tag:theconversation.com,2011:/ca-fr/topics/cigarette-smoking-54338/articlescigarette smoking – La Conversation2019-09-13T11:36:24Ztag:theconversation.com,2011:article/1225272019-09-13T11:36:24Z2019-09-13T11:36:24ZHow a person vapes, not just what a person vapes, could also play a big role in vaping harm<figure><img src="https://images.theconversation.com/files/291839/original/file-20190910-190021-zhg4f9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A smoking machine in the author's lab. Smoking by a machine is not the same as smoking by a person, the author and others have found.</span> <span class="attribution"><span class="source">Katie DiFrancesco</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>In the wake of six deaths and <a href="https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html">380 cases of confirmed and probable</a> lung disease across the U.S., the Trump administration has called for <a href="https://www.nytimes.com/2019/09/11/health/trump-vaping.html">banning most flavored e-cigarettes </a> because of their huge appeal to young people. </p>
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Read more:
<a href="https://theconversation.com/flavored-e-cigarettes-are-fueling-a-dangerous-increase-in-vaping-use-107998">Flavored e-cigarettes are fueling a dangerous increase in vaping use</a>
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<p>The Centers for Disease Control and Prevention is <a href="https://www.cdc.gov/media/releases/2019/s0823-vaping-related-death.html">looking closely at the different flavored nicotine juices</a> and other substances users may be vaping in e-cigarettes to determine how the aerosol might be affecting users’ lungs. </p>
<p>On Sept. 12, 2019, the CDC lowered the number of confirmed and probable cases from more than 400 to 380. The number was lower, the agency said, because it is no longer reporting “possible cases.”</p>
<p>The mystery and concern remain. And, many smokers who use these devices to quit are concerned that a valuable tool may be taken away from them. </p>
<p>There’s much more that researchers need to know. These devices have a short history. As an engineer who studies how people use tobacco products, I believe that users’ behavior is key to understanding the positive and negative health effects resulting from e-cigarettes. After all, their intent was to help people stop smoking, the number one cause of preventable death in the U.S. </p>
<p>The way users puff, how long they puff and what they puff all play a role. We do not yet know how this behavior affects how much of each substance vapers consume over the course of their daily lives, but we have reason to believe it is significant.</p>
<h2>The failed promise of alternative nicotine products</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/292272/original/file-20190912-190007-80htcl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/292272/original/file-20190912-190007-80htcl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/292272/original/file-20190912-190007-80htcl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/292272/original/file-20190912-190007-80htcl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/292272/original/file-20190912-190007-80htcl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/292272/original/file-20190912-190007-80htcl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/292272/original/file-20190912-190007-80htcl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Tens of thousands of people who smoked low-tar cigarettes still developed lung cancer.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-shows-results-old-patient-xray-543601138?src=nHlgfSkF_0PA5Ryr91OwZA-1-51">didesign021/Shutterstock.com</a></span>
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<p>Many are skeptical that e-cigarettes will reduce death rates related to smoking. Historically safer cigarettes have not delivered on a similar promise. After the U.S. surgeon general <a href="https://www.fda.gov/media/127853/download">declared smoking harmful</a> in 1964, smokers who could not quit migrated to what were then considered <a href="https://cancercontrol.cancer.gov/brp/tcrb/monographs/13/m13_complete.pdf">low-yield cigarettes</a>, marketed as safer and having less tar than regular cigarettes. </p>
<p>But the wide use of low-yield cigarettes did not lower death rates for smokers.
