friends and family smoke</a>, and many live and work in places <a href="https://truthinitiative.org/news/smoking-and-low-income-communities">where indoor smoking is allowed</a>. </p>
<p>Reducing the smoking rate by more than 50 percent is one of the great public health successes of the past hundred years, but poorer Americans were left behind. Broader implementation of effective tobacco prevention strategies could reduce lung cancer in this population, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3828959/">studies suggest</a>. </p>
<h2>Telling kids the costs, and the truth</h2>
<p>Studies show that one of the first steps in reducing smoking is to change the way that people think about tobacco. Successful media campaigns must go beyond simply warning about the health risks of smoking. Campaigns should provide youth with new information that reframes the images of smoking portrayed in tobacco ads. One recent national campaign to prevent youth smoking demonstrates this strategy.</p>
<p>Launched in 2014 by the FDA, “<a href="https://therealcost.betobaccofree.hhs.gov/videos.html">The Real Cost</a>” campaign reframes smoking. Rather than glamorized images of smoking, youth learn that every cigarette costs them something. These costs include the cosmetic damage of smoking, loss of control due to addiction, and the <a href="https://www.cancer.org/cancer/cancer-causes/tobacco-and-cancer/carcinogens-found-in-tobacco-products.html">chemistry set of toxicity</a> in cigarette smoke. <a href="https://www.cdc.gov/mmwr/volumes/66/wr/mm6602a2.htm?s_cid=mm6602a2_w#contribAff">Longitudinal surveys</a> that followed youth over four surveys administered from 2013 to 2016 revealed that this campaign prevented approximately 350,000 youths from starting to smoke between 2014 and 2016.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/242836/original/file-20181029-76390-16ppqes.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/242836/original/file-20181029-76390-16ppqes.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=500&fit=crop&dpr=1 600w, https://images.theconversation.com/files/242836/original/file-20181029-76390-16ppqes.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=500&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/242836/original/file-20181029-76390-16ppqes.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=500&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/242836/original/file-20181029-76390-16ppqes.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=628&fit=crop&dpr=1 754w, https://images.theconversation.com/files/242836/original/file-20181029-76390-16ppqes.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=628&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/242836/original/file-20181029-76390-16ppqes.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=628&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 is the leading cause of lung cancer, and it also accounts for close to 1 in 5 deaths.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/tobaccorelated-mortality-deaths-by-tobacco-vector-140935645?src=F_vEMNzkfV7VoH-qVlwaZw-1-22">SunnySideUp/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Media campaigns can reframe the way people think about smoking and quitting smoking, but they do not directly compel people to quit smoking or not to start to smoke. Laws and policies such as no smoking in restaurants provide a booster to these media campaigns. By constraining the behavior of tobacco companies, retailers and smokers, regulatory action strongly nudges smokers toward quitting and youth away from smoking. </p>
<p>And, while regulatory actions restrict individual and commercial freedoms, most Americans <a href="https://www.tobaccofreekids.org/assets/factsheets/0290.pdf">support policies</a> to prevent smoking. Secondhand smoke harms nonsmokers and smoking costs all of us <a href="https://www.cdc.gov/tobacco/data_statistics/fact_sheets/economics/econ_facts/index.htm">billions of dollar in health care</a>. The benefits of less smoking outweigh any perceptions of regulatory burden. Moreover, these actions are low to no cost to implement, and tobacco taxes actually generate revenue. </p>
<p>Starting in the 1990s, cities and states began banning smoking in offices restaurants to protect nonsmokers. These policies also changed the social climate impacting people’s decisions about tobacco use. Teens who were experimenting with tobacco and smokers began to get the message that most people do not smoke and do not find it acceptable. <a href="https://jamanetwork.com/journals/jama/fullarticle/192966">Fewer teens started smoking</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449303/">more adults quit smoking</a> in the wake of these smoke free policies. </p>
<p>Although tobacco companies resist these smoking bans, these policies are <a href="https://www.tobaccofreekids.org/assets/factsheets/0290.pdf">popular with Republican and Democratic voters</a>. In recent years, smoking bans have extended to private venues. Several states ban smoking in cars if there is a child present, while landlords and property associations frequently ban smoking in <a href="https://smokefreehomes.iowa.gov/smoke-free-housing/property-ownersmanagers/landlord-rights">private residences</a>. And this year, the federal government <a href="https://www.hud.gov/smokefreepublichousing">banned smoking inside of apartments</a> managed by the Housing and Urban Development Authority (however, this policy does not apply to Section 8 housing).</p>
<h2>Taxation without misrepresentation</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/242838/original/file-20181029-76413-b2zm0a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/242838/original/file-20181029-76413-b2zm0a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/242838/original/file-20181029-76413-b2zm0a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/242838/original/file-20181029-76413-b2zm0a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/242838/original/file-20181029-76413-b2zm0a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/242838/original/file-20181029-76413-b2zm0a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/242838/original/file-20181029-76413-b2zm0a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A rally in Helena, Montana, in August 2018, to garner support for an increase in the tobacco tax in Montana.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Election-2018-Progressive-Initiatives/2e2dc9418234403592f56b338d5c27a6/1/0">Matt Volz/AP Photo</a></span>
</figcaption>
</figure>
<p>Beyond restricting where people can smoke, many cities and states prohibit the sale of tobacco products to people under 21. The social circles of most high school students do not include 21-year-olds, so these teens are unlikely to have friends who can legally buy cigarettes. Needham, Massachusetts, a suburb of Boston, was the first city to raise the age to 21, and teen smoking decreased <a href="http://tobaccocontrol.bmj.com/lookup/doi/10.1136/tobaccocontrol-2014-052207">compared to neighboring suburbs</a>. Preliminary evidence from California indicates that this policy is <a href="http://tobaccocontrol.bmj.com/lookup/doi/10.1136/tobaccocontrol-2017-054088">limiting teens’</a> ability to buy cigarettes.</p>
<p>Taxes on tobacco are <a href="https://www.tobaccofreekids.org/assets/factsheets/0290.pdf">popular with many voters</a>, and represent a win-win for lawmakers. With higher prices, <a href="https://tobaccocontrol.bmj.com/content/11/suppl_1/i62">people buy fewer cigarettes</a> and the higher taxes generate <a href="https://www.tobaccofreekids.org/assets/factsheets/0303.pdf">more revenue</a>. This new revenue could provide support for quit attempts and fund programs to prevent teens from becoming smokers. The District of Columbia recently enacted a $2 a pack tax increase on cigarettes, and voters in Montana and South Dakota will vote Nov. 6 on whether to increase tobacco taxes in their states.</p>
<p>Lung cancer remains a deadly disease, but our country has the vaccine to prevent this disease. Informed by more than 60 years of research on effective hard-hitting media campaigns and regulatory policies, lawmakers have the tools to eliminate most lung cancers. Studies suggest that wider implementation of these policies, especially in places with more poverty, would reduce smoking and prevent lung cancer. Quitting smoking is hard, but these popular evidence-based strategies can help.</p><img src="https://counter.theconversation.com/content/105273/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robert McMillen receives funding from the Flight Attendant Medical Research Institute, the American Academy of Pediatrics, and the Mississippi State Department of Health. </span></em></p>Lung Cancer Awareness Month starts today, but observance of it often slips under the radar, in part because there are so few survivors. Here’s how the biggest cancer killer could actually be halted.Robert McMillen, Professor & Associate Director of the Social Science Research Center, Mississippi State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1050962018-10-23T10:45:06Z2018-10-23T10:45:06ZE-cigarettes and a new threat: How to dispose of them<figure><img src="https://images.theconversation.com/files/241648/original/file-20181022-105748-i9ta7f.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A discarded Juul on the floor of a San Francisco streetcar March 20, 2018.</span> <span class="attribution"><span class="source">Julia McQuoid</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>The two largest global brands of capsule coffee, <a href="http://www.abc.net.au/news/2016-08-24/former-nespresso-boss-warns-coffee-pods-are-killing-environment/7781810">Nespresso</a> and <a href="https://www.nytimes.com/2016/04/17/business/energy-environment/keurigs-new-k-cup-coffee-is-recyclable-but-hardly-green.html">Keurig</a>, are regarded by many as <a href="https://www.npr.org/sections/thesalt/2015/01/28/379395819/coffee-horror-parody-pokes-at-environmental-absurdity-of-k-cups">environmental nightmares</a>. Billions of the throwaway nonrecyclable plastic products currently clutter waste dumps, waterways and city streets. Both inventor of the “K-cups” <a href="https://www.theatlantic.com/technology/archive/2015/03/the-abominable-k-cup-coffee-pod-environment-problem/386501/">John Sylvan</a> and former Nespresso CEO <a href="http://www.abc.net.au/news/2016-08-24/former-nespresso-boss-warns-coffee-pods-are-killing-environment/7781810">Jean-Paul Gaillard</a> have publicly bemoaned the environmental consequences of the products they once championed. <a href="https://www.theatlantic.com/technology/archive/2015/03/the-abominable-k-cup-coffee-pod-environment-problem/386501/">Sylvan</a> has stated that the disposable (but not biodegradable) coffee capsule is “like a cigarette for coffee, a single-serve delivery mechanism for an addictive substance.”</p>
