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Robert B. Sklaroff, M.D., F.A.C.P.

Medical Oncology/Hematology  Telephone: (215) 333-4900

Smylie Times Building - Suite #500-C  Facsimile: (215) 333-2023
8001 Roosevelt Boulevard 
Philadelphia, PA 19152 

February 22, 2017

Preventive Oncology - II

1. To identify the major carcinogens that can reasonably be undermined.
2. To identify the major “preventive” strategies that can reasonably be
3. To identify the major “screening” strategies that can reasonably be


1. Cancer – Principles & Practice of Oncology [10 th Edition] –
2. CME – Cancer Screening –
3. The Surgeon General vs. the Marlboro Man: Who Really Won?
4. ASCO-Post – CMS Issues Preliminary Decision to Cover Annual Lung Cancer
Screening [12/15/2014]


Handout: Flip Focus [Tobacco ←→ Cancer Control]
3/Preventive-Oncology Original Research re: Anti-Tobacco
3/Preventive-Oncology TOBACCO” … despite its not being a
tobacco product.
Topics Covered with Specificity: {
Screening [CME] 4/12/24/three-e-cig-ads-banned-for-
Tobacco [E-Cigs] glamourising-tobacco/}

Topics Covered Generically: Levity: How to handle an in-your-face
Oncogenic Viruses smoker
Chemical Carcinogens {
Diet ?

v=10152507186904667&set=vb.8948 General’s Report on Smoking and
2359666&type=2&theater} Health [January 11, 1964] by Luther
Leonidas Terry, M.D.
The Surgeon General vs the {
Marlboro Man: Who Really Won? es/surgeon-general-vs-marlboro-man-
Alan Blum, M.D., curated an exhibit at who-really-won}.
Univ. of Alabama commemorating the
50th anniversary of the Surgeon [Giovanni Battista Morgagni]

Tobacco and Public Health

A meta-analysis of smoking status on clinical outcomes of NSCLC patients harboring
activating epidermal growth factor receptor mutations receiving first-line EGFR
tyrosine kinase inhibitor. In several univariate analyses from randomized phase 3
trials, ever-smokers with advanced epidermal growth factor receptor (EGFR)
mutated (m) NSCLC did not seem to benefit from improved progression-free survival
(PFS) even when EGFR TKIs were is used compared to doublet chemotherapy as
first-line treatment. In this meta-analysis analysis, EGFRm NSCLC patients derived
significant PFS benefit from TKI over chemotherapy regardless of smoking status but
the PFS benefit from EGFR TKIs over chemotherapy is significantly higher in never-
smokers than ever-smokers by meta-regression analysis.

The Federal Aviation Administration is warning airlines about fire risks from
electronic cigarettes stored in checked luggage and is recommending that
passengers bring them into the cabins instead.


Louis Sullivan Finds a New Target Market: the Tobacco Industry Itself. “Uptown. The
place. The taste.” The proposed ads for R.J. Reynolds's new menthol cigarette aimed
at black smokers promised glamour and sophistication. But to Secretary of Health
and Human Services Louis Sullivan, 56, RJR's campaign amounted to "Uptown—The
Disgrace." Lambasting the company's marketing tactics as "slick and sinister,"
Sullivan seethed in a January speech that "at a time when our people desperately
need the message of health promotion, Uptown's message is more disease, more
suffering and more death...."

Limits on tobacco products in the U.S. have come a long way. “…Sullivan wanted to
mention the controversy, but knew that Cabinet members' speeches had to be
screened by the White House 24 hours in advance to avoid contradictions. Worried
his comments would be censored by tobacco-industry operatives in the
government, he turned-in his written speech just two hours before his appearance.”


Snus (/ˈsnuːs/; Swedish pronunciation: [snʉːs]) is a moist powder tobacco product
originating from a variant of dry snuff in early 18th-century Sweden. It is placed
under the upper lip for extended periods. Snus is not fermented and contains no
added sugar. Although used similarly to American dipping tobacco, snus does not
typically result in the need for spitting and, unlike naswar, snus is steam-
pasteurized. The sale of snus is illegal in the European Union and Turkmenistan but,
due to special exemptions, it is still manufactured and consumed primarily in
Sweden, Norway, Finland and Denmark
(both loose and portion). The Russian State Duma drafted a bill which banned snus
in Russia from 1 June 2013 onwards, but it was never ratified. Local varieties of
snus, growing in popularity in the United States, are seen as an alternative to
smoking, chewing, and dipping tobacco. However, some believe US-manufactured
snus is different from Swedish snus and should not be called "snus".