Cases of squamous cell lung cancer did decrease after the surgeon general’s warning, but another type, <a href="https://cancercontrol.cancer.gov/brp/tcrb/monographs/13/m13_complete.pdf">adenocarcinoma, increased</a>. </p>
<p>Engineering models suggest that changes in smoke characteristics combined with smokers’ compensating behaviors <a href="https://www.tandfonline.com/doi/pdf/10.1080/027868201300034844">changed where the particles deposited in the lung</a> played a role. Smokers may have consumed more smoke to maintain their addiction. Different cancer types originate in different lung locations. The thought is that smokers changed their behavior, and in doing so, may have traded one type of cancer for another. </p>
<p>How did we miss this?</p>
<p>Traditionally, cigarettes were tested in a laboratory, using smoking machines – not a smoker – <a href="https://tobaccocontrol.bmj.com/content/10/2/96">using an industry standard protocol established in 1966</a>. <a href="https://cancercontrol.cancer.gov/brp/tcrb/monographs/13/m13_complete.pdf">Research later revealed</a> that this “mechanized smoking” <a href="https://www.hri.global/files/2011/07/13/Hammond_-_Secret_Science_-_No_Copyright.pdf">does not represent realistic behavior</a> and so did not represent realistic exposure to harmful constituents. The former standard (<a href="https://tobaccocontrol.bmj.com/content/10/2/96">FTC/ISO puffing protocol) was repealed in 2008</a>, with the hope that a new, more realistic standard would take its place.</p>
<p>Now, thanks to a <a href="https://www.congress.gov/bill/111th-congress/house-bill/1256">law passed in 2009</a>, tobacco product manufacturers cannot claim reduced risk without scientific evidence. Researchers like me are applying lessons learned from the low-tar debacle and generating scientific evidence to understand the true health impact of e-cigarettes. </p>
<h2>Regulatory authority over e-cigarettes</h2>
<p>Since e-cigarettes entered the market in Europe in 2006, demand increased from those hoping to quit cigarettes to those who have never smoked, including an <a href="https://www.fda.gov/tobacco-products/youth-and-tobacco/2018-nyts-data-startling-rise-youth-e-cigarette-use">unusually high number of young people</a>. This has raised concerns. Is vaping a gateway for youth to start smoking? Do young people use e-cigarettes in a different way than adults?</p>
<p>In June, 2019 the FDA <a href="https://www.fda.gov/media/127853/download">released guidelines</a> for e-cigarette manufacturers, recognizing the significant role behavior plays in determining whether or not a product poses a health threat. The guidelines call for an assessment of how individual users consume the product, including such things as the number of puffs, puff duration, puff intensity, puff duration and the frequency of use.</p>
<p>This behavior data is very important for many reasons. Users may adopt a behavior that nullifies any anticipated health effect based on lab tests. A puff generated in the lab may contain less nicotine, but the user may simply take more puffs during the day to achieve their nicotine addiction, and so consume more toxins than expected.</p>
<h2>Other potential dangers</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/292275/original/file-20190912-190065-panpnm.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/292275/original/file-20190912-190065-panpnm.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=455&fit=crop&dpr=1 600w, https://images.theconversation.com/files/292275/original/file-20190912-190065-panpnm.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=455&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/292275/original/file-20190912-190065-panpnm.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=455&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/292275/original/file-20190912-190065-panpnm.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=572&fit=crop&dpr=1 754w, https://images.theconversation.com/files/292275/original/file-20190912-190065-panpnm.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=572&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/292275/original/file-20190912-190065-panpnm.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=572&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Designs of vaping devices vary greatly, with some, like Juul, so small they can be concealed by a teen using in a classroom.</span>
<span class="attribution"><span class="source">Katie DiFrancesco</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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<p>Researchers and physicians also need to know what substances are being vaped and also various device designs. The FDA maintains a list called harmful and potentially harmful constituents, or <a href="https://www.federalregister.gov/documents/2012/04/03/2012-7727/harmful-and-potentially-harmful-constituents-in-tobacco-products-and-tobacco-smoke-established-list">HPHCs</a>, based on data related to traditional cigarette smoking, but less is known about the effect of product designs. Users can tamper with the various modular devices, which could change their effects. Teens may be particularly likely to toy with devices. </p>
<p>The FDA is currently updating the list to include <a href="https://www.federalregister.gov/documents/2019/08/05/2019-16658/harmful-and-potentially-harmful-constituents-in-tobacco-products-established-list-proposed-additions">ingredients that might be found in e-cigarettes</a>. Nicotine is already on the list, as well as various metals and other non-nicotine substances. </p>
