Vaping is one of the most innovative and exciting public health developments in the last few decades but unfortunately, there’s been almost misinformation against vaping over the years and one of the earliest culprits was the federal government. There’s been a huge surge of high schoolers using e-cigarettes. If the FDA wants regulations specifically with regard to… It’s all so new. We don’t know anything about the long term… It’s about 95% less harmful than a normal, traditional… Vaping is far less harmful than smoking. Although from everything we know these products appear to be safer than traditional cigarettes, they’re not safe. If you ask adults are combustibles more harmful, same, or less harmful than e-cigarettes, only about 30% get it right. Well, I first heard of vaping actually through my child. Vaping is becoming increasingly more popular. Vaping has grown an astonishing 900% among high school students in recent years. 3 million high school students this year using e-cigarettes, up more than 75% from last year. We had a number of presentations noting the dramatic increase in vaping, including students who presented, and put forth a somewhat worrisome picture. I’ve been involved in questions concerning vaping and possible vaping regulations and I have sort of a long history. I was very much involved in the litigation in the 90’s against the tobacco companies, was one of the leaders in that effort and as a result of that became very concerned about cigarette smoking and really about the number of lives of people that die as a result of tobacco-related disease. I got interested in vaping regulation because vaping falls under a category of public health called “harm reduction” and, as an addiction psychiatrist, I’m very familiar with harm reduction but somehow in the arena of nicotine tobacco use, harm reduction is a very, very contested concept. You have a situation where all the deadly combustible products aren’t regulated at all as a matter of fact because they’ve been grandfathered and the newer, much less harmful products are having much more rigorous regulation. Yes, these products appear to be safer than cigarettes. Yes, they’re a preferred alternative to cigarettes but no, they’re not safe. It’s not something that you can do without risks. Sell me on why these flavored e-cigs shouldn’t be regulated. What is the difference between vapor and smoke? E-cigarettes carry a number of health risks. The five main chemicals that we found are either shown to be cancer-causing or thought to be cancer-causing. I think the context is critically important. This product was put on the market for adult smokers who are using a product that kills half of them. Every legitimate, rational scientist who’s investigated this issue has said, “We don’t know all the risks but we can say that they are less harmful than smoking.” Many more people stop smoking using e-cigarettes. This whole thing, this harm reduction concept of non-combustibles, it’s happening and it’s saving lives. We just think if Americans knew the facts about the relative harm, if smokers knew about it, we could do a lot more. We know that children, or young people who vape, go on at greater rates to use conventional cigarettes. We just don’t know if they wouldn’t smoke in the absence of vaping. Regulation exists to protect the public. We’re trying to maximize the benefits and minimize the harms from certain products or actions that could potentially be harmful. The chief aims of regulation should be that when people vape — and the people who vape should be teen or adult smokers, mainly adult smokers of course, but anyone who smokes and can’t quit or doesn’t want to give up nicotine — should vape and the function of regulation should be that they have access to safe and effective products. You can say, “Well they have a right to do that but I think there are some people who feel that there can be a situation in which they’re potentially being taken advantage of, particularly when a substance is addicting, and that sometimes we need to protect people from bad choices. I think that we have to make sure that the government doesn’t make a huge mistake and overregulate e-cigarettes because there are 34 million American smokers today and if they don’t quit 17 million will die, and we’ve seen with the rise of e-cigarettes that adult smoking rates are dropping at a faster rate than ever before. So, right now you have a group of activists, pediatricians, for example — the American Academy of Pediatrics and National Cancer Society Action Fund — you have groups that are arguing that FDA isn’t strong enough, isn’t working hard enough. If society bears the cost of certain behaviors, there does come a point in which society then has a right to intervene in individual behavior. The Food and Drug Administration is targeting the teen vaping epidemic. The report found a 78% increase in high school students using e-cigarettes. We see another 30, 40% increase this year on top of that. There’s nothing compared to that. Well, we’ve got to regulate this more. We’ve got to get our arms around this, right? The FDA conducting a national undercover blitz to stop stores from selling to youth and their first ever comprehensive public health campaign about e-cigarettes. We’re going to have to look at more draconian measures like potentially taking