Naswār (Pashto: ‫ ;نسوار‬Cyrillic script: насваа р), also called nās (‫ ;ناس‬наа с), nāts (‫;ناڅ‬
наа ц), nasvay (‫ ;نسوای‬насвай), is a moist, powdered tobacco snuff consumed mostly
in Afghanistan, Pakistan, India, Iran, Kazakhstan, Kyrgyzstan, Russia, Tajikistan,
Turkmenistan, and Uzbekistan.
DeVita [Chapter 31] discusses tobacco use by cancer patients, the clinical effects of
smoking in cancer patients, methods to address tobacco use by cancer patients,
and areas of needed research.

The International Agency for Research on Cancer (IARC) has classified both
cigarette smoke and smokeless tobacco as Group 1 carcinogens. IARC has also
identified 72 measurable carcinogens in cigarette smoke where evidence is
sufficient to classify them as Group 1 (carcinogenic to humans), 2A (probably
carcinogenic to humans), or 2B (possibly carcinogenic to humans). Carcinogen
exposure leads to the formation of carcinogen–DNA adducts, which then cause
mutations that, if not repaired or removed by apoptosis, will eventually give rise to


The increases in adenocarcinoma of the lung observed in the United States over
recent decades may reflect changes made to the cigarette, such as filters, filter
ventilation, and tobacco-specific nitrosamines (TSNA) in smoke produced by the
relatively high amount of burley tobacco used in the typical US cigarette blend.

[Increased incidence of lung cancer [and recently-observed reversal in leading cell-
type from squamous cell to adenocarcinoma] may be due to radioactive polonium
in cigarettes, as per clinical, experimental, and epidemiologic evidence. Changes in
modern cigarettes (with or without filters) allow inhalation of increased amounts of
radioactive lead and polonium and decreased amounts of benzopyrene. This
hypothesis is based upon measurements of increased concentrations of radioactive
polonium in the lungs of cigarette smokers, in modern tobaccos grown since 1950,
and in high-phosphate fertilizers used for tobacco farming in industrialized
countries. Critical support for this thesis is based upon experimental animal studies
in which lung cancers that resemble adenocarcinomas are induced with as little as
15 rads of radioactive polonium, equal to one fifth the dosage inhaled by cigarette
smokers who average two packs a day during a 25-year period. {South Med J. 1986


[Aryl hydrocarbon hydroxylase is an inducible, membrane-bound enzyme
involved in the metabolism of chemical carcinogens. In cultured human
lymphocytes, there is genetic variation. The normal white population in the United
States can be divided into three separate groups having low, intermediate, and high
inducible aryl hydrocarbon hydroxylase activities, with frequencies of 44.7 per cent,
45.9 per cent and 9.4 per cent respectively. Fifty patients with bronchogenic
carcinoma were studied, and the frequencies of the three groups were 4.0 per cent,
66.0 per cent and 30.0 per cent respectively. The data indicate that susceptibility to
bronchogenic carcinoma is associated with the higher levels of inducible aryl
hydrocarbon hyroxylase activity. {N Engl J Med 289:934–937, 1973}]

[Positive Correlation between High Aryl Hydrocarbon Hydroxylase Activity and
Primary Lung Cancer as Analyzed in Cryopreserved Lymphocytes; whether the
higher AHH levels are the cause or the result of the primary lung cancer is unclear.]


Smoking is an “elastic” process, for smokers affect the amount of nicotine (and
accompanying toxicants) drawn from a cigarette by altering “smoking
topography” [the number of puffs, puff size, frequency, duration, and velocity];
also, Africans and Asians show slower metabolism than do Caucasians.
Tobacco may [or may not] be a Precipitating Factor in Angina Pectoris. Ten patients
with classical angina pectoris due to coronary artery disease were exercised in an
upright position with a fixed exercise load on a bicycle ergometer until they
developed the first manifestation of angina pectoris. They each performed this
exercise four times in a nonsmoking state and four times after smoking a cigarette
of high nicotine content for 5 min. All subjects developed angina sooner if they
smoked before exercising. The average percent of shortening of the exercise period
before angina developed in the smoking state as compared with the nonsmoking
state was 24. All patients developed an increase in the modified tension-time index
after smoking. This increase represents an increase in myocardial oxygen
consumption. After exercise, patients with diseased coronary arteries who smoke
may not meet the increased demand for myocardial oxygen and, therefore, may
develop angina sooner. [9/1/1968] {Aronow, Ann Intern Med. 1968;69(3):529-536.


Levels of Evidence for Cancer Genetics Studies (PDQ®) reflect the strength of
study-design and results. Screening, Prevention and Therapy studies are ranked
accordingly [using screening as the paradigm].

