One June 30, 2023, the US Department of Health and Human Services released its Draft HHS 2023 Framework to Support and Accelerate Smoking Cessation and requested public input. The Framework has the following goals:
- Promoting access to cessation resources that are culturally competent and use consumers’ preferred languages
- Engaging community partners in promotion and outreach to key population groups, focusing especially on groups with high smoking prevalence and/or persistent cessation-related disparities
- Building capacity for cessation services and supports in care settings serving key populations
- Regulating the manufacturing, marketing, and distribution of tobacco products to protect public health
Led by UCSF professor Maya Vijayaraghavan et al. several of us submitted a public comment generally endorsing the HHS goals and offering some specific suggestions for refinement and implementation. In particular, they noted “cessation program strategies that only address combustible products will not be as effective as developing a coordinated strategy that addresses quitting other forms of tobacco and nicotine products.”
We did not develop this point in detail, because they said they would address e-cigarettes and other products in more detail later. The problem is that e-cigarettes are other tobacco products are often presented as smoking cessation despite the fact that none have been approved as smoking cessation medicines and that, when used as consumer products, do not help and may inhibit smoking cessation.
The problem with this approach is that these products are out there now and the continued unfounded assumption FDA (which is part of HHS) makes that e-cigarettes have smoking cessation value directly undermines broader efforts to fight nicotine addiction.
It turns out that Jerimiah Mock, another UCSF professor, was concurrently putting in a comment that highlights these issues, particularly how the HHS’ limited focus inadvertently ends up supporting the tobacco companies’ broader political agenda.
Let’s hope HHS pays attention.
Here is his comment (PDF):
Comment on Draft HHS 2023 Framework to Support and Accelerate Smoking Cessation
Jeremiah Mock, MSc, PhD
Associate Professor
Department of Social Behavioral Sciences
Institute for Health & Aging
University of California San Francisco
July 30, 2023
I am writing in support of the comments submitted by my colleagues Vijayaraghavan et al. at the University of California San Francisco on July 29, 2023. I wish to amplify a statement made by my colleagues.
The Draft HHS Framework to Support and Accelerate Smoking Cessation states:
The scope is focused on cessation of the use of commercial cigarettes, cigars, and cigarillos, for people of all ages across the lifespan. The Department also recognizes the importance of tobacco use prevention and cessation of other tobacco products. These issues as well as those related to e-cigarettes are topics that are out of scope for this phase but will be addressed in a later phase of this effort.
Cigarette smoking clearly remains a major public health problem. HHS has rightly included cigars and cigarillos in the scope of the proposed Framework because little cigars and cigarillos are used widely by youth and young adults, particularly Black/African American and Hispanic/Latinx youth.
However, the lack of inclusion of other nicotine delivery products is a concerning oversight. As my colleagues at UCSF pointed out in their comment,
…cessation program strategies that only address combustible products will not be as effective as developing a coordinated strategy that addresses quitting other forms of tobacco and nicotine products.
For the proposed first phase, HHS has provided no justification for defining as “out of scope” the provision of cessation support for users of other nicotine-delivery products, particularly nicotine vaping devices, hookahs, and smokeless tobacco products. Defining users of these nicotine delivery modalities as being out of scope is a significant deficiency that does advance the protection of public health for two reasons:
1. A cessation support policy that focuses exclusively on providing cessation services for users of combustible cigarettes, cigars, and cigarillos will play directly into the hands of major tobacco companies. Phillip Morris International (PMI), Altria Group, British American Tobacco (BAT), and Reynolds America have all made public statements about their corporate “transformations” away from selling cigarettes. PMI has, in describing their “transformation,” stated that they envision a “smoke-free future,” further elaborating by stating that, “To make our vision a reality we are transforming and staking our entire future on a line of smoke-free products.”1 The other companies have made similar statements.
Clearly, these tobacco companies have developed a corporate strategy of normalizing nicotine consumption by marketing a range of “smoke-free alternative” products, including e-cigarettes, heated tobacco products, and oral products (e.g., dissolvable nicotine pouches), none of which has been classified by the FDA as being safe for consumer use. All of these products deliver nicotine, a highly addictive substance, that has been identified as a tumor accelerator and a cause of fetal abnormalities.2-5
If HHS pursues a cessation support framework that excludes these other nicotine delivery products, the public will likely interpret this policy decision as a signal that HHS believes these other nicotine delivery products are not sufficiently harmful to warrant quitting. This interpretation will advance the tobacco companies’ corporate goals of normalizing nicotine consumption through the use of non-combustible products. Against the grain of two decades of declining rates of youth cigarette smoking, the rapid emergence of the youth and young adult nicotine vaping epidemic provides clear evidence that the public interprets permissive, lax public policy as a signal that nicotine consumption and nicotine addiction are not health concerns. Thus, HHS should, in this first phase, avoid establishing public policy that reinforces the tobacco companies’ strategy to addict millions of young people to nicotine.
