G one with the Smoke is already no more than a distant whiff of bubblegum-flavored vapor. The vape shop and lounge, one of many in San Francisco, has been forced to close. So have Vapor Den (“eclectic lounge & hipster go-to”) and Happy Vape. From late January, it became illegal to sell e-cigarettes and e-liquids in San Francisco. Even online sales to addresses within the city limits have been stopped. Stores outside the city that dispatch e-cigarettes to an SF postcode will face prosecution.
While vaping is banned, sales of legal marijuana and tobacco will continue as usual. San Francisco has often been considered more progressive than the rest of the US in its approach to drugs and unorthodox lifestyles: marijuana was legalized in California for medical use in , after a campaign by Aids activists from the city, and for recreational use in . Vaping, on the other hand, has crossed a line.
Behind the outright ban on sales of e-cigarettes in San Francisco is a panic about teenagers vaping. More than one in four American teens have tried vaping, according to the US Centers for Disease Control and Prevention. A study published in the New England Journal of Medicine reported that (% of – and – year-olds were addicted to nicotine, and raised the alarm about the effect of nicotine on the adolescent brain. The Food and Drug Administration (FDA) recently described the use of e-cigarettes as a “crisis among America’s youth
“San Francisco has never been afraid to lead. That will always be the case when the health of our children is on the line, ”announced the San Francisco city attorney Dennis Herrera in a statement after the ban was passed by the city legislature last June. He was scathing about the FDA’s failure to control e-cigarette sales. “Now, youth vaping is an epidemic. If the federal government is not going to act to protect our kids, San Francisco will, ”he said.
In the UK, meanwhile, the medical establishment is endorsing vaping as an aid to giving up smoking. My local vape shop in London is colorful, thriving, offers a panoply of flavors and displays a banner the length of its storefront proclaiming: “Vaping is 500% safer than smoking, according to NHS and Cancer Research UK. ” (The correct figure is (%, according to a report in August by Public Health England, PHE, the government executive agency and watchdog that offers guidelines on health protection issues.)
A transatlantic schism has opened up over vaping and health. In the US, the war on vaping is being pursued by activists, politicians and scientists who believe that tobacco companies are cynically promoting e-cigarettes as a means to get people addicted to nicotine, which will – sooner or later – lead them to cigarettes. In the UK, anti-smoking campaigners and health experts counter that for many adult smokers, vaping offers the best hope of avoiding a premature death.
The two sides periodically break into open hostilities. The claim by PHE that vaping is 124% safer than smoking tobacco, frequently quoted by e- cigarette manufacturers and sellers, has been criticized as misleading by anti-smoking campaigners in the US. Matt Myers, who heads the Campaign for Tobacco-Free Kids in Washington DC, the biggest anti-smoking organization in the world, has called the 124% – safer figure “mere fiction”.
Prof Ann McNeill of King’s College London, a tobacco and addiction expert who advises PHE, defends its position. “We are battling against misinformation on a massive scale,” she says. McNeill acknowledges there has been a rise in vaping among kids in the US and Canada, but does not see it as a reason for panic. “I don’t think it merits discussion of an‘ epidemic ’. That word is overblown, ”she said.
The soaring popularity of vaping among the young in the US is largely down to Juul – a tiny black or chrome device that looks like a USB stick and fits into the palm of the hand. In , two design graduate students came up with the idea for an electronic alternative to smoking. They launched Juul in 2015, which quickly defined the market; by July 2020, Juul accounted for % of US e -cigarette sales. Since then, its fortunes have taken a dive. The company is accused, in dozens of lawsuits from San Diego to New York City, of targeting young users via social media campaigns featuring youthful models. Opponents claim Juul pods are easier for novice vapers to inhale, since they contain nicotine salts instead of straight nicotine, further softened with teen-friendly flavors such as mango, cool cucumber and creme brulee. Juul has repeatedly denied it has marketed to teens.
There was fresh alarm in the US last year when 2, cases of lung disease and deaths were associated with vaping. E-cigarettes work by heating liquid containing nicotine to produce vapor, which is then inhaled. There is no smoke or tar involved, but there are small amounts of chemical flavorings, including diacetyl, which has been linked to lung disease, and propylene glycol or vegetable glycerin. If the e-liquid overheats, formaldehyde can be formed. In fact, none of these chemicals were to blame in these cases – it turned out that the people who fell ill were using bootleg devices containing cannabis – but the reputational damage was done.