<p>The comparison between cigarette butts and capsule coffee is surprisingly fitting. Both butts and capsules are intentionally designed to be convenient, single-use products. Both are also nonbiodegradable and unrecyclable. As pervasive and polluting as cigarette butts are, however, the e-waste from e-cigarettes presents an even more apt comparison.</p>
<p>As a postdoctoral researcher at the Center for Tobacco Control Research and Education at the University of California, San Francisco with a background in environmental philosophy and public health, I became curious how the waste stream of e-cigarettes has passed <a href="https://doi.org/10.2105/AJPH.2018.304699">completely outside the regulatory radar</a>. </p>
<h2>A smoking gun?</h2>
<p>San Francisco’s Pax Labs, maker of the market-leading electronic cigarette (e-cigarette) <a href="https://www.wired.com/2015/04/pax-juul-ecig/">Juul</a>, thinks of its product as a “Nespresso machine, if Nespresso still made great coffee.” It also describes its e-cigarette as a <a href="https://www.wired.com/2015/04/pax-juul-ecig/">“gun.”</a> </p>
<p>The product has soared in popularity, particularly among teenagers, leading Dr. Scott Gottlieb, commissioner of the Food and Drug Administration, in September 2018 to call Juul smoking among teens an <a href="https://www.cnbc.com/2018/09/13/fda-chief-targets-juul-for-epidemic-of-teens-using-e-cigarettes.html">epidemic</a>.</p>
<p>While the health outcomes for e-cigarette vapor versus an inveterate capsule coffee drinker vary greatly, both “disruptive” products present lingering harms to the environment greater than the products they replace. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/241286/original/file-20181018-67176-1bt1dr9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/241286/original/file-20181018-67176-1bt1dr9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=499&fit=crop&dpr=1 600w, https://images.theconversation.com/files/241286/original/file-20181018-67176-1bt1dr9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=499&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/241286/original/file-20181018-67176-1bt1dr9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=499&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/241286/original/file-20181018-67176-1bt1dr9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=627&fit=crop&dpr=1 754w, https://images.theconversation.com/files/241286/original/file-20181018-67176-1bt1dr9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=627&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/241286/original/file-20181018-67176-1bt1dr9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=627&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Volunteers pick up cigarette butts at Point Pleasant Beach, New Jersey, on Oct. 12, 2012.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Beach-Sweeps/f7415c90f11d42018c07b2735092807b/62/0">Michael Parry/AP Photo</a></span>
</figcaption>
</figure>
<p>The legacy of cigarette butts imparts a dark story. An estimated <a href="https://link.springer.com/article/10.1007/s40572-014-0016-x">two-thirds of cigarette butts are littered</a>, clogging sewer drains, blighting city parks and contributing to estimated cleanup costs of <a href="http://infohouse.p2ric.org/ref/50/49409.pdf">US$11 billion</a> yearly for U.S. litter alone. Cigarettes are environmentally irresponsible by design, and yet <a href="http://www.who.int/tobacco/publications/environmental-impact-overview/en/">e-cigarettes pose an environmental threat</a> of considerable proportions. Instead of merely being thrown away, these complex devices present simultaneously a <a href="http://linkinghub.elsevier.com/retrieve/pii/S0956053X15000884">biohazard risk</a> with potential high quantities of leftover or residual nicotine and an environmental health threat as littered electronic waste.</p>
<p>Their <a href="https://www.ncbi.nlm.nih.gov/pubmed/29526076">endocrine-disrupting plastics</a>, lithium ion batteries and electronic circuit boards require disassembly, sorting and proper further recycling and disposal. Their instructions do not say anything about disposal. Electronic waste (e-waste) already presents <a href="http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(13)70101-3/abstract">a daunting environmental quandary</a> and is notoriously difficult to recycle. When littered, broken devices can leach metals, battery acid and nicotine into the local environment and urban landscape.</p>
<h2>A preventable environmental health disaster</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/241283/original/file-20181018-67164-18xcdyw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/241283/original/file-20181018-67164-18xcdyw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=384&fit=crop&dpr=1 600w, https://images.theconversation.com/files/241283/original/file-20181018-67164-18xcdyw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=384&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/241283/original/file-20181018-67164-18xcdyw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=384&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/241283/original/file-20181018-67164-18xcdyw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=483&fit=crop&dpr=1 754w, https://images.theconversation.com/files/241283/original/file-20181018-67164-18xcdyw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=483&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/241283/original/file-20181018-67164-18xcdyw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=483&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">E-cigarettes remain controversial because of the inability to know whether they are a gateway to cigarette smoking. One thing is clear: They are an environmental threat.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-woman-inhaling-electronic-cigarette-140876200?src=nKklxIak-EQeSpManB5h2g-1-2">RedPixel.pl/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>A main question public health regulators must face is: How are these new devices being disposed of? Are e-cigarettes being thrown away carelessly, like cigarette butts? Or disposed of in special electronic waste facilities, like smartphones? Preliminary results from litter pickups give mixed results. Juul pods are found routinely littered, especially where young people congregate. But because of the double-bind of e-cigarette waste being both electronic waste due to the components and hazardous waste due to the nicotine liquid residue, <a href="http://dx.doi.org/10.1016/j.wasman.2015.02.005">currently there is no legal way to recycle them in the U.S.</a> The Office on Smoking and Health and the EPA need to coordinate their regulations to allow for the safe recycling and waste minimization of these products. </p>
<p>More than <a href="https://ajph.aphapublications.org/doi/10.2105/AJPH.2017.303660">58 million e-cigarette products were sold in the U.S.</a> (not including those sold in vape shops or online) in 2015, 19.2 million of which were disposable e-cigarettes. A <a href="https://tobaccocontrol.bmj.com/content/23/suppl_2/ii54">2014 study</a> found that none of the surveyed e-cigarette packages contained disposal instructions.</p>
<p>The major transnational tobacco companies so far primarily sell throwaway, one-use <a href="http://www.ingentaconnect.com/content/trsg/trs/2017/00000003/00000003/art00008;jsessionid=lfubscfo1k9r.x-ic-live-01">“closed” system products</a>. Vuse and MarkTen, owned by Reynolds American and Altria, respectively, are <a href="https://www.statista.com/statistics/285116/us-e-cigarettes-companies-trend-in-market-share/">two leading U.S. e-cigarettes</a>, and both are closed systems. While these products may prevent nicotine poisoning in small children, their environmental health harms may be significantly larger due to their expendable design. </p>
<p>Most independent vaporizer manufacturers sell open, or reusable, systems, which are more popular with longer-term users and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4992632/">possibly more effective to quit than traditional cigarettes</a>. In other markets, however, like the U.K. and Japan, transnational tobacco companies British American Tobacco (BAT) and Japan Tobacco International have begun to heavily market open systems. </p>
<p>BAT’s <a href="https://www.govype.com/uk/disposal">website</a> on the disposal of their Vype e-cigarette warns “electrical waste and electronic equipment can contain hazardous substances which, if not treated properly, could lead to damage to the environment and human health.” So <a href="http://dx.doi.org/10.5888/pcd13.150502">neither open</a> nor closed systems are environmentally sustainable.</p>
<p>The World Health Organization, in its report <a href="http://www.who.int/tobacco/publications/environmental-impact-overview/en/">Tobacco and Its Environmental Impact: An Overview</a>, recently noted the “quieter but shockingly widespread impacts of tobacco from an environmental perspective.” <a href="http://www.who.int/tobacco/framework/WHO_FCTC_english.pdf">Article 18</a> of the WHO Framework Convention on Tobacco Control states that all signatory parties “agree to have due regard to the protection of the environment and the health of persons in relation to the environment in respect of tobacco cultivation and manufacture within their respective territories.” It is time to close the loop and pay increased attention to tobacco product disposal as well.</p>
<p>As regulatory agencies continue deciding how to regulate e-cigarettes, not only should the immediate health effects and secondhand effects of the products be taken into account, but I believe the <a href="https://doi.org/10.2105/AJPH.2018.304699">environmental effects</a> of these products should be too.</p>
<p>The <a href="https://www.npr.org/sections/thesalt/2015/01/28/379395819/coffee-horror-parody-pokes-at-environmental-absurdity-of-k-cups">mounting environmental impact</a> of the single-use nonrecyclable coffee fad has left coffee capsule Keurig inventor John Sylvan regretting his invention. Will apocryphal e-cigarette inventor Hon Lik ever have a similar reckoning regarding the mountains of e-cigarette e-waste? Let’s hope it never gets to that point.</p><img src="https://counter.theconversation.com/content/105096/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Yogi H. Hendlin 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>E-cigarettes are hotly debated because of the uncertainty of whether they are a gateway to cigarette smoking for teens, or an aid to smoking cessation. One thing is clear: They are not biodegradable.Yogi H. Hendlin, Postdoctoral Research Fellow in Public Health Policy, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1009662018-08-14T20:26:44Z2018-08-14T20:26:44ZWhy Australian prisoners are smoking nicotine-infused tea leaves<figure><img src="https://images.theconversation.com/files/231807/original/file-20180813-2900-1igpw2p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Prison represents only a temporary disruption in tobacco use for many smokers.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1119711299?src=StGCHrvIZoRW7ATFs2QQSw-1-18&size=huge_jpg">TeodorLazarev</a></span></figcaption></figure><p>Following a ban on tobacco smoking in prisons, some Australian prisoners are creating substitute cigarettes from crushed nicotine lozenges mixed with tea leaves. More than half of the participants we sampled in our <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/dar.12848">recent study</a> have used this product, known as “teabacco”.</p>
