December 7, 2016

Stanton A. Glantz, PhD

Surgeon General releases first report on e-cigarettes; calls for more aggressive regulation and education

Here is the press release:
 
Surgeon General Reports Youth and Young Adult E-Cigarette Use Poses a Public Health Threat
Issues call to action to reduce e-cigarette use among young people
 
A new report from the U.S. Surgeon General raises public health concerns about e-cigarette use among U.S. youth and young adults. The report comes amid alarming rates of youth and young adult use of e-cigarettes; in 2015, about 1 in 6 high school students used an e-cigarette in the past month. The report finds that, while nicotine is a highly addictive drug at any age, youth and young adults are uniquely vulnerable to the long-term consequences of exposing the brain to nicotine, and concludes that youth use of nicotine in any form is unsafe. The report also finds that secondhand aerosol that is exhaled into the air by e-cigarette users can expose others to potentially harmful chemicals.
 
Today’s report, which was written and reviewed by more than 150 experts, is the first comprehensive federal review of the public health impact of e-cigarettes on U.S. youth and young adults. These devices are referred to, by the companies themselves, and by consumers, as “e-cigarettes,” “e-cigs,” “cigalikes,” “e-hookahs,” “mods,” “vape pens,” “vapes,” and “tank systems.” The report uses the term “e-cigarette” to represent all of the diverse products in this rapidly diversifying product category. In addition to documenting the evidence on the health risks of e-cigarettes among young people, the report describes industry influences on e-cigarette use and outlines potential actions to prevent youth and young adults from the harms of e-cigarette use.
 
“All Americans need to know that e-cigarettes are dangerous to youth and young adults,” said U.S. Surgeon General Dr. Vivek H. Murthy, in releasing the report. “Any tobacco use, including e-cigarettes, is a health threat, particularly to young people.”
 
Call to Action
 
In light of the fact that about 1 in 6 high school students used an e-cigarette in the past 30 days in 2015, the report issues a Call to Action to prevent e-cigarette use and related harms among America’s young people.
 
Those recommended actions include:

  • continuing to regulate e-cigarettes at the Federal level to protect public health,
  • raising and strongly enforcing minimum age-of-sale laws for all tobacco products, including e-cigarettes,
  • incorporating e-cigarettes into smoke-free policies,
  • regulating e-cigarette marketing,
  • sponsoring high-impact media campaigns to educate the public on the harms of e-cigarettes among young people, and
  • expanding research efforts related to e-cigarettes.

 
“Protecting our nation’s youth from the harms of tobacco and nicotine is a top priority for HHS and this Administration.  And this report, outlining the harms of e-cigs and providing clear steps to reduce their impact on our kids, is an important step in our fight,” said Secretary of Health and Human Services Sylvia Burwell. “We cannot let the enormous progress we’ve made toward a tobacco-free generation be undermined by e-cigarettes and other emerging tobacco products.”
 
Major Conclusions from the Report

  • E-cigarettes are a rapidly emerging and diversified class of products typically delivering nicotine, flavorings, and other additives to users via inhaled aerosol.
  • E-cigarette use among youth and young adults has become a public health concern.
  • E-cigarettes are now the most commonly used tobacco product among youth.   E-cigarette use is strongly associated with the use of other tobacco products among youth and young adults, including combustible tobacco products such as cigarettes.
  • The use of products containing nicotine poses dangers to youth, pregnant women and fetuses. The use of products containing nicotine in any form among youth, including e-cigarettes, is unsafe.
  • E-cigarette aerosol is not harmless.  It can contain harmful and potentially harmful ingredients, including nicotine.
  • E-cigarettes are marketed by promoting flavors and using a wide variety of media channels and approaches that have been used in the past for marketing conventional tobacco products to youth and young adults.
  • Action can be taken at the national, state and local levels to reduce youth and young adult use of e-cigarettes.

 
“We need parents, teachers, health care providers, and other influencers to help make it clear that e-cigarettes contain harmful chemicals and are not okay for kids to use” Dr. Murthy said. “Today’s report gives them the facts about how these products can be harmful to young people’s health.”
 
