October 21, 2015

Stanton A. Glantz, PhD

When listening to what CDC people say about e-cigs, pay attention to their caveats

Recently I received the following email from a colleague working for a state health department:

Throughout the last six months my colleges and I have been hearing professionals refer to e-cigarettes as harm reduction. A  few months ago I was attending a Youth Engagement Alliance webinar where Dr. Terry Pechacek was presenting. During his presentation made it sound like e-cigarettes are harm reduction and mentioned moving all current cigarette smokers to exclusive use of e-cigarettes. Then a few weeks ago after meeting with an individual who works at our state health department he stated that he had heard something similar at a conference he attended a few weeks ago by Dr. Brian King. Now we are seeing more and more information come out to the public referring to e-cigarettes as less harmful than cigarettes. How should public health advocates respond to statements like this from well-known individuals when a large amount of our work has been focused on educating on the harms of e-cigarettes?
Any insight or recommendations would be greatly appreciated. Thank you for your time.

To provide some clarity, I contacted both Brian King and Terry Pechacek to see if this is an accurate understanding of what they think.
Here is what Brian King said:

I’m assuming this individual is referring to the presentation I gave at CDC’s recent state grantee meeting, in which case this is a broad mischaracterization of what was presented.
With regard to youth, I have never messaged around e-cigarettes in the context of harm reduction. Primary messaging has been around precautionary principal and that youth should not be using any tobacco product, irrespective of whether it’s combustible, non-combustible, or electronic.
With regard to adults, my messaging has aligned with the public health standard outlined in the 2014 SGR. More specifically, if an adult combustible user were to quit smoking completely and switch to e-cigarettes exclusively there would be a net public health benefit. However, this has always been presented with the caveat that the efficacy of e-cigarettes for cessation is inconclusive and that cross-sectional literature shows high prevalence of dual use of both products, with nearly three-quarters of e-cigarette users reporting that they also use conventional cigarettes.

Here is what Terry Pechacek  said:

I agree with Brian that I assume this was the CDC’s recent state grantee meeting, and that this appears to be a broad mischaracterization of what was presented.  If mature adult smokers would quit completely and switch exclusively to the new non-combusted nicotine sources like the various ENDS, there likely would be an individual public health benefit,  if this pattern does not include increased initiation and continued high rates of exposure of youth, young adults, and reproductive age women to nicotine.

Note that neither person said that e-cigarettes are harmless.  What they did say (and which I agree with) is that:

  1. If smokers switched entirely to e-cigarettes things would be better.
  2. Continued dual use of e-cigarettes and cigarettes is a bad thing.
  3. There is not yet convincing evidence that e-cigarettes help with cessation.
  4. Youth use of e-cigarettes is a bad thing.

Unfortunately, the reality is that, for the population as a whole

  1. Most smokers who use e-cigarettes are less, not more, likely to quit smoking
  2. Dual use is the dominant use pattern
  3. Youth use is exploding

What the net population effect will be depends on how all these competing factors play out.  The analysis that Sara Kalkhoran and I did found that if e-cigarettes are more than 20-30% as bad as cigarettes (which I would guess is likely),  then the net population health effect will be negative.
So, in short, I don’t see anything that either person said that would, in any way, obviate the need to educate the public about the harms of e-cigarettes, in particular that they are not just “harmless water vapor.”
San Francisco, Alaska, and California have good models for what states and others should be doing.



A key player in the early e-cigarette education campaigns was the Chicago Department of Public Health. In January 2014, the CDPH launched its public education campaign one week prior to the Chicago City Council hearing debate on an ordinance to regulate e-cigarettes as tobacco products. The campaign was launched on Twitter as a series of messages on the harms of e-cigarettes, including:
“The “water vapor” from #ECigs contains benzene, nickel, tin, arsenic, formaldehyde & acrolein #ecigtruths”
“Percentage of middle school and high school students who used e-cigarettes DOUBLED from 2011 to 2012. They must be regulated. #ecigtruths”
“Electronic cigs contain a dangerous, addictive drug & should be regulated like other nicotine products #ecigtruths”
Shortly after the campaign, e-cigarette user groups launched an aggressive Twitter bomb attack. To learn more about the Chicago public health campaign and the anti-policy campaign, Jenine Harris and colleages at Washington State University conducted an analysis of Twitter activity in Chicago at that time. Read more here:“Tweeting for and Against Public Health Policy: Response to the Chicago Department of Public Health's Electronic Cigarette Twitter Campaign” doi:10.2196/jmir.3622
More importantly, Chicago’s law was successful despite aggressive opposition because of the dedicated efforts of the health department staff, led by Commissioner Bechara Choucair and Senior Adviser Kendall Stagg. The CDPH continued to provide technical assistance to several governments in Illinois and other cities such as Los Angeles, San Francisco, and Philadelphia on passing strong e-cigarette legislation.
In February 2014, CDPH’s Kendall Stagg presented up-to-date science on the harms of e-cigarettes and lessons learned in Chicago in a webinar hosted by the National Association of City and County Health Officials to health departments and health advocates across the U.S. Read more on the webinar here, page 44 begins Kendall’s presentation: http://www.astho.org/Programs/Prevention/Tobacco/ECigarette-Webinar-Slid... title="http://www.astho.org/Programs/Prevention/Tobacco/ECigarette-Webinar-Slid...
<strong;Key Lessons Learned:</strong;
1) Be prepared for the tobacco industry’s playbook!
2) Must refute “it is just water vapor” head on.
3) Blowing smoke: Harm reduction and cessation arguments are a red herring.
4) One can be in favor harm reduction and common sense regulations.
5) Everyone has the right to breathe clean indoor air.
The CDPH played an important leadership role in setting the standard for other governments to regulate e-cigarettes as tobacco products. The CDPH was one of the first to refute the claims made by e-cigarette user groups, retailers, and companies that e-cigarettes emit “only harmless water vapor” or that their products were made from nicotine derived from vegetable sources. The fact that the CDPH was one of the first to experience an aggressive Twitter bombing campaign by e-cigarette user groups and retailers indicates that they must have been doing something right.

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