<p>Around <a href="https://www.aihw.gov.au/reports/prisoners/health-of-australias-prisoners-2015/contents/smoking">74% of prisoners entering the system</a> are smokers. This is partly because groups who smoke at higher rates in the community – such as people who <a href="http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4364.0.55.001%7E2014-15%7EMain%20Features%7ESmoking%7E24">are poor and disadvantaged</a>, identify as <a href="https://www.mja.com.au/journal/2015/202/10/talking-about-smokes-large-scale-community-based-participatory-research-project">Indigenous</a>, or experience <a href="https://www.ncbi.nlm.nih.gov/pubmed/16492581">mental health or substance use disorders</a> – are all <a href="https://www.aihw.gov.au/reports/prisoners/health-of-australias-prisoners-2015/contents/table-of-contents">overrepresented</a> in prisons.</p>
<p>But despite not having access to regular cigarettes while incarcerated, <a href="https://www.ncbi.nlm.nih.gov/pubmed/29660697">most former prisoners</a> (94%) resume the habit on release, and many will go on to develop <a href="https://www.nejm.org/doi/full/10.1056/NEJMsa064115">smoking-related illnesses</a>. In other words, prison represents only a temporary disruption in tobacco use for many smokers, and many are still smoking, albeit a different substance.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/breaking-bad-habits-classical-conditioning-and-smoking-11578">Breaking bad habits: classical conditioning and smoking</a>
</strong>
</em>
</p>
<hr>
<p>Simply providing nicotine lozenges isn’t enough to change the entrenched behaviour of long-term smokers. We need to provide better support for Australians in prison to quit smoking and improve their long-term health. They deserve the same quitting services as those in the community.</p>
<h2>When was smoking banned?</h2>
<p>Smoking has been banned in all prisons in Queensland, the Northern Territory, Tasmania, Victoria, and New South Wales <a href="https://www.mja.com.au/journal/2015/203/8/smoking-bans-prison-time-breather">since 2015</a>. While <a href="http://www.corrections.sa.gov.au/about/our-research/smokefree-prisons-strategy">South Australia</a> is due to follow in 2019, smoking is still permitted in prison cells in Western Australia and the Australian Capital Territory.</p>
<p>Smoking bans have been well received by most Australian prisoners, with <a href="https://www.ncbi.nlm.nih.gov/pubmed/29660697">most</a> saying they want to stay off cigarettes. Only one documented riot (at <a href="https://theconversation.com/why-banning-smoking-in-prisons-is-a-good-idea-44139">the Melbourne’s Metropolitan Remand Centre</a>*) has coincided with a smoking ban in Australia, and an <a href="http://assets.justice.vic.gov.au/corrections/resources/198d00c1-c2ad-4089-98c6-bffc074880c3/mrc_riot_final_report.pdf">independent evaluation</a> determined that overcrowding and inadequate fencing were also contributing factors.</p>
<p>However, besides making nicotine lozenges available for purchase (and patches before that), Australian prison or health authorities have not implemented any formal program to help people in prison to quit smoking, or to stay off cigarettes when they are released.</p>
<h2>How teabacco is used</h2>
<p><a href="https://onlinelibrary.wiley.com/doi/full/10.1111/dar.12848">To make teabacco</a>, prisoners first crush nicotine lozenges, which are available for sale from most prison shops. They then mix the crushed lozenges with rinsed tea leaves. This blend is then wrapped in Bible paper, which is easily obtained from prison-based ministry services.</p>
<p>To get a sense of how widespread this practice is, we <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/dar.12848">surveyed 82 former smokers recently released from Queensland prisons</a> about their teabacco use. More than half (57%) said they had tried teabacco while in prison. One-third (37%) had used it more than once a week, mainly to alleviate cravings for cigarettes. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/231838/original/file-20180814-2921-12r14cw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/231838/original/file-20180814-2921-12r14cw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/231838/original/file-20180814-2921-12r14cw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/231838/original/file-20180814-2921-12r14cw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/231838/original/file-20180814-2921-12r14cw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/231838/original/file-20180814-2921-12r14cw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/231838/original/file-20180814-2921-12r14cw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Prisoners should have access to the same subsidised medications to quit smoking as the rest of the population.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1154216977?src=_hnUQp0HjD1IgI21o4lB4A-1-2&size=huge_jpg">Shutterstock</a></span>
</figcaption>
</figure>
<p>Previously, prisoners in Queensland were making teabacco from nicotine patches, which were provided for free when the smoking ban was implemented. But after <a href="https://www.ncbi.nlm.nih.gov/pubmed/26094737">researchers found</a> that smoking nicotine patches releases potentially harmful toxins, the patches were removed from all prisons. </p>
<p>Participants in <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/dar.12848">our study</a> described how prisoners then switched to making teabacco from nicotine lozenges instead.</p>
<h2>Should lozenges be banned?</h2>
<p>No, removing nicotine lozenges from prisons isn’t the answer. </p>
<p>Our forensic analysis of the chemical compounds of teabacco made from nicotine lozenges, published today in the journal <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/dta.2471">Drug Testing and Analysis</a>, reveals only small amounts of most potentially harmful compounds. This means that teabacco made from lozenges is actually <em>less</em> harmful to smoke than commercial cigarettes. </p>
<p>In light of these findings, and considering that nicotine lozenges are the only quit tool available in most prisons, we caution against removing nicotine lozenges from prisons – at least until further research can clearly determine the potential harms. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-banning-smoking-in-prisons-is-a-good-idea-44139">Why banning smoking in prisons is a good idea</a>
</strong>
</em>
</p>
<hr>
<p>A few participants in <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/dar.12848">our study</a> also reported smoking plain tea leaves when nicotine lozenges were not available, suggesting a degree of inevitability in some prisoners finding something to smoke. </p>
<p>Prison-based awareness campaigns may help to alert prisoners to the fact that more nicotine can be absorbed from sucking lozenges, as outlined on the dosage instructions.</p>
<h2>How to improve prisoners’ health</h2>
<p>Helping prisoners to quit smoking has both health and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5801657/">financial</a> benefits, both for individuals and <a href="https://www.ncbi.nlm.nih.gov/pubmed/24922122">at the population level</a>, by reducing the burden on the health system. </p>
<p>While most Australians can access cheaper medications to help quit smoking through the Pharmaceutical Benefits Scheme, <a href="https://www.doctorportal.com.au/mjainsight/2017/27/call-to-include-prisoners-in-medicare-and-pbs/">prisoners are excluded</a> from this scheme. This is in violation of <a href="https://www.unodc.org/documents/justice-and-prison-reform/GA-RESOLUTION/E_ebook.pdf">United Nations’ “Mandela Rule” 24.1</a>, which requires health services in prison to be equivalent to those available in the community. </p>
<p>Prisoners would also benefit from access to other forms of quit smoking support, such as <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1675874">behavioural counselling</a> or <a href="https://www.bmj.com/content/360/bmj.j5543">e-cigarettes</a>. These options help people to cope with symptoms of nicotine withdrawal and other behavioural triggers that cause smoking relapse. </p>
<p>If we’re serious about helping prisoners quit smoking tobacco – or teabacco – we need to offer evidence-based options to help prisoners quit smoking for good. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/three-charts-on-australias-booming-prison-population-76940">Three charts on: Australia's booming prison population</a>
</strong>
</em>
</p>
<hr>
<p><em>* This article originally said the riot was at Ravenhall Prison, rather than the Metropolitan Remand Centre.</em></p><img src="https://counter.theconversation.com/content/100966/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jason Ferris is the chief data scientist for the Global Drug Survey, founded by Adam Winstock. He has received funding from National Health and Medical Research Council, The Australian Research Council, the Foundation for Alcohol Research and Education, Queensland Government, Australian & New Zealand Association of Oral & Maxillofacial Surgeons, Tasmanian Department of Health and Human Services, Criminology Research Grant, Victorian Law Enforcement Drug Fund, Department of Health and Ageing, VicHealth, Australian National Preventive Health Agency</span></em></p><p class="fine-print"><em><span>Stuart Kinner receives funding from the National Health and Medical Research Council, and the Victorian Health Promotion Foundation.</span></em></p><p class="fine-print"><em><span>Cheneal Puljević and Ross Coomber 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>The only quitting tool most Australian prisoners have access to is nicotine lozenges. These are being mixed with tea leaves to create a smokable product known as “teabacco”.Cheneal Puljević, Research Fellow, Centre for Health Services Research, The University of QueenslandJason Ferris, Associate Professor, Senior Biostatistician and Program Leader, The University of QueenslandRoss Coomber, Professor of Criminology and Sociology, University of LiverpoolStuart Kinner, Professor, Murdoch Children's Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/989872018-06-29T10:37:23Z2018-06-29T10:37:23ZIs Juul making it easy for kids to vape in school? New study suggests yes<figure><img src="https://images.theconversation.com/files/224996/original/file-20180626-112598-sr7kqp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Young people may be vaping during school, a study of Twitter posts suggests.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/vape-smoke-that-contains-harmful-ingredients-1074617216?customer_ID=&campaign_ID=shutters.11154505&launch_ID=10580185&utm_source=sstkemail&utm_medium=email&utm_campaign=!Auto_API_Share_Module"> J.A. Dunbar/shutterstock.com </a></span></figcaption></figure><p>The <a href="https://theconversation.com/juul-why-a-trendy-e-cig-is-causing-a-social-and-public-health-commotion-90985">Juul</a> vaporizer is the latest advancement in electronic cigarette technology, delivering nicotine to the user from a device about the size and shape of a thumb drive. Juul has taken the electronic cigarette market by storm experiencing a <a href="https://www.cnbc.com/2017/12/19/JUUL-labs-raising-150-million-in-debt-after-spinning-out-of-pax.html">year-over-year growth of about 700 percent.</a></p>