<p>The liquids used to deliver the nicotine could be a problem. The base [e-liquids], typically made of a combination of vegetable gylcerine and propylene glycol, may alone <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0116732">cause inflammatory response</a> in the lung, even if flavor additives are banned.</p>
<p>And with regard to flavors, it is important to understand that the toxicity of a substance may be different if it is inhaled versus ingested. For example, vanilla flavoring may be deemed safe for eating, but it may not be safe for vaping. Some flavorings <a href="https://www.mdpi.com/1660-4601/15/2/323">decompose when heated</a> and generate molecules that are not in the base e-liquid. </p>
<p>Would reducing the intake of flavorings also reduce harmful effects? And how much of these additives can be consumed before harmful effects materialized? Or, alternatively, how much must be reduced before health benefits can be realized? </p>
<h2>Engineering tools can advance the regulatory process</h2>
<p>By reenacting vaping behavior in the lab, those of us who study design and behavior can better understand the nature of the constituents being consumed.<br>
What have we have found so far? </p>
<ul>
<li><p>Puff flow rate <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0206341">alters the nature of the aerosol</a>, so users can control the strength of each puff simply by altering the way they puff.</p></li>
<li><p>E-cigarette users change their puffing flow rate when they switch flavors or nicotine levels and are <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0196640">altering their exposure to harmful or potentially harmful</a> constituents. </p></li>
<li><p>For a given e-cigarette brand and flavor, there is a <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0129296">wide range of use behaviors</a>, <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0164038">such as</a> puff flow rates and puff durations. </p></li>
<li><p><a href="https://www.nature.com/articles/s41598-019-44983-w">Machine replays</a> of vapor behaviors show exposure varies over a wide range for any given product. </p></li>
<li><p>Some e-cigarette users puff all day long, whereas others puff in more discrete time intervals, similar to smoking. </p></li>
<li><p>Even if there is less nicotine per puff in some cases for e-cigarettes compared to cigarettes, e-cigarette users can indeed consume the same amount or more nicotine in a day compared to smoking. </p></li>
</ul>
<p>We and other researchers aim to continue studying how new e-cigarette products are being used so manufacturers can develop safer products, and the FDA can develop meaningful regulations, so the consumer, in consultation with their physician, can make informed decisions. </p>
<p>[ <em>You’re smart and curious about the world. So are The Conversation’s authors and editors.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=youresmart">You can read us daily by subscribing to our newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/122527/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Risa Robinson receives funding from National Institution of Health.</span></em></p>Vaping is under heavy scrutiny in the wake of six deaths and hundreds of illnesses. A product engineer who studies how people puff explains why the way users vape could be a clue.Risa Robinson, Professor and Department Chair, Mechanical Engineering, Rochester Institute of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1066692019-03-01T11:40:11Z2019-03-01T11:40:11ZYour lungs are really amazing. An anatomy professor explains why<figure><img src="https://images.theconversation.com/files/244828/original/file-20181109-116820-1oqq38v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A 3D image of lungs.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/3d-illustration-lungs-part-human-organic-417318079?src=KjqZGrlNVZp4XYjszzMEuA-1-2">MDGRPHC/Shutterstock.com</a></span></figcaption></figure><p>Lungs are remarkable organs that continuously achieve amazing feats, which they do so well that we take them for granted, except when their function is diminished. It all happens in a space inside your chest, divided in two and reduced by the presence of the heart, the great vessels and the esophagus.</p>
<p>With Supreme Court Justice Ruth Bader Ginsburg having <a href="https://www.apnews.com/0248a100a932418fac5c1ea7d287a355">recently returned</a> to the court after surgery for lung cancer, I have been asked a lot of questions about the lungs, as I am a professor of anatomy. </p>
<p>Many lung cancers are not operable, but to treat some types of lung disease, such as early stages of lung cancer, a surgical treatment called a lobectomy may be performed. In this operation, a lobe of a lung (your right lung has three lobes, your left lung has two) is removed. Afterward, the other lobes expand to adapt and compensate for the missing tissue, allowing the lungs to work as well or better than they did before.</p>
<p>In addition to being highly efficient organs, the lungs are beautifully complex in their structure. I can’t help but wonder: If we appreciated them more, would we be more proactive in taking care of them? </p>
<h2>Breath of life</h2>
<p>The primary function of the respiratory system is to bring oxygen into our lungs. There it is exchanged for a waste product, carbon dioxide, which is then removed from the body.</p>