A new interactive website containing key information from the report, written especially for parents and adult influencers of youth, is available at E-cigarettes.SurgeonGeneral.gov
 
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Comments

Comment: 

i have suffered severely from using electronic cigarettes.  i have quit using them and threw all of my electronic cigarette material in the trash.  i used electronic cigarettes for a total of 46 months and will never use them again.  i had mild to severe adverse effects from using electronic cigarettes including formaldehyde and nicotine poisoning. 
 
electronic cigarettes are MORE dangerous than tobacco cigaretts but in their own way, different from tobacco.
 
i smoked cigarettes for over 2 decades and while i did experience mild to severe adverse effects from tobacco cigarettes i have NEVER experienced the sort of symptoms and suffering that i did with electronic cigarettes.
 
the electronic cigarette (vapers) community are in <strong;hyper-vigilant denial</strong; as to the facts and the truth of the risks and dangers of electronic cigarettes, which i judge as a hallmark of their drug addiction.&nbsp; they have no willingness (or perhaps no cognitive ability) to acknowledge that thousands of reports of poisoning symptoms do exist.
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http://link.springer.com/article/10.1007%2Fs13181-016-0563-7";http://lin...
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"It is important for health care providers <strong;and the public </strong;to be aware of potential acute health effects from e-cigarettes."
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~ mjk

Comment: 

While I think that the Surgeon General report on e-cigarettes understated the evidence on some areas (most notably the strong evidence for a gateway effect to cigarettes for kids who start with e-cigarettes), this behaviour is well-established with the Surgeon General setting a https://www.ncbi.nlm.nih.gov/pubmed/24420985";extremely high bar for calling something “causal.”&nbsp;
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But this is a small point and did not affect the recommendations.
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Given the Surgeon General’s cautious approach to the science and the fact that hundreds of scientists (including a small contribution of materials from me), the reaction of the e-cigarette enthusiasts is puzzling.&nbsp; Here are some examples that have come across my email stream:
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<strong;ASH News:</strong;
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<strong;E-cigarette alert from US angers experts in Britain</strong;
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British and American health experts are at loggerheads over e-cigarettes after the US Surgeon General said they should be treated in the same way as tobacco.
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The&nbsp;report provoked an angry response from British experts who believe that the devices could save thousands of lives by helping people to quit smoking.
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Linda Bauld, of the University of Stirling, accused him of a fundamental misunderstanding of the evidence. She said that he used studies in mice and rats to predict what might happen in humans. Professor Bauld said that vaping was a relatively safe way for pregnant women to stop smoking.
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The disagreement reflects the fact that British experts tend to compare vaping with smoking.
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Kevin Fenton, of Public Health England, which has endorsed vaping as a way to quit smoking, said the picture was different in Britain, where studies found that few non-smoking teenagers had tried e-cigarettes.
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“We have comprehensive regulations in place including a ban on selling e-cigarettes to under-18s,” Professor Fenton said. “Our review of the evidence found e-cigarette use carries a fraction of the risk of smoking.”
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A spokeswoman for ASH said she was puzzled by Dr Murthy’s dire warnings. “While nicotine is not completely harmless, it is smoking that is lethal,” she said. “There is no evidence of significant regular use [of e-cigarettes] by non-smoking children.”
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<strong;See also:</strong;
-&nbsp;http://ash.us14.list-manage1.com/track/click?u=3d5578d8735672472bede942b... target="_blank";U.S. surgeon general e-cigarette report sparks controversy, Reuters
-&nbsp;http://ash.us14.list-manage2.com/track/click?u=3d5578d8735672472bede942b... target="_blank";US and UK differ on dangers of vaping – so who’s right?, The Grocer (£)
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Source: The Times - 09 December 2016 (£)
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Derek Yach (on Twitter): @Surgeon_General.&nbsp; Full of false, misleading, deceptive statements re #ecigs.&nbsp; Needs a health warning: do not read!
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&nbsp;
Deborah Arnott, Chief Executive of ASH said: “ASH is puzzled by the level of concern being expressed about e-cigarettes by the Surgeon-General. In the US as in the UK, young people are experimenting with e-cigarettes but vaping has not been associated with an increase in smoking, a point which is not made sufficiently clear in the report. While nicotine is not completely harmless, it is smoking that is lethal.&nbsp; In the UK we have a regulatory system that restricts advertising and controls sales to young people.&nbsp; There is no evidence of significant regular use by non-smoking children and, as in the US, smoking rates are going down, not up.”&nbsp;
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Mike Siegel:
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Surgeon General’s Report on E-Cigarettes is Scientifically Dishonest
Today, the Surgeon General released a new report on electronic cigarettes, purporting to provide a scientific summary of the evidence regarding e-cigarettes and vaping products. However, the report is scientifically dishonest and it essentially lies about the single most important fact that the public needs to understand about e-cigarettes and vaping products: that they do not contain tobacco and therefore, vaping is <strong;not</strong; a form of tobacco use. (Full post at http://tobaccoanalysis.blogspot.com/2016/12/surgeon-generals-report-on-e....)
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Comment: 