<p>In recent months, stories about a possible Juul craze among teenagers have circulated in the media. In April, <a href="https://www.wsj.com/articles/schools-parents-fight-a-juul-e-cigarette-epidemic-1522677246">The Wall Street Journal</a> reported that parents are fighting a Juul
epidemic. In May, <a href="https://www.newyorker.com/magazine/2018/05/14/the-promise-of-vaping-and-the-rise-of-juul">The New Yorker</a> told a story about Juul’s presence at high schools in America’s more affluent ZIP codes.</p>
<p>I study ways to inform public health and policy by using data from social media. According to new research my colleagues and I conducted that was just published in <a href="https://www.sciencedirect.com/science/article/pii/S0376871618303338">Drug and Alcohol Dependence</a>, thousands of students sneak this nicotine delivery system on to school grounds to use during school hours.</p>
<h2>Using social media for science</h2>
<p>Our study adds to this discussion by considering a novel source: posts to Twitter. Because posts on social media reflect the attitudes and behaviors of the public in their own words, researchers can treat this data source like a massive focus group.</p>
<p>For this reason, my colleagues and I will often turn to social media to track health behaviors, including the use of emerging tobacco products, to better understand the social and environmental setting in which they are used. <a href="http://europepmc.org/articles/pmc5362347">For example</a>, last year we discovered that “cloud chasing,” or the act of blowing the largest aerosol cloud possible in a competition, was one of the more appealing characteristics of electronic cigarettes among Instagram users.</p>
<p>In our most recent study, we wanted to document and describe the public’s initial experiences with Juul. We collected posts to Twitter containing the term “Juul” from April 1, 2017 to December 14, 2017. We analyzed over 80,000 posts representing tweets from 52,098 unique users during this period and used text classifiers (automated processes that find specified words and phrases) to identify topics in posts. </p>
<p>We found that 1 in 25 posts, or 4 percent, was indicative of use of Juul while at high school, middle school and even elementary school. These posts described young people talking about using Juul on school grounds, in classrooms, in bathrooms, in the library, at recess and during gym. </p>
<p>For example, if the words “school,” “principal,” “teacher,” “elementary” or “recess,” among dozens of others, co-occurred in posts with the word “Juul,” we identified that post as reflective of a young person using Juul or seeing someone use Juul while on school grounds.</p>
<p>In comparison, a <a href="https://tobaccocontrol.bmj.com/content/early/2018/04/07/tobaccocontrol-2018-054273">recent national online survey</a> showed that 7 percent of participants 15 to 17 years of age, who would most likely be high school students, reported ever using a Juul. </p>
<p>We only had access to posts from public accounts, so our findings do not reflect posts from private users suggesting our numbers may underreport the amount of youth talking about Juul on Twitter.</p>
<p>Juul’s discreetness may facilitate its use in places where vaping is prohibited, also known as “stealth vaping.” </p>
<h2>How to handle vaping</h2>
<p>Our findings suggest educators may be in need of training on how to identify Juul in the classroom. School administrators may consider installing vapor detectors in bathrooms and classrooms to deter use of Juul on school grounds. </p>
<p>Our study’s data source – posts to Twitter – may highlight a way parents can determine if their child is using Juul. While we analyzed anonymized data, parents could follow their child’s account to monitor such activities.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/224999/original/file-20180626-112644-vttf23.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/224999/original/file-20180626-112644-vttf23.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=396&fit=crop&dpr=1 600w, https://images.theconversation.com/files/224999/original/file-20180626-112644-vttf23.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=396&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/224999/original/file-20180626-112644-vttf23.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=396&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/224999/original/file-20180626-112644-vttf23.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=498&fit=crop&dpr=1 754w, https://images.theconversation.com/files/224999/original/file-20180626-112644-vttf23.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=498&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/224999/original/file-20180626-112644-vttf23.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=498&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.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Juul_in_hand.jpg">Mylesclark96/Wikimedia commons</a></span>
</figcaption>
</figure>
<p>Twitter does not make its users’ demographic information (e.g., age) public in order to protect user privacy. As such, our study could not determine the exact age of Twitter users. However, posts contained combined words like “Juul” and “recess” suggesting posts were made by youth.</p>
<p>While Juul is marketed as a “smoking alternative” for adults trying to quit, we found relatively few posts containing phrases like “quit smoking.” One in 350 posts do. </p>
<p><a href="https://theconversation.com/juul-why-a-trendy-e-cig-is-causing-a-social-and-public-health-commotion-90985">Electronic cigarettes have stirred national debate</a> where public health officials are trying to determine if these devices, like Juul, will help smokers quit combustible cigarettes or serve as a possible gateway product to combustible cigarette use among youth. While this debate will likely go on for some time, it is clear that nicotine use of any kind is known to be addictive and <a href="https://e-cigarettes.surgeongeneral.gov/documents/2016_sgr_full_report_non-508.pdf">harmful to adolescent brain development</a>. We believe that our findings underscore the need for policies to be implemented to keep such products out of the hands of youth.</p><img src="https://counter.theconversation.com/content/98987/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jon-Patrick Allem receives funding from the Tobacco-Related Disease Research Program and the National Institutes of Health. </span></em></p>A new e-cigarette called Juul may be gaining popularity among youth. A new study used a novel approach to see if kids are vaping in school.Jon-Patrick Allem, Research Scientist, University of Southern CaliforniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/909852018-05-31T13:50:20Z2018-05-31T13:50:20ZJuul: Why a trendy e-cig is causing a social – and public health – commotion<figure><img src="https://images.theconversation.com/files/221046/original/file-20180530-120502-j0wr2r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A woman exhaling after taking a hit from a Juul. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/vaping360/42226974632/in/photolist-27kshoL-24DV8rN-24DV8bN-262TbTg-KgEtrm-262Tc7c-24DV8HE-24DV7Sb-24DVaf7-262TeqR-27kscps-4cenrU-drCRt-drCQK-drCQm-a6kezT-27pzJ4V-27pzHpt-u58ox-262TcHc-2rwY1s-262ThH2-64gZJt-aEBW6c-4BxM6w-nVR1d9-bnSLfh-a6jKMc-drCZQ-27pzEhB-27pzC24-27pzGj2-drCtx-drCnw-drCoz-drCwG-drCGp-drCn5-24DVUyw-27pzCCp-drCpR-drCEe-KgFiKW-7nJLkz-262TauV-jp25EU-27pzGrX-262Taar-262Sc8M-fSnKDy"> vaping360.com/juul/juul-vapor-review/</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>The U.S. Department of Health and Human Services has launched a <a href="https://therealcost.betobaccofree.hhs.gov/gm/hacked-ends.html?g=t">campaign to discourage e-cigarette</a> vaping. While it targeted all e-cigarette vaping, the campaign makes a powerful visual reference to <a href="https://truthinitiative.org/news/what-is-juul">Juul</a>, a device that can be recharged in a computer USB drive and <a href="https://www.nytimes.com/2018/02/16/nyregion/juul-teenagers-vaping-ecigarettes-dangers.html">has been reported</a> to be gaining popularity among youth, even though Juul Labs created it for adults who want to stop smoking. The HHS campaign depicts seemingly emotionless teenagers with USB ports where their mouths should be.</p>
<p>The campaign is part of a long, successful history of <a href="http://tobaccocontrol.bmj.com/content/7/1/5">fear-based</a> campaigns that have effectively <a href="https://www.nejm.org/doi/full/10.1056/NEJMp1313940">“denormalized”</a> smoking. But, in the case of <a href="https://www.juul.com/">Juul</a>, is it a new public health threat? Or is it a disruptive technology that threatens to make combustible tobacco products, <a href="https://www.cancer.org/cancer/cancer-causes/tobacco-and-cancer/health-risks-of-smoking-tobacco.html">which kill half of all smokers</a>, obsolete? In short, could it help or hurt public health?</p>
<h2>Harm reduction or harm extension?</h2>
<p>I am a public health scholar who has studied the history, ethics and evidence in scientific and policy debates over the value of e-cigarettes as a harm reduction strategy. Harm reduction is a public health strategy that involves providing individuals with addiction safer but not necessarily safe substitutes. Providing clean needles to injecting drug users to prevent HIV, substituting methadone for heroin, and even offering seat belts are all examples of harm reduction tactics.</p>