<p>Several weeks following conception, the work of the lungs is performed by the <a href="https://www.medicalnewstoday.com/articles/318993.php">placenta</a>, a structure outside our fetal bodies where our blood exchanges carbon dioxide and oxygen with the maternal blood of the uterus. </p>
<p>Before birth, we just practice respiratory movements, moving <a href="https://www.medicalnewstoday.com/articles/307082.php">amniotic fluid</a> instead of air in and out of the lungs.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/256175/original/file-20190129-42594-9grp28.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/256175/original/file-20190129-42594-9grp28.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/256175/original/file-20190129-42594-9grp28.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/256175/original/file-20190129-42594-9grp28.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/256175/original/file-20190129-42594-9grp28.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/256175/original/file-20190129-42594-9grp28.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/256175/original/file-20190129-42594-9grp28.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A newborn and mother. After birth, a baby gasps because of a buildup of CO2 and takes its first breath to take in oxygen.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/beautiful-african-mother-pink-lace-dress-630663665?src=k2KnKNT9g-KxuiSvzXkMSA-3-25">Anneka/Shutterstock.com</a></span>
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<p>Within seconds after the umbilical cord is cut, a buildup of carbon dioxide causes <a href="https://medlineplus.gov/ency/article/002395.htm">newborns to gasp for breath</a> to exchange it for oxygen, an activity that will continue until our death. The average person breathes some 13 million cubic feet of air during their lifetime.</p>
<p>During quiet activity, such as bed rest or sitting, we take eight to 16 breaths per minute, each breath inhaling about a pint of air containing 21 percent oxygen and a small amount of carbon dioxide for about two seconds. Then for three seconds, we exhale the same amount of air, but it now contains 16 percent oxygen and a 100-fold increase in carbon dioxide. In other words, you spend about 40 percent of your life drawing air in, and 60 percent of your life expelling it.</p>
<h2>Your lungs, by the numbers</h2>
<p>Each day, 5,000 gallons of air are transported through airways leading into and extending throughout the lungs. The airways branch and diminish in size 22 times. Almost of all this occurs within our lungs, with these airways reaching a combined length of 14,900 miles. </p>
<p>About 2,600 gallons of the transported air are delivered into and removed from 300 million tiny, thin-walled, hollow sacs, or <a href="https://www.britannica.com/science/pulmonary-alveolus">alveoli</a>, that provide an enormous surface for the exchange of oxygen, required by all our cells, for carbon dioxide, a waste product from them. This is an area varying in size between half and most of a regulation tennis court. </p>
<p>This immense area is contained within two lungs, each only somewhat smaller than three, 1-liter bottles. The left lung is 10 percent smaller than the right, due to the left-sided position of the heart. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/256176/original/file-20190129-108355-up6ry.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/256176/original/file-20190129-108355-up6ry.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/256176/original/file-20190129-108355-up6ry.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/256176/original/file-20190129-108355-up6ry.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/256176/original/file-20190129-108355-up6ry.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/256176/original/file-20190129-108355-up6ry.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/256176/original/file-20190129-108355-up6ry.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A 3-D illustration of alveoli.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/digital-illustration-alveoli-colour-background-236439439?src=4jGDr1QwqRUug8d1HzCPkg-1-19">RAJ CREATIONZS/Shutterstock.com</a></span>
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</figure>
<p>The alveoli are tightly surrounded by blood vessels, or capillaries, so small that red blood cells continuously pass through them squeezed into a single row as they exchange carbon dioxide for oxygen. </p>
<p>The capillaries of the lung receive an immense blood supply, equal to that distributed to all other parts of the entire body. The alveoli expand and contract 15,000 times a day. During activity, the rate of respiration doubles – and in extreme activities triples – and the amount of air reaching the alveoli increases three to five times. Breathing deeper and faster uses lung capacity that’s held in reserve while at rest. Stress can also result in deeper and faster respiration.</p>
<h2>Your lungs at work</h2>
<p>The air we breathe is far from clean, however, and one of the primary jobs of the respiratory system is to “condition” the air before it reaches the air sacs deep inside your lungs. </p>
<p>Indoor air pollutants can have <a href="https://www.epa.gov/iaq-schools/why-indoor-air-quality-important-schools">two to five times more pollutants than outdoor air</a>. (Have you observed and changed filters on your heating/AC system recently?) </p>
<p>The respiratory system “conditions” the air in several ways. First, it raises the temperature of cool air to body temperature, or it cools hot air to body temperature. Second, it moisturizes the air to 100 percent humidity to prevent dehydration of alveolar membranes. Last, it cleans the air. </p>