2. HHS has a responsibility to urgently respond to the epidemic of youth and young adult nicotine vaping, an epidemic that was created and has been exacerbated by misguided federal public policy allowing e-cigarettes such as JUUL to be marketed unregulated, and further allowing new generations of “disposable” vaping devices, particularly Puff Bar, Flum and Elfbar, to proliferate.6 Millions of youth and young adults have, and will in the foreseeable future, unwittingly become addicted to the highly potent form of nicotine delivered by vaping devices. Millions of youth and young adults are, and will be, in need of effective evidence-based cessation support tailored to the types of products they use, the topographies of their nicotine consumption, and their sociocultural patterns of use. Research is urgently needed to advance e-cigarette-specific cessation support. If HHS is going to support “people of all ages across the lifespan,” then HHS needs to support youth and young adults who are primarily using nicotine vaping devices at far higher rates than they are smoking cigarettes, cigars, and cigarillos.
The 2022 Monitoring the Future survey shows clearly that “nicotine vaping now one of top forms of substance use among teens.”7 The survey findings show that in 2022 among 12th graders who were 17-18 years old, the prevalence of past-30-day use of nicotine vaping devices was 20.7%, far above cigarette smoking at 4.0%, and smoking flavored little cigars/cigarillos at 2.2%. Among 10th graders who were just 15-16 years old, 14.2% vaped nicotine in the past 30 days, compared to 1.7% who smoked cigarettes and 1.4% who smoked flavored little cigars/cigarillos. Even among 8th graders – children just 13-14 years old –– 7.1% vaped nicotine in the past 30 days, compared to 0.8% who smoked cigarettes and 0.7% who smoked flavored little cigars/cigarillos.
While youth smoking of tobacco in hookahs had declined steadily, in 2022 1.8% of 12th graders reported smoking through hookahs in the past 30 days. Between 2021 and 2022, there was a slight increase in annual youth use of what the tobacco companies call “smoke-free” dissolvable products, among 10th graders, increasing from 0.3% to 0.9%, and among 12th graders from 1.1% to 1.7%.
As my colleagues have recommended, rather than playing into the tobacco companies’ hand and abandoning millions of youth and young adults, HHS should focus on developing a coordinated strategy that addresses quitting other forms of tobacco and nicotine products. This approach will meet the standard of protection of public health across the lifespan.
Ciitations
1. Philip Morris International. Our transformation 2023 [cited 2023 July 30]. Available from: https://www.pmi.com/our-transformation.
2. Natori T, Sata M, Washida M, Hirata Y, Nagai R, Makuuchi M. Nicotine enhances neovascularization and promotes tumor growth. Mol Cells. 2003;16(2):143-6. Epub 2003/12/04. PubMed PMID: 14651253.
3. Wong HP, Yu L, Lam EK, Tai EK, Wu WK, Cho CH. Nicotine promotes colon tumor growth and angiogenesis through beta-adrenergic activation. Toxicol Sci. 2007;97(2):279-87. Epub 2007/03/21. doi: 10.1093/toxsci/kfm060. PubMed PMID: 17369603.
4. Mao C, Yuan X, Cui Y, Li H, Lv J, Feng X, Liu Y, Chen L, Xu Z. Prenatal exposure to nicotine with associated in utero hypoxia decreased fetal brain muscarinic mRNA in the rat. Brain Res. 2008;1189:43-50. Epub 2007/12/07. doi: 10.1016/j.brainres.2007.10.089. PubMed PMID: 18053972.
5. Hafström O, Milerad J, Sandberg KL, Sundell HW. Cardiorespiratory effects of nicotine exposure during development. Respir Physiol Neurobiol. 2005;149(1-3):325-41. Epub 2005/06/23. doi: 10.1016/j.resp.2005.05.004. PubMed PMID: 15970470.
6. Ali FRM, Seidenberg AB, Crane E, Seaman E, Tynan MA, Marynak K. E-cigarette Unit Sales by Product and Flavor Type, and Top-Selling Brands, United States, 2020-2022. MMWR Morb Mortal Wkly Rep. 2023;72(25):672-7. PubMed PMID: 37347717.
7. Miech RA, Johnston, L. D., Patrick, M. E., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. Monitoring the Future National Survey Results on Drug Use, 1975–2022: Secondary School Students. Ann Arbor: Institute for Social Research, The University of Michigan, 2023.
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