<p>Juul entered the market in 2015 without the legacy of having previously manufactured combustible products. <a href="https://support.juul.com/learn/read/juul-labs-announces-comprehensive-strategy-to-combat-underage-use">Juul Labs CEO</a> describes the company’s mission as “to eliminate cigarettes and help the more than one billion smokers worldwide switch to a better alternative.” The <a href="https://www.juul.com/">company’s website</a> invites visitors to “Learn about our mission to improve the lives of the world’s one billion adult smokers.”</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/220861/original/file-20180529-80658-apn2he.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/220861/original/file-20180529-80658-apn2he.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/220861/original/file-20180529-80658-apn2he.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/220861/original/file-20180529-80658-apn2he.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/220861/original/file-20180529-80658-apn2he.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/220861/original/file-20180529-80658-apn2he.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/220861/original/file-20180529-80658-apn2he.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 man and a woman holding a Juul device.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/vaping360/40466840100/in/photolist-24DV8HE-KgEnZ9-69pdnu-69pbGm-5AgiLh-5cZEYN-H88WKV-nXKmS-okvrq-2hjL6A-JjNVo-opxtg-opxJp-o95Kg-4Qtpoi-4p8DqY-bY4oYh-bY4n1A-gVbSxw-mVjKz-4QxB11-oYTwg-rruYDh-26iQPxs-okqb7a-vjJ6QN-6wkiPL-55cwuu-adxFE4-27pzGrX-3bhy3-bzmXXw-4R2YoN-6wg7rz-pzVnFu-mc2HH-WVY3T5-mbh2E-8B9Bgi-JgsjSF-21f5M8-JDkw7-V24Dah-6wkm5q-8786EM-dpZfRg-pFbtkX-fbxJx9-qBSZ4u-262Tc7c">Vaping360.com</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>The device itself is trim and high tech. It looks like a long, elegant thumb drive and easily fits in a user’s hand. It is relatively expensive. The Juul <a href="https://www.juul.com/shop/devices/starter-kit">starter kit</a>, which includes the device, charger and four nicotine pods, costs US$49.99 on the company’s website. On May 30, 2018, the company was <a href="https://www.juul.com/shop/devices/starter-kit">offering a $20 discount</a> for people who were willing to sign up.</p>
<p>Juul has improved nicotine delivery to users, meaning that they get more nicotine, faster, than they do with other vaping products. Most products on the market use <a href="https://www.atsdr.cdc.gov/phs/phs.asp?id=1120&tid=240">propylene glycol</a> and glycerin as the solvents that allow the delivery of nicotine. Distinguishing Juul is its use of <a href="http://nationalacademies.org/hmd/reports/2018/public-health-consequences-of-e-cigarettes.aspx">nicotine salts</a>, a combination of a nicotine base combined with a weak organic acid. Nicotine salts allow for absorption of nicotine in a fashion similar to combustible products. A recent study has suggested that the nicotine hit from Juul is also <a href="https://cen.acs.org/analyticalChemistry/spectroscopy/E-cigaretteschemistry-explain-popularity-among/96/i22">less harsh on the throat</a>, which may produce a more pleasant experience for both seasoned smokers and new users. </p>
<p>Even without an aggressive marketing strategy, sales of Juul kits have increased 680 percent and sales of refills have increased 710 percent since 2017, according to RBC Capital Markets. Juul has quickly taken command of the e-cigarette market. On May 29, 2018, Wells Fargo Equity attributed 45.7 percent of e-cigarette market unit shares to Juul.</p>
<h2>Nicotine: Addictive but not carcinogenic</h2>
<p>Juul is increasingly viable as a safer alternative for smokers who are trying to quit. But it raises concerns about kids and e-cigarette experimentation.</p>
<p>For adults, nicotine is relatively benign; the tars resulting from tobacco combustion are deadly.</p>
<p>In 2000, the chair of a <a href="https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.94.2.192">Public Health Service expert panel</a> made the case that, if necessary, smokers could stay “on (nicotine replacement) medication for the rest of their lives because I know it saves lives.” According to the <a href="https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0">Royal College of Physicians</a>, nicotine is not a carcinogen. </p>
<p>But nicotine is a stimulant that can increases both heart rate and blood pressure, suggesting that <a href="https://truthinitiative.org/sites/default/files/ReThinking-Nicotine.pdf">“it may contribute to cardiovascular disease.”</a></p>
<p>Nonetheless, over the counter <a href="https://truthinitiative.org/sites/default/files/ReThinking-Nicotine.pdf">nicotine replacement</a> therapies have been established as safe and effective and are not associated with an increase in the risk of heart attacks.</p>
<p><a href="https://truthinitiative.org/sites/default/files/ReThinking-Nicotine.pdf">Smoking has been established as a leading cause of cardiovascular disease</a> and cancer. Thus, many in the public health and medical communities were prepared to accept lifelong dependence on nicotine replacement therapies like the patch and nicotine gum if they helped to sustain smoking cessation.</p>
<p>The <a href="https://www.cancer.org/healthy/stay-away-from-tobacco/e-cigarette-position-statement.html">American Cancer Society</a> issued clinical guidelines acknowledging the potential of e-cigarettes to help smokers who have not been successful with going cold turkey or FDA approved nicotine replacement therapies. It notes that smokers who can’t or won’t quit “should be encouraged to switch to the least harmful form of tobacco product possible; switching to the exclusive use of e-cigarettes is preferable to continuing to smoke combustible products.”</p>
<h2>A different story for teens</h2>
<p>Nicotine does, however, pose risks to the developing adolescent brain. </p>
<p>The <a href="https://www.cancer.org/healthy/stay-away-from-tobacco/e-cigarette-position-statement.html">American Cancer Society</a> states that “the use of products containing nicotine in any form among youth is unsafe and can harm brain development.” Public health experts and organizations supportive of e-cigarettes as a promising harm reduction strategy for smokers and staunch opponents of e-cigarettes agree that kids should not be using any type of product containing nicotine. </p>
<p>For this reason, Juul may represent a new kind of risk when it comes to kids. And because it is small and generates little aerosol, it is easy to conceal and use without attracting attention.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/220859/original/file-20180529-80640-19jzxui.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/220859/original/file-20180529-80640-19jzxui.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=384&fit=crop&dpr=1 600w, https://images.theconversation.com/files/220859/original/file-20180529-80640-19jzxui.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=384&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/220859/original/file-20180529-80640-19jzxui.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=384&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/220859/original/file-20180529-80640-19jzxui.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=483&fit=crop&dpr=1 754w, https://images.theconversation.com/files/220859/original/file-20180529-80640-19jzxui.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=483&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/220859/original/file-20180529-80640-19jzxui.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=483&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Public health officials worry that vaping among teens can lead to cigarette smoking.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/686721556?src=hdmSPk0EyejhOgnwkFQfqA-1-16&size=small_jpg">Ostarcov Vladislav/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Juul has certainly captured teens’ attention. A Truth Initiative study found that, in a national sample of 1,012 people aged 15-17, <a href="http://tobaccocontrol.bmj.com/content/early/2018/04/07/tobaccocontrol-2018-054273">7 percent</a> reported ever having used a Juul. Twenty-one percent of the kids in this age group also recognized a photograph of a Juul. Recognition (34 percent) and past 30-day use (11 percent) were higher among those in the sample who were more affluent. Kids who are just experimenting may not realize that Juul delivers nicotine as efficiently as a combustible product, potentially increasing their risk of addiction. </p>
<p>The backdrop of this growing attention is one in which data on children and vaping remains contested. On the one hand, a landmark 2018 <a href="http://nationalacademies.org/hmd/reports/2018/public-health-consequences-of-e-cigarettes.aspx">National Academies of Science, Engineering, and Medicine</a> report concluded that “there is substantial evidence that e-cigarette use increases risk of ever using combustible tobacco cigarettes amongst youth and young adults.”</p>
<p>On the other, several years of painstaking, systematic reviews have led <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/684963/Evidence_review_of_e-cigarettes_and_heated_tobacco_products_2018.pdf">Public Health England</a> to conclude: “Despite some experimentation with these devices among never smokers, e-cigarettes are attracting very few young people who have never smoked in to regular use.” Both groups, it is important to underscore, agree that for adults, e-cigarettes are substantially safer than combustible products.</p>
<p>In May 2018, the former chair of the American Academy of Pediatrics Tobacco Consortium weighed in on the side of peril. Dr. Jonathan Winickoff described Juul in <a href="https://www.newyorker.com/magazine/2018/05/14/the-promise-of-vaping-and-the-rise-of-juul">The New Yorker</a> as nothing short of “bioterrorism” and declared that Juul already represents “a massive public-health disaster.” </p>
<p><a href="https://www.iowaattorneygeneral.gov/newsroom/attorney-general-miller-juul-labs-ecigarette/">Iowa Attorney General Tom Miller</a> sees promise in Juul and other products that deliver nicotine electronically. Miller, a longtime consumer advocate, has argued that public health has an obligation to inform the public that e-cigarettes are substantially safer than combustible products. While Miller said that Juul gives “cause for concern” when it comes to kids “it has not reached panic or epidemic stages.” </p>
