In addition to the excellent paper by Samet and Barrington-Trimis the American Journal of Public Health recently published two letters to the editor — one from Wasim Maziak and one from me — criticizing the paper “Balancing consideration of the risks and benefits of e-cigarettes.” That paper argues that concerns over youth e-cigarette use needs to be “better balanced” against the value of e-cigarettes for adult cessation. Ken Warner “wrote much of the original draft of the article and supervised revisions.”
The first letter, by Wasim Maziak, argued that Warner and colleagues
[presented an] unbalanced analysis of the evidence can be found in [their] discussion of the gateway potential of e-cigarettes, that is, e-cigarette use among adolescents leading to later cigarette smoking. Here the authors presented and discussed several studies for and against the gateway effect among youths. Yet, only studies suggesting a gateway effect were subjected to scrutiny by the authors in terms of their limitations, despite the fact that they were for the most part based on stronger longitudinal designs than the studies presented to refute the gateway effect. They also ignored studies that addressed their critiques of the gateway effect—by having a longitudinal design, adjusting for other tobacco and substance use, and examining regular cigarette smoking rather than experimentation—and still revealed the same association (see, e.g., Osibogun et al.). [citations deleted]
While acknowledging that “[Maziak] is correct that we [Warner et al] subject the prospective studies to greater scrutiny than we do the articles challenging them” Warner and colleagues responded that they “did not have space to analyze every cited article,” then cited five papers that they used to argue that accounting for other tobacco product or marijuana use could explain the observed effect of e-cigarettes on subsequent cigarette smoking. They also acknowledged that they were unaware of Osibogun et al study.
In citing these papers, however, Warner and colleagues ignored each paper’s stated conclusion:
- Osibogun et al concluded: “Current e-cigarette use among U.S. youth is associated with higher odds of transitioning to regular cigarette smoking, likely reflecting robust transitions rather than experimentation.”
- Loukas et al concluded: “ENDS [e-cigarette] use by young adults is a specific risk factor for later cigarette initiation and not an extension of a constellation of existing tobacco use behaviors.”
- Spindle et al concluded: “Given that never-smoking [college students] who had tried e-cigarettes were more likely to initiate cigarette use later, limiting young adults’ access to these products may be beneficial.”
- Watkins et al concluded: “Any use of e-cigarettes, hookah, noncigarette combustible tobacco, or smokeless tobacco was independently associated with cigarette smoking 1 year later. Use of more than 1 product increased the odds of progressing to cigarette use.”
- Wills et al concluded: “the relation between adolescent e-cigarette use and smoking onset is in part attributable to cognitive and social processes that follow from e-cigarette use.”
In contrast to what Wills et al concluded in their paper, Warner and colleagues interpreted the results as showing that inclusion of marijuana “eliminated the link between vaping and subsequent smoking.” Wills et al estimated both direct and indirect determinants of the association between e-cigarette use and smoking and showed was that e-cigarette use resulted in significantly more positive expectancies about smoking, increased affiliation with peer smokers, and increased marijuana use, all of which were significantly linked to smoking onset. That is why they concluded that adolescent e-cigarette use was linked to and smoking onset and marijuana initiation in part through cognitive and social processes that follow from e-cigarette use.
Indeed, kids who start with e-cigarettes are also more likely to take up marijuana (and vice versa). Indeed, in 2019 “triple use” (e-cigarettes, marijuana and cigarettes) was the most common patten of e-cigarette use among youth. This situation amplifies the negative effects of e-cigarette use on kids.
In response to my letter that pointed out that Warner and colleagues only quoted the finding from our meta-analysis of e-cig use and quitting smoking that daily e-cig users quit smoking significantly more while ignoring the equally important finding that non-daily e-cig users quit smoking significantly less. They also ignored our finding that, overall, among all adult e-cig users, there is no significant association between e-cig use and quitting smoking.
Warner and colleagues argued that ignoring the finding of no overall benefit was reasonable because
This finding derives from the authors combining daily e-cigarette users, who show significantly increased smoking cessation rates, with nondaily users, who have significantly lower quit rates. We consider it illogical to merge the two. In our article, we say that the difference in quit rates could reflect self-selection: daily e-cigarette users may be more motivated to quit smoking, whereas some infrequent vapers may use e-cigarettes as a temporary nicotine source where smoking is prohibited. The point is that people who want to quit smoking and use e-cigarettes frequently exhibit a statistically significantly increased odds of quitting, just as with daily versus infrequent adherence to nicotine replacement therapy. [citations omitted]
This speculation ignores the fact that e-cigarette use is not associated with increased quitting smoking among smokers motivated to quit as shown in Figure 2 of our meta-analysis (reproduced above).
Warner and colleagues also ignore the fact that the FDA Center for Tobacco Products can only authorize or not authorize the sale of e-cigarettes (and other tobacco products). Unlike the FDA Center for Drug Evaluation and Research decisions on medicines, the FDA Center for Tobacco Products cannot put restrictions on how tobacco products are used in the way that is done with prescription drugs. Indeed, the law expressly prohibits CTP from requiring that the tobacco products it regulates be available only by prescription.
Perhaps the most laughable thing Warner and colleagues wrote was in their response to Maziak:
Having devoted our careers to the welfare of both youth and adult smokers, we call for a more balanced consideration of the impacts of vaping because both are important and the current fervent emphasis on youth may come at a potentially significant cost to adult smokers. The powerful influence on the media and legislators of well-funded organizations like the Campaign for Tobacco Free Kids and the Truth Initiative, singularly focused on youth vaping, belies Maziak’s claim that “adolescents are a vulnerable population without a legal and political voice.” One could argue that the marginalized populations comprising adult smokers are the vulnerable groups lacking a political voice.
Leaving aside the ethically dubious willingness to trade off known risks to kids for hypothetical benefits to adults, TFK and Truth’s funding pales in comparison to e-cigarette companies like Juul and the multinational tobacco companies that dominate the e-cigarette market.
In terms of protecting smokers, encouraging them to take up e-cigarettes as a way to quit smoking is no different than urging people to use hydroxychloroquine or ivermectin to prevent or treat COVID-19. They don’t work and promoting them, like promoting e-cigarettes for smoking cessation, displaces effective interventions like COVID-19 vaccinations.
Finally, while Warner “wrote much of the original draft of the article and supervised revisions,” all the authors are responsible for both the original paper and the responses to these letters: David Balfour, Neal L. Benowitz, Suzanne Colby, Dorothy Hatsukami, Harry Lando, Scott Leischow, Caryn Lerman, Robin Mermelstein, Raymond Niaura, Kenneth Perkins, Ovide Pomerleau, Nancy Rigotti, Gary SwanPhD, and Robert West.