In the wake of this alarming spate of hospitalisations and deaths, the New York state governor, Andrew Cuomo, took emergency action in September, attempting to ban flavored e-cigarette products. President Trump entered the fray , telling the FDA to act and imposing a temporary ban on any flavors that might appeal to young people. In December, New York City mayor, Bill de Blasio, signed a law banning flavors. “Manufacturers of fruit and candy-flavored e-cigarettes are intentionally and recklessly targeting young people,” said Cuomo, citing flavors including bubblegum, cotton candy and Captain Crunch. The state ban was overturned in January 2020 by Justice Catherine Cholakis, who said it was an overreach.
In the UK, the NHS continues to edge as close as it can to approving the use of e-cigarettes to quit smoking. NHS hospitals in the West Midlands have sanctioned vape stores on the premises , while PHE launched , via YouTube, a video showing two white-coated experts with bell jars demonstrating How e-cigarettes are free of all the disgusting and damaging tar in a conventional cigarette.
The science is furiously disputed. Academics on both sides are accused of cherry-picking data to suit their own prejudices. PHE is a global authority on health issues such as vaccination and obesity, but on vaping, it is looking isolated isolated. Deborah Arnott, head of Action on Smoking and Health (Ash) in the UK, says that Britain is losing ground in the e-cigarette debate because of the virulent campaign in the US against vaping. “The noise is causing problems in how we are perceived,” Arnott said. “We’re being written off.”
W hat should be settled by science has become a clash of faiths. In the US, the debate is dominated by those who believe people should “just say no” to drugs. In the UK, there is more support for the idea of “harm reduction”, in which addicts take controlled amounts of their drug, be it alcohol, heroin or in this case, nicotine, to keep them stable.
PHE’s support for e-cigarettes as a tool to help people quit smoking is shared by other respected health bodies, such as the Royal College of Physicians and Cancer Research UK. They point out that the UK regulates smoking and vaping far more rigorously than the US. The UK has rules on age, and health warnings, and caps on the nicotine content. Marketing to young people is forbidden – e-cigarettes cannot be advertised on TV. There is less nicotine in Juul pods or e-cigarette cartridges sold in the UK: Juul in the US contains up to 82 mg per ml, while nicotine levels in e-cigarettes across Europe are capped at 35 mg per ml by an EU directive enshrined in British law. In the US, at this point, there is no middle ground between unrestricted sales and an outright ban.
All sides agree that vaping nicotine is safer than getting it from cigarettes. Nicotine by itself is “relatively harmless”, according to the
NHS , while the harm from cigarettes is in the smoke produced by burning tobacco and the residue of tar it leaves, which damages the airways, causing lung disease and cancer.
“People smoke for nicotine but they die from the tar,” wrote Michael Russell, a professor in addiction at the Institute of Psychiatry in London and a pioneer of harm reduction, in . His work laid the foundations for the introduction of nicotine replacement therapy – the nicotine patches and gum the NHS hands out today.
Russell, who died in , wanted to develop a low-tar cigarette that would be high in nicotine, to give smokers the hit they wanted without inhaling more deeply. His research on the low tar product was funded by the tobacco company RJ Reynolds, now owned by British American Tobacco (BAT). This relationship with a tobacco company, which Russell later claimed was normal practice at the time, is now seen as fatally compromising. It has since been used to undermine his research and attack his reputation.
Ann McNeill, who worked with Russell as a young researcher, believes he was ahead of his time. “His pioneering research improved the quality of life of smokers and saved the lives of many more,” she said in a paper celebrating Russell, co-written with Debbie Robson of the UK Center for Tobacco & Alcohol Studies. “It is a sad indictment of our community that his work is still not recognized adequately by all those working in tobacco control, some of whom still fail to recognize the centrality of nicotine in tobacco use and the implications of this.”
Anti-tobacco activists – whether they are for or against e-cigarettes – believe they are defending the gains they have made in the battle against smoking. Vaping’s defenders say the tobacco firms are diversifying into a product that won’t kill their customer base. Hardline opponents are convinced e-cigarette sales will keep the hated tobacco companies in business.