<p>Meanwhile, the evidence on whether e-cigarettes help smokers quit remains limited and hotly contested. A recent <a href="https://www.nejm.org/doi/full/10.1056/NEJMsa1715757?query=featured_home&utm_source=STAT+Newsletters&utm_campaign=bd5d5c8814-MR&utm_medium=email&utm_term=0_8cab1d7961-bd5d5c8814-150488817&">New England Journal of Medicine study</a> has done little to <a href="http://www.kansascity.com/news/nation-world/article211771854.html">quell controversy</a>. Even as e-cigarettes continue to represent a increasing share of the tobacco market, smoking rates among adults and children <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2016">continue to decline</a> in both the U.K., where the <a href="https://www.bmj.com/content/358/bmj.j3262">lead public health agency</a> has explicitly endorsed e-cigarettes, and the U.S. </p>
<h2>Tobacco companies making their push</h2>
<p>As companies like the Altria Group, which manufacturers Marlboro, and Imperial Tobacco Group, which produces Winston and Kool, are successful at mimicking Juul and “getting into the (nicotine) ‘salt game,’” this will certainly fuel public health concerns that kids or even adults who never smoked will try a product like Juul and eventually graduate to a deadly combustible cigarette. And, indeed, careful monitoring will remain an imperative.</p>
<p>When it comes to kids, even if they do not represent a step on the way to combustible products, any product that delivers nicotine as effectively as cigarettes will remain a public health concern. And all e-cigarettes will continue to demand vigorous public health interventions, such as the April 2018 <a href="https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm605432.htm">Food and Drug Administration’s</a> “undercover nationwide blitz to crack down on the sale of e-cigarettes.”</p>
<p>But in my view, neither rigorous monitoring nor muscular efforts to prevent sales to kids make products like Juul as dangerous as cigarettes, which remain the <a href="https://www.cdc.gov/tobacco/data_statistics/index.htm">leading cause</a> of preventable death in the U.S. Combustible products are a genuine cause for fear, for both smokers and kids alike. </p>
<p>The most vexing challenge that Juul poses may be to tolerance: How will we view adults looking to quit smoking who either cannot or will not give up the pleasures of nicotine? Will the old consensus that lifelong treatment is acceptable hold when it’s a recreational rather than a pharmaceutical product?</p><img src="https://counter.theconversation.com/content/90985/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amy L. Fairchild has received funding on the politics of e-cigarettes from the Robert Wood Johnson Foundation. She is currently funded for work on the history of e-cigarettes and harm reduction from the Wellcome Trust. She has received funding on the politics of fear from the Greenwall Foundation and the National Endowment for the Humanities. </span></em></p>Some experts believe that e-cigarettes can help people stop smoking cigarettes. But do they lead others, especially teens, to start? The question intensifies as teens take up Juul.Amy Lauren Fairchild, Associate Dean of Academic Affairs at the School of Public Health, Associate Vice President for Faculty and Academic Affairs at Texas A&M Health Science Center, Professor of Health Policy & Management, Texas A&M UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/874212017-12-18T18:33:16Z2017-12-18T18:33:16ZWhy anti-tobacco messages are failing to reach rural Botswana<figure><img src="https://images.theconversation.com/files/198966/original/file-20171213-27555-w2brn4.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">Shutterstock</span></span></figcaption></figure><p>Twenty-year-old Thuso lives in a small rural farming village in <a href="http://www.statsbots.org.bw/sites/default/files/publications/Kgalagadi%20South%20District.pdf">Kgalagadi South</a> about 500 kilometres outside of Botswana’s capital city of Gaborone. It has a population of about <a href="http://www.statsbots.org.bw/population-census-atlas-2011-botswana">30,000 people</a>. Only one in five households have access to flush toilets and less than half use electricity to light their homes. </p>
<p>Thuso is not employed but he makes some money with “on and off” part-time jobs. Despite this, he smokes a pack of cigarettes a day. And on a good day – by his own admission – he can drink two cases of beer. </p>
<p>His girlfriend Lindah – the mother of his two-year-old child – is also unemployed. She uses snuff three to four times a day. It’s a habit she picked up since she was 12. And her drinking patterns are much the same as Thuso’s. </p>
<p>Both realise that drinking too much could harm them. They have heard about the dangers of alcohol from messages on radio, at school, teachings at community gatherings and even from some family members. But neither have ever really heard that tobacco use could be harmful. In fact snuff was suggested for Lindah by a family member as remedy for her frequent nose bleeds as a child. </p>
<p>Thuso and Lindah are not alone. Across the region’s villages smoking and drinking patterns mirror those of Thuso and Lindah.</p>
<p>I was part of a Ministry of Health and Wellness team that visited the region to talk about living healthily and understanding what challenges people faced doing so. We met with health providers, community members and leaders, and conducted screenings for tobacco and harmful alcohol use, blood pressure, diabetes, obesity, and cervical cancer. Our visit coincided with a debate in Botswana’s Parliament about a new law, the <a href="http://www.mmegi.bw/index.php?aid=70830&dir=2017/august/09">National Tobacco Control Bill</a>. </p>
<p>We found that in each village drinking and smoking rates were much higher than the average in <a href="https://www.cugh.org/events/2018-annual-cugh-global-health-conference">the country</a>. Furthermore, there was more pronounced use of smokeless tobacco such as sniffing or chewing snuff, predominantly by women. </p>
<p>This shows us that there are differences in the smoking patterns of rural and urban communities. Unless these are recognised and included in the in-country tobacco control interventions, efforts to reduce tobacco use will fail.</p>
<p>These were not good signs. Globally, tobacco is the <a href="https://books.google.co.bw/books?hl=en&lr=&id=hrIXDAAAQBAJ&oi=fnd&pg=PP1&dq=World+Health+Organization.+WHO+report+on+the+global+tobacco+epidemic,+2013:+enforcing+bans+on+tobacco+advertising,+promotion+and+sponsorship:+World+Health+Organization%3B+2013.&ots=xk8Wjod5hr&sig=Mbmc90XsWTQNTl3rScwuDtJG7i4&redir_esc=y#v=onepage&q=World%20Health%20Organization.%20WHO%20report%20on%20the%20global%20tobacco%20epidemic%2C%202013%3A%20enforcing%20bans%20on%20tobacco%20advertising%2C%20promotion%20and%20sponsorship%3A%20World%20Health%20Organization%3B%202013.&f=false">leading preventable cause of death</a>. According to the World Health Organisation, currently one billion people smoke and about 6 million die each year due to the <a href="http://www.who.int/bulletin/volumes/95/5/16-175596.pdf?ua=1">effects of tobacco</a>. It’s also among the four major risk factors for non-communicable diseases.</p>
<p>On the continent these diseases have become a major reason for premature deaths. And it’s estimated that there will be about 3.9 million deaths from non-communicable diseases in Africa by 2020.</p>
<p>This is against a backdrop of increasing smoking rates on the continent where about <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0132401">14% of men and 2% of women</a> smoke. This rising trend is seen only in <a href="http://www.who.int/gho/tobacco/use/en/">Africa and the Eastern Mediterranean region</a>, while all other regions in he world are experiencing declines in tobacco use.</p>
<h2>A vulnerable choice?</h2>
<p>Tobacco control efforts in Africa have centred on the rising smoking rates among middle-class urban communities. Messages are not in indigenous languages and are primarily distributed through commercial media. </p>
<p>Research shows that tobacco use is more popular in <a href="http://www.tandfonline.com/doi/abs/10.3402/gha.v6i0.19216">urban areas compared to rural areas</a>. But the patterns of tobacco use in rural Botswana tell a different story. There are pockets of the population where rates of tobacco use are far higher. While the national average sits at 18% in Botswana, in Kgalaladi South it jumps to 29%.</p>
<p>If passed, the bill being considered by Botswana’s parliament will mark a milestone in the country moving towards fully implementing recommendations by the World Health Organisation. Botswana signed up to them <a href="http://apps.who.int/fctc/implementation/database/parties/Botswana">in 2005</a> and to date has established a Tobacco levy, restricted smoking in public venues (designated smoking areas) and has outlawed direct marketing of tobacco products such as through TV, radio and other media. </p>
<p>The bill would outlaw smoking in all indoor public places and the sale of tobacco to individuals younger than 21. It would further restrict marketing of tobacco products (including indirect advertising) and mandate plain packaging, thus enacting regulatory and policy interventions that have been shown by <a href="http://www.nejm.org/doi/full/10.1056/nejmra1308383#t=article">studies</a> to reduce tobacco use.</p>
<p>The bill also includes strategies to reduce use of smokeless tobacco, which affects key populations such as in Kgalagadi South. </p>
<h2>Multiple interventions</h2>
<p>But the bill won’t be enough on its own. Significant tobacco use takes place in people’s private homes, and ‘passed down’ at an early age from family members who have been using tobacco. Peer pressure significantly affects whether an adolescent will use tobacco, independent of the influence of advertising. </p>
<p>In an analysis of Botswana’s population based national survey (STEPS) on non-communicable disease risk factors that was conducted in 2014, peer pressure was cited as reasons for tobacco use among 20.3% of daily users. We need to find more effective ways to raise awareness and change mindsets of families, of peers, of communities to reduce social acceptability of tobacco use. </p>
<p>In poor, remote communities such as in Kgalagadi South, tobacco is not a ‘new’ trend. It is a slow brewing problem that has been present since colonial times. </p>
<p>In some communities in Botswana, smoking has been seen as a symbol of wealth. Tobacco was once a <a href="https://www.google.co.za/url?sa=t&rct=j&q=&esrc=s&source=web&cd=10&cad=rja&uact=8&ved=0ahUKEwjuxM7MioTYAhVBtRoKHcptByEQFghjMAk&url=http%3A%2F%2Fdspace.nwu.ac.za%2Fbitstream%2Fhandle%2F10394%2F2281%2Fpilane_gabaitsiwee(1).pdf%3Fsequence%3D1&usg=AOvVaw1gANk9otLZYM3KfqBiakGx">form of currency</a>. As a result, those growing up in these communities begin to see the practice as not only normal but aspirational.</p>
<p>These traditional beliefs and lack of reach by conventional media makes addressing tobacco use more challenging. </p>
<h2>Targeted messaging</h2>