these pod-based products off the market entirely. Like Juul? Like Juul, exactly. It’s the cartridge-based products that the kids are using. We will have to consider the marketability of this entire category of products and I’ve told them that. Instead of the burdensome regime that the FDA is about to implement, I’d like to see something more along the lines of product standards, where any device that met certain regulations — a minimum regulation for battery safety, electronics, additives to the e-liquid — that kind of thing. Kids can vape in class and you don’t smell it, the teacher can’t detect it. Not only that, but there’s an ability to substitute vaping products within the device itself and so if you catch a kid — if you’re a school administrator, you’re a teacher — you catch a kid vaping at school, you don’t necessarily know for sure what the kid is vaping. Could they be vaping a marijuana, a cannabis-related product or is it tobacco? There is always going to be a population of people who want to continue using nicotine, so then the question becomes: how can they do that in the safest way possible? And vaping is a device that allows that to happen. Public Health England has done the best job, I think, of looking at the health consequences. Their conclusion is that e-cigarettes are at least 95% less harmful than combustible cigarettes. We should be encouraging vaping as much as possible for smokers. We should be more like the UK, where their National Health Service prescribes vaping for patients who smoke. We should be giving tax credits. The VA should be giving free vaping devices. We should be encouraging these instead of fomenting panic. We’ve allowed our concern about speculative harms to teens to overshadow the known benefits to adult smokers. In these types of situations, I think one of the things we worry about is information asymmetry. Although we may be benefiting current smokers, we might be risking hooking another generation on just a different form of nicotine that might not otherwise have started. A number of people have come out with the simple but really important proposition that we should regulate according to harm, so that the least harmful should be regulated much less than the more harmful and I subscribe to that proposition. I don’t know how large the vaping movement is going to be. The concern is, again, that the adolescent brain appears to be more susceptible to addiction. Are we creating a generation of nicotine addicts who are at risk of cigarette smoking? Are they prolonging the addiction? Is this a process that in fact is preventing people from quitting smoking because it’s continuing to feed the
nicotine addiction? Whereas, perhaps if they didn’t vape they would stop smoking. The average smoking rate is about 14% of the population. It was almost three times that high back in the 50’s. So, definitely progress has been made. There’s another important development and that’s the proposal to move the age of smoking and e-cigarettes to 21. We have done a lot more studies and research and we know more. And what we know now is social contacts are by far the largest source of e-cigarettes for kids. That some surveys have it in the 70% range. 70% of kids get their cigarettes from brothers, sisters, friends that are 18 or older. So, moving the whole paradigm to 21 is going to have a situation where e-cigarettes are going to be potentially much less available to kids and that’s something that we should be exploring. There are at least two main axes of tension. Many do advocate harm reduction for nicotine but there is a very large contingent, I’d say the majority, who are in that camp — very paternalistic, very risk-averse — and their interests are in tension with the pragmatists — people who say, “Listen, folks are still going to want to use nicotine or they’re still going to smoke.” They’re not a cessation product. They’re an alternative product and they seem to be a substitute product, and what happens is most people end up using both. There’re always going to be people who want to use nicotine who can’t quit no matter how hard they try, and for them finding a safer way of consuming nicotine has been an imperative public health goal for a long time. We don’t have data on what the long-term effects of these products are. There’s no question that some of the chemicals used are potentially toxic to cells. This is an ideal opportunity to look at that because we have a complex, challenging product with possibly significant harms and FDA is grappling with what to do. It’s true that we don’t know everything about e-cigarettes. Things could and will develop five years from now or ten years from now. You have to weigh the consequences of waiting and the consequences of acting. The consequences of waiting when we do have substantial information is a lot of people could die because they don’t switch to e-cigarettes. The irony is that cigarettes are freely available, so we’re making the safer product less available to people, we’re perpetuating false information about its risks. Don’t go smoking cigarettes, that’s even worse. But these are not a safe recreational activity. I think that’s the key point and I think it really needs to be understood. If we can educate people as to that point, a lot of the problems that we’re worried about will lessen and perhaps go away.