<p>Foreign and possibly harmful substances are filtered from in-flowing air and removed by several means, including nasal hairs and sticky mucus lining the airways that is produced at a rate of about a quart a day. It contains antimicrobial agents that help to neutralize harmful germs and many viruses. </p>
<p>Importantly, hair-like projections on cells lining the airways, called cilia, move the soiled mucus out of the lungs and air passages to the throat to be swallowed and destroyed by stomach acid. </p>
<p>Pollutants reaching the alveolar gas-exchanging membranes are removed by specialized cells called phagocytes and macrophages that ingest particles to move most to be carried away via lymph vessels and nodes. However, much of the black carbon is merely moved to non-exchanging portions of the lung. </p>
<p>In addition to conditioning air for the alveoli, ventilation of the lungs helps to cool the body down when it is overheated. About 7 percent of body heat is removed via evaporation from airways inside and outside the lungs. Eleven ounces of water per day are lost as water vapor. Three percent of body heat is lost by heating air below body temperature as the lungs are ventilated.</p>
<p>Other amazing functions of the lungs include controlling the acid-base balance (pH) of the body as a whole by selectively retaining or eliminating carbon dioxide. In order to be ventilated for gas exchange, the lungs act as bellows. The propulsion of air from the lungs enables the larynx to serve as a “voice box,” vibrating the vocal cords to produce the tone that is modified by the tongue, teeth and lips to produce our voice for interpersonal communication and for singing. This air output also allows us to blow up balloons or play wind instruments.</p>
<p>Air drawn in by expansion of the lungs passes over the olfactory areas of the nose, enabling our sense of smell. The lungs also act as “packing foam” inside the rib cage, supporting and protecting the vital heart that delivers half of its output to the lungs, and the other half to the rest of the body.</p>
<h2>The dark side of the lungs, and of their care</h2>
<p>While the lungs were a pristine pink at birth, our lungs gradually darken to a gray and mottled appearance due to these carbon particles, much of which remains in place, usually with no detrimental effect. Larger, irritating particles are commonly “blasted” away by reflexive coughing and sneezing. This air conditioning system is compromised in smokers, whose airways lose cilia and their directional coordination, and so must revert to coughing as a major means of pollutant removal. </p>
<p>Smokers’ lungs darken faster, becoming more mottled, and take on an orange tone due to nicotine and brown tars. Prolonged exposure to these carcinogens causes chronic bronchitis, emphysema and cancer in many parts of the body, but especially around airways just inside the entrance to the lungs. In emphysema, the alveolar structure of the lungs collapses, especially in the upper lung, making it difficult to fully exhale.</p>
<p>Take a deep breath and consider all the miraculous activities your incredible lungs are performing.</p><img src="https://counter.theconversation.com/content/106669/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Arthur Dalley authors and edits anatomical textbooks and atlases for, and consults with, Wolters Kluwer Health, LLC, a publisher for health care students and professionals.</span></em></p>As organs go, lungs do not receive a lot of attention, and diseases associated with them, such as lung cancer, historically have been underfunded. Here’s a look at how your amazing lungs function.Arthur Dalley, Professor of Anatomy, Vanderbilt UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1079982018-12-21T11:41:15Z2018-12-21T11:41:15ZFlavored e-cigarettes are fueling a dangerous increase in vaping use<figure><img src="https://images.theconversation.com/files/251603/original/file-20181219-45391-158rcdq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Studies have suggested that teens' perception of risk in these products is influenced by flavor.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/health-problems-social-issues-teenagers-smoking-441252415?src=UNWOaWnEmJbYlrHYnqeD5Q-1-0">Diego Cervo/Shutterstock.com</a></span></figcaption></figure><p>An upsurge in e-cigarette use among middle and high school students occurred nationally between 2011 and 2018, with nearly 21 of every 100 high school students surveyed reporting e-cigarette use in the past 30 days, according to <a href="https://www.cdc.gov/mmwr/volumes/67/wr/mm6745a5.htm?s_cid=mm6745a5_w#contribAff">data from experts</a> at the U.S. Food and Drug Administration and the Centers for Disease Control and Prevention.</p>
<p>This trend is not by chance. Tobacco companies have spent billions of dollars annually on tobacco product advertisement, <a href="https://www.ftc.gov/system/files/documents/reports/federal-trade-commission-cigarette-report-2016-federal-trade-commission-smokeless-tobacco-report/ftc_cigarette_report_for_2016_0.pdf">according to a Federal Trade Commission</a> report, and have used appealing packaging, culturally tailored brand names and advertisements <a href="https://www.sciencedirect.com/science/article/pii/S003335061830283X?via%3Dihub">that appear to target specific minorities and youth</a>. The colorful packaging and other strategies employed by the industry contribute to lower harm perceptions of these products and higher susceptibility to use among young people, according to <a href="https://tobaccocontrol.bmj.com/content/24/e4/e233.long">researchers at the Center for Global Tobacco Control</a>, Harvard School of Public Health and <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0196236">recent research on cigarillo packaging I conducted with my research team</a>.</p>