<p>To reach marginalised communities like in Kgalagadi South, public health messages must take into account everyone who is affected. This means messages need to take into account those whose first language may not be the official language, or who may have less interaction with conventional media. </p>
<p>Beyond having the information, interventions are needed that address culturally entrenched practices and beliefs through grassroots efforts that involve community leaders and school based programmes that impart life skills and prevent regular tobacco use at an early age. Tobacco cessation may sometime require pharmacological treatment for heavy users; we need to ensure that this is available equitable. This is the way to break the vicious patterns of tobacco use.</p>
<p>If these do not take place, Botswana – and many other countries like it – will fail those who are the most vulnerable.</p><img src="https://counter.theconversation.com/content/87421/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Neo Tapela 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>There are differences in the smoking patterns of rural and urban communities. These must be recognised and included in tobacco control interventions to reduce use.Neo Tapela, Senior Research Fellow, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/822412017-08-21T10:54:12Z2017-08-21T10:54:12ZWhy lowering nicotine in cigarettes could change the course of health<figure><img src="https://images.theconversation.com/files/182620/original/file-20170818-7949-6sk4rf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Studies have shown that most smokers wish they had never smoked and that they wish they could stop. Lowering the levels of nicotine, the addictive chemical in cigarettes, would be a big step. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/nicotine-dangerous-life-vintage-burnt-paper-678117133?src=RoCjlelrfEbq96ShH8UWpA-1-16">DenisProductions.com/Shutterstock.com</a></span></figcaption></figure><p>The new commissioner of the Food and Drug Administration (FDA) recently made a <a href="https://www.washingtonpost.com/news/to-your-health/wp/2017/07/28/fda-delay-e-cigarette-rules-years-explore-reducing-nicotine-conventional-cigarettes/?utm_term=.da1049189ba3">surprising and bold announcement</a> that could potentially save more lives than if we ended the opioid epidemic today. FDA Commissioner Scott Gottlieb, a physician and cancer survivor, said that federal regulators will start a conversation about dramatically reducing the amount of nicotine in cigarettes, low enough to make them nonaddictive, while taking a go-slow approach to adopting new regulations on electronic cigarettes and other devices that are increasingly popular for consuming nicotine.</p>
<p><a href="https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm568923.htm">As Gottlieb put it</a>, efforts to reduce smoking in the United States call for “Envisioning a world where cigarettes would no longer create or sustain addiction, and where adults who still need or want nicotine could get it from alternative and less harmful sources.”</p>
<p>This is a potentially historic announcement that offers a common-sense approach to moving the nation forward in our effort to reduce the number of illnesses and deaths caused by smoking. It is certainly an approach that has scientific merit.</p>
<p>I have spent decades working to reduce the harm of tobacco use. In 1992, I joined the Centers for Disease Control and Prevention as director of the Office on Smoking and Health. I can recall when the FDA’s standard response to requests that it regulate nicotine in cigarettes was to assert that cigarettes are neither a food nor a drug, but “a device of pleasure” outside of their authority.</p>
<p>I can assure you that few smokers derive true pleasure from their addiction. My research team has found that <a href="https://www.ncbi.nlm.nih.gov/pubmed/28383508">most smokers regret that they ever started</a>, and they desperately want to quit the habit. </p>
<h2>The death toll of smoking: 15 times higher than for opioids</h2>
<p>Though the opioid crisis is currently attracting the attention of the media and decision-makers across society, <a href="https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm">smoking remains the leading cause of preventable death and disease</a> in the United States, causing more than 480,000 deaths a year. To put the scourge of conventional cigarettes in context, <a href="https://www.vox.com/science-and-health/2017/8/1/16069684/fda-tobacco-regulation-nicotine-cigarette-smoking-deaths">smoking kills 15 times more Americans</a> per year than opioids.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/182621/original/file-20170818-7944-1ceq5w1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/182621/original/file-20170818-7944-1ceq5w1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=453&fit=crop&dpr=1 600w, https://images.theconversation.com/files/182621/original/file-20170818-7944-1ceq5w1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=453&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/182621/original/file-20170818-7944-1ceq5w1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=453&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/182621/original/file-20170818-7944-1ceq5w1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=569&fit=crop&dpr=1 754w, https://images.theconversation.com/files/182621/original/file-20170818-7944-1ceq5w1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=569&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/182621/original/file-20170818-7944-1ceq5w1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=569&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 the number one risk factor for lung cancer, but it also harms our lungs in other ways. In addition, smoking has been linked to 30 types of cancer and heart disease.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/lungs-234361483?src=ij2Pj5KHHPBk_GUtt-Ty1w-1-77">sciencepics/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Most Americans understand that smoking can cause cancer, but they may not be aware that it is also tied to a wide range of other health problems including heart disease, stroke and chronic obstructive pulmonary disease. In fact, <a href="http://content.healthaffairs.org/content/36/8/1423.abstract">a new study published in the journal Health Affairs</a> found that infant mortality across the 13-state Appalachia region was 16 percent higher than the rest of the U.S. and overall life expectancy 2.4 years shorter, largely due to the higher rates of smoking in Appalachia.</p>
<p>As Gottlieb has noted, cigarettes are the only legal consumer product that, when used as intended, <a href="https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm568923.htm">will kill half of all long-term users</a>.</p>
<p>The new approach that Gottlieb proposes is a first step on a long journey that has great promise. If nicotine levels in cigarettes can be reduced significantly, it won’t take long for smokers to realize that lighting up more frequently and dragging more deeply will never give them the same nicotine hit as in the past. This novel and intriguing idea is that smokers would quickly switch to e-cigarettes or other alternatives to get the nicotine they seek, a much <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1707409#t=article">safer option than burning tobacco</a> and inhaling the smoke. Of course, regulators would have to figure out how to prevent black market sales of high-nicotine cigarettes.</p>
<p>Meanwhile, low-nicotine cigarettes would be less likely to hook a new generation of young smokers. Nearly <a href="https://www.tobaccofreekids.org/research/factsheets/pdf/0127.pdf">90 percent of adult smokers took up the habit</a> before they turned 18. Making cigarettes less appealing and addictive to young people would be revolutionary and would put the goal of a smoke-free generation within grasp.</p>
<h2>An opening to e-cigarettes?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/182624/original/file-20170818-7959-1nxlmie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/182624/original/file-20170818-7959-1nxlmie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/182624/original/file-20170818-7959-1nxlmie.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/182624/original/file-20170818-7959-1nxlmie.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/182624/original/file-20170818-7959-1nxlmie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/182624/original/file-20170818-7959-1nxlmie.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/182624/original/file-20170818-7959-1nxlmie.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">Critics of Scott Gottlieb’s announcement on lowering nicotine in cigarettes fear that a side component of his plan will encourage more e-cigarettes, which many health experts see as a gateway to cigarettes.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/closeup-man-vaping-electronic-cigarette-390689176?src=XNbURhYklTXj5zL2Nb3tvA-1-12">Oleg GawriloFF/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Some critics have focused on Gottlieb’s <a href="https://www.washingtonpost.com/news/to-your-health/wp/2017/07/28/fda-delay-e-cigarette-rules-years-explore-reducing-nicotine-conventional-cigarettes/?utm_term=.da1049189ba3">decision to delay the regulatory process for e-cigarettes</a>, hookahs and other novel products while exploring how to reduce nicotine in traditional cigarettes. But he has pledged not to delay important, common-sense regulations to protect children from accidental poisoning by making the containers of liquid nicotine for e-cigarettes child-proof, and by setting standards for battery packs which occasionally burn or explode, injuring users.</p>
<p>The public will need to be patient because the regulatory process is extraordinarily slow. In fact, the first step is the arcane-sounding “Advance notice of proposed rule-making,” and there are <a href="https://www.reginfo.gov/public/reginfo/Regmap/index.jsp">nine steps</a> in all to adopting a new regulation.</p>
<p>It’s also unclear whether <a href="https://www.bloomberg.com/news/articles/2017-08-03/big-tobacco-won-t-let-the-fda-cut-nicotine-without-a-fight">tobacco companies will fight the FDA’s proposal</a> to reduce nicotine in conventional cigarettes by dragging the debate through the court system. In the past, cigarette makers have been quick to file lawsuits or mount lobbying campaigns to head off perceived threats to their industry. Right now, an organization receiving substantial financial support from R.J. Reynolds Tobacco Co. is <a href="http://www.sfchronicle.com/bayarea/article/SF-ban-on-flavored-tobacco-looks-headed-for-the-11408689.php">pushing for a repeal</a> of a decision by San Francisco city leaders to ban the sale of flavored tobacco products, which are widely seen as appealing to young people. Indeed, <a href="http://money.cnn.com/2017/07/28/investing/tobacco-stocks-altria-fda-cigarettes-nicotine/index.html">stock prices for the big cigarette producers</a> plunged after the FDA announcement, a signal that the FDA proposal was seen as bad for their bottom line.</p>