Did you omit Prof. Hajek's reaction because it accurately refutes the gate claims of the Surgeon General's report?
Prof Peter Hajek, Director of the Tobacco Dependence Research Unit at Queen Mary University of London (QMUL), said:
“The UK Royal College of Physicians published its ground-breaking report Smoking and Health in 1962. The US Surgeon General Report followed two years later and replicated the findings and recommendations. Things are very different this time. The RCP report on e-cigarettes published earlier this year identified vaping as a great public health opportunity. The new US report on e-cigarette use among youths portrays vaping as a threat to public health. Which one is right?
“The new US report’s conclusions do not tally with what the actual data show. It is simply not true that e-cigarettes are a tobacco product or that vaping lures children to smoking or that it creates dependence in non-smokers. The prevalence of smoking among young people is at all time low and regular use of nicotine containing e-cigarettes among never-smokers is extremely rare. On-going vigilance is needed, but so far, e-cigarettes have acted as a gateway away from smoking, for adults and adolescents alike.  The report also ignores the huge benefits of vaping for adult smokers who are switching from deadly smoking to much less risky vaping in large numbers.
“The worst part of the report is its policy recommendations. They may be well meant, but no consideration is given to their likely unintended consequences. Limiting smokers’ access to the much less risky option of vaping is likely to contribute to keeping smokers smoking and smoking-related disease and death going at the current rate.”?

Comment: 

Prof Glantz,
Could much of the push back be because conflatong e-cigarettes with tobacco will 'leave smokers behind'? I submit for your review the words of C. Everett Koop from an Op-ed in 1998.
https://www.washingtonpost.com/archive/opinions/1998/03/08/dont-forget-t... title="https://www.washingtonpost.com/archive/opinions/1998/03/08/dont-forget-t......
By C. Everett Koop March 8, 1998
To date, most of the tobacco control efforts of this administration have focused on preventing young people from taking up smoking. Everyone can agree that teenagers and younger children should not smoke. Even the tobacco industry can safely join in that refrain, and frequently does, with characteristic and clamorous hypocrisy as it turns its marketing machines loose on the young. But at exactly what age does the plight of American smokers lose its poignancy?
One-third of teenagers who experiment casually with cigarettes will become regular smokers, with one-half of these trying to quit, but failing, by age 18. In fact, the vast majority of current smokers were hooked in their teens or earlier. During the '80s, the tobacco industry mounted a public relations campaign maintaining that smoking was "an adult decision." It was a model of reverse psychology, tempting teens at the same time it offered false assurance to their elders. The vast majority of smokers are captive to their addiction, so that most who "decide" to quit cannot -- not without help or years of repeated tries.
If we pretend that adult smoking is a consumer choice like any other, we fall prey to the trap laid by Big Tobacco. Addiction makes the very notion of choice moot. Who would freely choose sickness and suffering, lost productivity or 50 percent chance of premature death? Yet cigarette smokers of all ages continue to die prematurely at the rate of more than 400,000 per year. If not one single young person started smoking from this day forward, these losses would still continue unabated for 30 years. Imagine 1,000 jumbo jets emblazoned with Marlboro and Winston and Camel insignia crashing each year for the next three decades. Should we accept such dramatic losses as par for the course?
We must not focus our efforts so narrowly on preventing tobacco use by youth that we send smokers the message that we have abandoned them -- that their addiction is their own fault and that we don't care about them. This is exactly what the tobacco industry wants them to hear. Forget quitting, hedge the health bets instead. Responding to founded fears, tobacco companies unleashed so-called "low-tar" brands in an effort to hold on to their smokers and reduce the concerns of the uninitiated. But in their attempt to avoid becoming yet another statistic, smokers have only changed the form of their resultant lung cancers from the squamous cell cancers of the upper lung to the adenocarcinomas of the lower lung as they inhaled more deeply to extract the nicotine their bodies craved from such cigarettes. There is an alternative. We can combine tobacco prevention initiatives with efforts to ensure that those who are hooked can obtain effective treatments.
The facts are that quitting smoking at any age reduces the risk of premature death; current treatments can substantially increase the odds of quitting. It therefore seems logical that each decision to smoke should present an equal opportunity not to smoke and an equal opportunity to get help. The Food and Drug Administration's actions in 1996 to restrict tobacco marketing to minors and to approve over-the-counter marketing of nicotine gum and patches for adults were pioneering steps in the right direction. So are several pieces of congressional legislation currently under discussion that include provisions for tobacco addiction treatments.Nevertheless, much remains to be done if our nation is to make tobacco dependence treatment as acceptable and as readily available as tobacco itself. We must evaluate and approve potentially life-saving treatments for tobacco dependence at the level of priority we assign to treatments for diseases such as AIDS and cancer. Signaling such a course could help empower the private sector to meet these challenges in a way that will contribute to the health of our nation in the short and long run.
Currently, the tobacco industry is lobbying Congress for its own solution to the needs of smokers. Under the guise of a new-found concern for the health of their consumers, these companies want incentives to market products that they claim will reduce the dangers of smoking. We do not want to stifle development of such products. Indeed, we should require reduced toxicity of tobacco products, as we now understand that they are unnecessarily dangerous and addictive. But such a course should not enable tobacco companies to undermine our efforts to reduce overall tobacco use by allowing them to advertise their products with claims such as "low tar" or "reduced delivery." Legitimate concern for the health of tobacco users should balance efforts to reduce the toxicity of tobacco products with the means to expedite the development of new treatments for those who are addicted. Under its existing authorities, including its designation of cigarettes and smokeless tobacco products as combination drug and device products, the FDA has many regulatory tools at its disposal to accomplish its goal of reducing the risk of death and disease in tobacco-addicted Americans. Congressional legislation that weakens the FDA's authority over tobacco reduces its ability to serve the public health.
I strongly encourage any forthcoming congressional legislation or executive actions to strengthen, if not leave alone, the FDA's authority over tobacco, and to support the FDA's ability to evaluate new treatments and treatment approaches in a manner that is consistent with the devastation wrought by unremitting tobacco use. Moreover, in our battle with Big Tobacco, we should not hide behind our children. Instead, as we take every action to save our children from the ravages of tobacco, we should demonstrate that our commitment to those who are already addicted, and those who will yet become addicted, will never expire. The writer was surgeon general from 1981 to 1989.