<p>The FDA <a href="https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm620185.htm">has announced</a> efforts to impose restrictions on flavored e-cigarettes and tobacco products. FDA recognizes the high rates of e-cigarette use among young people as a public health concern, and sees the urgent need for stricter product access.</p>
<p>Part of the agency’s plans call for restricting young people under the age of 18 from accessing flavored e-cigarettes via retail establishments and online websites. The FDA is seeking to have retailers move flavored e-cigarette products – excluding mint- and menthol-flavored products – to age-restricted areas in stores, and the FDA is proposing to heighten practices for age verification online. Agency officials have also called for removing e-cigarette products that are marketed to kids, <a href="https://www.nytimes.com/2018/11/15/health/ecigarettes-fda-flavors-ban.html">among other measures</a>.</p>
<p>And with the announcement that tobacco giant Altria paid US$13 billion for a <a href="https://www.wsj.com/articles/altria-takes-35-stake-in-e-cigarette-maker-juul-11545309399">35 percent stake in Juul</a>, the vaping company that uses flavors to market its e-cigarettes, the need to impose youth restrictions on flavored tobacco products takes on even more urgency.</p>
<h2>Flavors change perception of risk</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/251628/original/file-20181219-45391-1hjk2u8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/251628/original/file-20181219-45391-1hjk2u8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/251628/original/file-20181219-45391-1hjk2u8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/251628/original/file-20181219-45391-1hjk2u8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/251628/original/file-20181219-45391-1hjk2u8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/251628/original/file-20181219-45391-1hjk2u8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/251628/original/file-20181219-45391-1hjk2u8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Studies have suggested that flavoring tobacco and other smoking products leads to a perception that they are not as dangerous.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-female-lighting-cigarillo-matches-woman-1186123162?src=vNx0pcH1Y4Fe-L33Ma9Pww-1-8">Bartlomiej Magierowski/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Using a survey of young adults aged 18 to 26 recruited through an online crowd-sourcing tool, our group of researchers at the University of North Carolina School of Medicine found in a study <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0196236">published in PLOS ONE</a> that cigarillo pack flavor descriptors, such as grape and sweet, and colors such as pink and purple resulted in more favorable product perceptions among young adults. These pack attributes had a greater impact on how people who had never used cigarillos perceived product flavor and taste, compared to current cigarillo users, and people who have previously used them.</p>
<p>Further, we conducted a systematic review of all the scientific literature through April 2016 examining the impact of flavors on tobacco product perceptions and use behaviors. Important findings from this study, published in <a href="https://tobaccocontrol.bmj.com/content/26/6/709">Tobacco Control,</a> suggested that flavored tobacco products have a strong appeal to youth and young adults because of the variety and availability of flavors; that flavors are a reason for use; and that flavors play a primary role in the use of e-cigarettes, little cigars and cigarillos, and hookah among younger people. </p>
<p>Two studies within our <a href="https://www.ncbi.nlm.nih.gov/pubmed/26650455">systematic review</a> found that packs containing flavor descriptions were more likely to be rated as having a lower health risk. Another <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3942180/">study</a> of smokeless tobacco packs in the United States found that young adults were more likely than older adults to report that packs without flavor descriptions would contain more dangerous chemicals. Research is clear that flavored tobacco products have the potential to undermine progress gained to reduce youth tobacco use in the United States.</p>
<h2>Importance of flavors in product use</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/251806/original/file-20181220-103657-1gj4nli.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/251806/original/file-20181220-103657-1gj4nli.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=417&fit=crop&dpr=1 600w, https://images.theconversation.com/files/251806/original/file-20181220-103657-1gj4nli.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=417&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/251806/original/file-20181220-103657-1gj4nli.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=417&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/251806/original/file-20181220-103657-1gj4nli.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=524&fit=crop&dpr=1 754w, https://images.theconversation.com/files/251806/original/file-20181220-103657-1gj4nli.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=524&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/251806/original/file-20181220-103657-1gj4nli.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=524&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The smoking habits of young people are changing, with fewer using traditional cigarettes but more using vaping products.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Teens-Vaping/c6afb61d77af48fa8878b19c7585d33c/2/0">Steven Senne/AP Photo</a></span>