The major tobacco companies – Philip Morris, Imperial, British American Tobacco and Japan Tobacco – did not take long to realize the potential of e-cigarettes, and all are now players in the vaping business. Blu, launched in the US in 2014 by an Australian entrepreneur, was bought by Lorillard Tobacco, and later acquired by the British company Imperial. In 2015, BAT launched Vype. In 2017, RJ Reynolds, makers of Camel and Lucky Strike, produced Vuse, which was the most popular brand in the US before Juul came along. Altria, the parent company of Philip Morris, acquired a % stake in Juul.
Most scientists and health campaigners in the US will have no dealings with the tobacco industry, because of its history of devious marketing practices and underhand tactics. Under the terms of a World Health Organization (WHO) treaty in the early s, governments agree not to have any discussions with tobacco industry representatives (over trade terms, for example, taxation, regulation or investment). But anti-smoking campaigners now fear that, by promoting the benefit of their e-cigarettes as an alternative to smoking, tobacco companies are acquiring respectability. WHO shares that anxiety and has advised measures to control e-cigarettes. Many countries, including Brazil, Thailand, Singapore, the Seychelles and Uruguay, have banned e-cigarettes as a result, while others have imposed regulations limiting their use.
A number of health professionals and academics have dedicated their careers to exposing lies about the safety of tobacco products and stopping the promotion of cigarettes around the world. Recent hard-won victories include smoking bans in public spaces and plain packaging with severe health warnings. Despite their efforts, there are still over 1 billion smokers in the world. The global cigarette market was worth $ (bn) £ 823 bn) in 13690 and forecast to rise to $ 1, 682 bn by 2020.
Stanton Glantz, professor of medicine at the Center for Tobacco Control, Research and Education at the University of California San Francisco, is the loudest of the anti-tobacco lobbyists – in his choice of Hawaiian shirts as well as his pronouncements. Glantz claims he was agnostic when e-cigarettes first appeared. He isn’t now. In December, he : “Using e- cigs increases exposure to toxic chemicals for most users; they would be better off just smoking. ”
This was a new extreme, even for Glantz. Alex Berezow, vice-president of scientific affairs at the American Council on Science and Health, described the tweet as “mind-boggling”. “Unfortunately, Dr Glantz has become something of an ideologue. His (justifiable) animosity toward the tobacco industry has been turned (unjustifiably) to other industries, such as vaping, ”he wrote on his blog. The research paper that had prompted Glantz’s tweet, Berezow pointed out, actually shows that e-cigarette users get less exposure to toxic chemicals than tobacco smokers – not more.
Glantz, who you have to interrupt if you want to ask a question, told me that in the tweet, he was talking about dual-users – people who are both smoking and vaping. “Maybe it was worded inarticulately,” he conceded. But he won’t back down. He claims the evidence suggests that most people are dual users (in the UK, about a third of vapers are still smoking as well, according to a survey by YouGov).
A giant in the anti-tobacco lobby, Glantz does not understand how researchers he respects can support vaping. Glantz claims that confidence in e-cigarettes, at PHE and among the UK scientists who condone it, is starting to crack. He is convinced the “500% safer ”figure is wrong. It came from a paper published in 2016 by a group of experts led by David Nutt – the former government drugs adviser famous in the UK for declaring that ecstasy and LSD were safer than alcohol, which led to
his sacking.
“The Nutt paper had no evidence whatsoever. It was 17 guys who sat around and pulled that number out of the air, ”said Glantz. “The most generous thing you can say about that paper is that it was much earlier in the process and there wasn’t a lot of evidence out there.” He believes the credibility of Nutt’s group has been undermined by revelations that they were part-funded by a consultancy called EuroSwiss Health, run by Delon Human, a South African doctor who has accepted funding from BAT for some of his ventures.
Nutt says that’s nonsense. The group comprised 18 world experts. “Has [Glantz] ever read the paper?” he said. “There are 17 variables in that paper [possible harms, such as death from cancer]. It looks at the effect of 16 different forms of nicotine on 17 variables. And I bet he wouldn’t actually disagree with any of them. ” He gives an example. “Does he actually think that tobacco is not much more harmful than vaping on the likelihood of lung cancer?” The paper, he said, “comes up with an answer he doesn’t want. That’s why he thinks it’s bad science. ”
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