Comment: 

... I hadn't seen it.&nbsp; My posts are not an exhaustive search, just what came across my email.
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But I added your comment to note that Hajeck also thinks the Surgeon General is wrong.

Comment: 

Citing the Koop editorial as if it supported e-cigarette enthusiasm is silly.
What the evidence says: on the whole e-cigarette use leads to less not more quitting:
http://www.thelancet.com/journals/lanres/article/PIIS2213-2600(15)00521-4/abstract
The suggestion that failure to celebrate e-cigarettes is leaving smokers behind is ludicrous. If anything it's the other way around.
If Koop were alive today he'd probably call the e-cigarette market what it is: extending the tobacco epidemic, not reducing it.
And he'd call out the e-cigarette industry, which is increasingly the tobacco industry. They're not in this business for your health.
Jon Krueger
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Comment: 

The recent Surgeon General report on e-cigarettes has attracted http://tobacco.ucsf.edu/surgeon-general-releases-first-report-e-cigarett... criticism from e-cigarette enthusiasts.&nbsp;&nbsp;&nbsp; These attacks surprised me because they do not take into account that fact that the process used to prepare these reports is https://www.ncbi.nlm.nih.gov/pubmed/24420985";exceptionally cautious in terms of drawing scientific conclusions, even compared to other scientific reviews and consensus reports.
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When comparing this report to other reports addressing e-cigarettes, it is important to keep in mind the process used to develop Surgeon General reports.&nbsp; This process, which is https://www.surgeongeneral.gov/library/reports/50-years-of-progress/sgr5... in detail in the 2014 Surgeon General report, involves senior scientific editors from outside government working with a large number of authors and reviewers to draft, review, and rewrite, and review, and rewrite, and review the content in the report.
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The e-cigarette report involved about 200 scientists working for about 2 years who produced a 300 page report together with another 300 pages of online supporting materials, making this a truly comprehensive review of the literature.&nbsp; Most important, a review of the authors and reviewers (which includes me) shows that the CDC in preparing the report sought out the full spectrum of views on e-cigarettes.
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This extensive process has led to a series of reports over more than the last 50 years that have stood the test of time and have consistently <em;understated</em; the strength of the evidence for the effects of smoking and other tobacco products.
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When assessing the credibility of people criticizing the conclusions of the e-cigarette report as overly aggressive it is important to keep this history and track record in mind.

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