</figcaption>
</figure>
<p>Research and survey data have shown that tobacco habits in this age group are changing. Youth cigarette smoking rates have declined substantially in recent years, with the <a href="https://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm">National Youth Tobacco Survey</a> showing current use of cigarettes declining from 15.8 percent in 2011 to 7.6 percent in 2017 among high school students, <a href="https://www.cdc.gov/mmwr/volumes/67/wr/mm6722a3.htm">according to data from experts at the CDC and FDA</a>. Meanwhile, e-cigarettes were the most commonly used product in that population in both middle and high school students in the survey data. </p>
<p>While traditional cigarette smoking has declined, patterns of dual (that is, use of two or more tobacco products in 30 days) and poly tobacco use (or the use of three or more tobacco products in 30 days) have emerged. In 2013, in a survey of North Carolina high school students, almost 30 percent reported use of any tobacco product, according to a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4661661/">study</a> from our team published in 2015 in the International Journal of Environmental Research and Public Health. </p>
<p>Within this sample, 19.1 percent used multiple tobacco products, compared with just 10.6 percent of the sample who were single product tobacco users. Youth predominately used cigarettes in combination with little cigars and cigarillos, or cigarettes with e-cigarettes. While there is substantial racial variation in multiple tobacco use patterns over time, in 2015, e-cigarettes were the most commonly used tobacco product among single product users across all racial groups, <a href="https://doi.org/10.1093/ntr/nty051">according to one of our studies published in Nicotine Tobacco Research</a>.</p>
<p>Using data from the 2015 <a href="https://www.tobaccopreventionandcontrol.ncdhhs.gov/data/yts/index.htm">North Carolina Youth Tobacco Survey</a>, we found in a study published earlier this year in <a href="https://www.cdc.gov/pcd/issues/2018/17_0368.htm">Preventing Chronic Disease</a> that among survey respondents who were not susceptible to smoking cigarettes, 26 percent were at “high risk” for future e-cigarette use; 11.3 percent were classified as “susceptible” to using e-cigarettes; 10.4 percent had already tried an e-cigarette; and 4.5 percent were current e-cigarette users. </p>
<p>Using school enrollment figures, we estimated that 55,725 high school students in our home state of North Carolina were at low-risk of smoking cigarettes, but at high risk for e-cigarette use – which meant that they were susceptible to using e-cigarettes, had experimented with e-cigarettes, or currently used e-cigarettes. On a national scale, these findings are a considerable public health problem.</p>
<p>Specifically, high school students who believed that e-cigarettes and secondhand e-cigarette vapor were not harmful, or only somewhat harmful, were more likely to be susceptible to using e-cigarettes than students who thought e-cigarettes and secondhand e-cigarette vapor were harmful, <a href="https://www.cdc.gov/pcd/issues/2018/17_0368.htm">our study found</a>. </p>
<p>Moreover, exposure to e-cigarette vapor in indoor or outdoor public places was associated with greater odds of being susceptible to using e-cigarettes. This could mean that restricting secondhand exposure to vapor of e-cigarettes in public places, such as in school buildings, stores, restaurants, school grounds and parks, and mass media efforts to educate youth about the harms of e-cigarette use could be just as necessary as restricting access to these products.</p>
<p><a href="https://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/factsheet.html">We know</a> that adolescents and teenagers are very vulnerable to the influence of tobacco marketing. The use of appealing packages and flavors has a significant impact on young people, causing them to perceive these tobacco products as less harmful and, in turn, making them more likely to experiment and continue using tobacco products. As research on the impact of flavored tobacco products builds, I look forward to increased action to help prevent youth tobacco use.</p><img src="https://counter.theconversation.com/content/107998/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Leah Ranney receives funding from NIH/FDA. I was part of the UNC Tobacco Centers of Regulatory Science award.</span></em></p>E-cigarette usage among teens has surged. A tobacco control expert explains how flavors may be contributing.Leah Ranney, Director of Tobacco Prevention and Evaluation, University of North Carolina at Chapel HillLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/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/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">
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<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>
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<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.