<p>However, it’s worth noting that several cigarette manufacturers are also entering the <a href="https://blogs.wsj.com/corporate-intelligence/2013/11/18/big-tobacco-begins-its-takeover-of-the-e-cigarette-market/">market for e-cigarettes and other novel nicotine delivery devices</a>, so they may be ready to switch rather than fight (to reverse a line from an <a href="https://www.youtube.com/watch?v=RB6C3o_-RdE">old tobacco ad</a>). For a sense of how the strategy, or at least the public messaging, of some cigarette makers is evolving, go to the homepage of tobacco giant <a href="https://www.pmi.com/">Philip Morris International</a>, where the splashy design claims the company is “Designing a Smoke-Free Future.”</p>
<p>There are many forces at work, but the good news is that scientists and the general public will get opportunities to offer their input as this process moves forward. And a growing number of state and local governments are adopting their own policies to protect young people from smoking cigarettes, including <a href="https://www.vox.com/policy-and-politics/2017/8/10/16125890/oregon-smoking-age-21">raising the legal age</a> to purchase tobacco products from 18 to 21.</p>
<p>In the meantime, I want to encourage smokers to do what they can to quit. Don’t get discouraged and don’t put it off. Most people make several “failed” attempts to quit before they manage to quit for good.</p>
<p><a href="https://smokefree.gov/">Find the method that works for you</a>, and if it’s e-cigarettes, make sure you really are using them to help you quit smoking conventional cigarettes and not falling into the trap of becoming a “dual user” who never kicks the smoking habit. Stay focused on the goal – to stop inhaling the toxic smoke that’s generated by setting tobacco on fire.</p><img src="https://counter.theconversation.com/content/82241/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael P. Eriksen receives funding from Pfizer, Inc for tobacco control work in China. He is also the Principal Investigator on the Georgia State University Tobacco Center of Regulatory Science (grant number P50DA036128 from the National Institute on Drug Abuse and FDA Center for Tobacco Products). The content is solely the responsibility of Dr. Eriksen and does not necessarily represent the official views of the NIH or the Food and Drug Administration.</span></em></p>FDA Director Scott Gottlieb has proposed discussions about drastically cutting nicotine levels in cigarettes. This could result in some of the biggest health gains in history.Michael P. Eriksen, Professor and Dean, School of Public Health, Georgia State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/799682017-08-14T02:32:20Z2017-08-14T02:32:20ZWhy social smoking can be just as bad for you as daily smoking<figure><img src="https://images.theconversation.com/files/181257/original/file-20170807-25565-1qmgliu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Social smoking is just as bad on your heart as regular smoking, a new study suggests. </span> <span class="attribution"><span class="source">California Department of Health Services</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><p>“Everything in moderation.” </p>
<p>It’s a common justification made for behaviors that may fall outside the realm of healthy. Whether it’s a drink or two or indulging in a favorite dessert, consuming small quantities, rather than abject abstinence, is a more palatable and acceptable option for most people.</p>
<p>The less-is-more approach may be sound when applied to many aspects of our frenzied daily lives, but when it comes to smoking, the same rationale cannot apply.</p>
<p>A <a href="http://journals.sagepub.com/doi/full/10.1177/0890117117706420">new study</a> that I conducted with other nursing and health services researchers has found that those who enjoy the occasional cigarette in social situations are risking their health just as much as the person who smokes a pack or more a day. </p>
<p>Ours is the first population health study to compare the blood pressure and cholesterol levels of people who self-identify as current versus social smokers.</p>
<p>To eliminate risks of cardiovascular disease, the only answer is not to ever start smoking or stop it completely. This needs to be a priority for health providers and policymakers.</p>
<h2>An on-ramp… to a dead end</h2>
<p>A study of nearly 40,000 people conducted over a four-year period as part of The Ohio State University’s Million Hearts educational program identified nonsmokers, current regular smokers and those who said they were “social smokers,” meaning they didn’t have a cigarette every day. The “social smokers” in our study tended to be younger, male and were disproportionately Hispanic. Social smokers have been identified in previous studies as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2771192/">those who smoke in nightclubs and bars</a>. Also, social smoking has been shown, in previous studies, to be associated on college campuses with alcohol consumption.</p>
<p>Our study defined a social smoker as “an individual who does not smoke cigarettes on a daily basis but who smokes in certain social situations on a regular basis.” </p>
<p>The researchers collected deidentified data from volunteers who completed Million Hearts cardiovascular screenings. After taking into account demographic and physical differences between the regular and social smokers, we found that there was virtually no difference in their risk of experiencing hypertension or high cholesterol, conditions that frequently lead to heart disease. </p>
<p>The study did not measure outcomes on cancer, but we know that smoking has been linked to 30 different types of cancer. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/181262/original/file-20170807-25565-z53dol.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/181262/original/file-20170807-25565-z53dol.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=430&fit=crop&dpr=1 600w, https://images.theconversation.com/files/181262/original/file-20170807-25565-z53dol.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=430&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/181262/original/file-20170807-25565-z53dol.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=430&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/181262/original/file-20170807-25565-z53dol.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=540&fit=crop&dpr=1 754w, https://images.theconversation.com/files/181262/original/file-20170807-25565-z53dol.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=540&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/181262/original/file-20170807-25565-z53dol.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=540&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 is the nation’s number one cause of preventable death.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/smoking-death-danger-concept-cigarette-burning-458145142?src=E8TUlQT9UwVbyqwALj-9Gw-1-10">LIghtspring/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>I believe that this is one of the most important findings in tobacco-related health in years, and it brings to light an issue, <a href="https://www.upi.com/Study-E-cigarettes-increase-risk-of-smoking-in-youth/9461498665521/">like e-cigarettes </a>and <a href="https://consumer.healthday.com/cancer-information-5/lung-cancer-news-100/secondhand-smoke-still-plagues-some-cancer-survivors-723855.html">secondhand smoke</a>, that we in the health care field must address with urgency. We now know that once people start opening packs of cigarettes, whether it’s for daily use or just to socialize at a party, they’re entering the same on-ramp toward serious health problems.</p>
<h2>When moderation becomes a vice</h2>
<p>This knowledge carries significant ramifications for the medical profession and the way nurse practitioners, doctors, nurses and physician assistants communicate with patients. It’s routine for clinicians to ask patients whether or not they are smokers during a checkup or exam. The social smokers will frequently respond negatively to that question because they don’t think of themselves in those terms and, thus, a significant health threat goes undetected.</p>
<p>Given these findings, it makes more sense for clinicians to reframe their questions. For example, “Do you ever use tobacco in social situations with friends or work colleagues?” or “When was the last time you had a cigarette or used tobacco?” </p>
<p>High levels of bad cholesterol, the type measured in our study, and high blood pressure are risk factors for heart attack and stroke. Knowing that these health risks for occasional smokers are the same as those who light up frequently, clinicians must become more precise in collecting this information from their patients.</p>
<p>This study should also affect the advice that patients receive in the examination room. In terms of heart health, it’s simply not sufficient for clinicians to advise patients to cut back on their smoking.</p>
<p>The societal impact of this new study could be enormous. It concluded that more than <a href="http://journals.sagepub.com/doi/full/10.1177/0890117117706420">one of every 10 Americans identifies as social smokers</a>, compared to the 17 percent who smoke regularly. Extrapolate those numbers to the country as a whole and it means that millions of people are placing their heart health at risk by occasionally indulging in cigarettes. We can’t ignore this problem.</p>
<p>Over the last few decades, the United States has done a commendable job in raising public awareness of the dangers of smoking and properly stigmatizing tobacco use as a pervasive and deadly health threat. Armed with this new knowledge regarding the dangers of social smoking, public health officials, anti-smoking advocates and the medical community need to focus their messaging on those who mistakenly believe the occasional cigarette leaves them exempt from the warnings directed toward heavier users. Moderation, in this case, is most definitely a vice from a health perspective, and a potentially life-shortening approach.</p><img src="https://counter.theconversation.com/content/79968/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bernadette Melnyk 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>About one in 10 Americans say they sometimes smoke, often in social settings. Many think it’s not so bad for them. A new study has some scary findings, when it comes to matters of the heart.Bernadette Melnyk, Dean and Professor of Nursing, The Ohio State UniversityLicensed as Creative Commons – attribution, no derivatives.