The five requirements that should be met before it is considered appropriate to
screen for a particular medical condition as part of routine medical practice are as
1. The medical condition being sought must cause a substantial burden of
suffering, measured both as mortality and as the frequency and severity of
morbidity and loss of function.
2. A screening test or procedure exists that will detect cancers earlier in their
natural history than when diagnosis is prompted by symptoms, and this test
must be acceptable to patients and society in terms of convenience, comfort,
risk, and cost.
3. Strong evidence exists that early detection and treatment improve disease
outcomes, particularly disease-specific survival.
4. The harms of screening must be known and acceptable.
5. Screening must be judged to do more good than harm, considering all
benefits and harms it induces in addition to the cost and cost-effectiveness of
the screening program.
In descending order of strength of evidence, the levels for screening studies are as
1. Evidence obtained from at least one well-designed and well-conducted
randomized controlled trial.
2. Evidence obtained from well-designed and well-conducted nonrandomized
controlled trials.
3. Evidence obtained from well-designed and well-conducted cohort or case-
control analytic studies, preferably from more than one center or research
4. Evidence obtained from multiple time series, with or without intervention.
5. Opinions of respected authorities based on clinical experience, descriptive
studies, or reports of expert committees.
Endpoints may relate to Incidence, Mortality, or an Intermediate-Point (e.g., large
adenomatous polyps for studies of colorectal cancer prevention).

Peter Greenwald, M.D., Dr.P.H. is NCI’s Associate Director for Cancer Prevention
[Division of Cancer Prevention and Control]. He started the American Stop Smoking
Intervention Study (ASSIST) and the “5 A Day” nutritional program in partnership
with industry and the private sector. He started a community clinical oncology
network that spawned the Breast Cancer Prevention Trial (Tamoxifen halved breast
cancer incidence in high-risk women) and the Prostate Cancer Prevention Trial
(Finasteride quartered prostate cancer incidence).
{} [Diet - vide infra.]
Tobacco-Use Cessation is commonly described as the greatest preventable cause
of cancer.
1. In cancer patients and survivors, the evidence is sufficient to infer a causal
relationship between cigarette smoking and adverse health outcomes;
quitting smoking improves the prognosis of cancer patients.
2. In cancer patients and survivors, the evidence is sufficient to infer a causal
relationship between cigarette smoking and increased all-cause mortality and
cancer-specific mortality.
3. In cancer patients and survivors, the evidence is sufficient to infer a causal
relationship between cigarette smoking and [two-fold] increased risk for
second primary cancers known to be caused by cigarette smoking, such as
lung cancer.
4. In cancer patients and survivors, the evidence is suggestive but not
sufficient to infer a causal relationship between cigarette smoking and
increased treatment-related toxicity and mortality (risk of recurrence and
poorer response to treatment).

Smoking-Cessation Decreases Risk. Some effects of “current” smoking are
distinct from an “ever” or “former” smoking history; many of the effects of smoking
are reversible. Indeed, the adverse effects of smoking and the benefits of cessation
may be more pronounced than currently reported because 30% of cancer patients
who smoke deny tobacco use; this reflects a potential discrepancy between the
effects of smoking based on subjective versus biochemically-confirmed
assessments. Complications may arise post-operatively, may preferentially affect
the lungs, may enhance XRT-toxicity, may worsen mucositis, may yield more
hospitalizations, and may even yield ongoing vasomotor symptoms.

Smoking Affects Treatment Response. Head and neck cancers that are human
papilloma virus (HPV) positive are known to have an improved prognosis as
compared with HPV-negative tumors. Patients who have HPV-positive tumors
typically have increased p16 expression and often respond better to conventional
cancer therapy, including RT and CT. Many HPV-positive patients are never smokers
or have a lighter smoking history; smoking was an independent adverse risk factor
for both overall and cancer-related mortality with a 1% increase in risk per pack-
year smoked. Current smoking increased cancer mortality approximately fivefold
even in p16-positive patients treated with surgery. Smoking also increased the risk
of developing second primary cancer in both HPV-positive and HPV-negative
patients. As a consequence, the presence of HPV does not appear to negate the
adverse effects of smoking. Also, light or never smokers have a higher rate of EGFR-
positive lung tumors that may respond to biologic therapy using EGFR tyrosine–
kinase inhibitors {EGFR = Epidermal Growth Factor Receptor}; smokers may be
better served with conventional cancer treatments rather than these biologic

Smoking-Cessation must entail an ongoing SOAP-model, emphasizing the need to
reformulate data. Tools abound [ALA, ACS, NCI, ASCO]; the Tobacco Cessation Guide
for Oncology Providers is on-line
{}. Most smokers
are unsuccessful in their attempts to quit smoking; the most effective evidence-
based treatments increase the odds of quitting by 3-times, with 12-month cessation
rates of approximately 40% relative to placebo. Low-tar cigarettes (as
compared to full-flavor varieties) afford neither an individual nor a public health
benefit, per both laboratory-based and epidemiologic studies.

The 5 A’s:
1. Ask about tobacco use for every patient.
2. Advise every tobacco user to quit.
3. Assess the willingness of patients to quit.
4. Assist patients with quitting through counseling and pharmacotherapy.
5. Arrange follow-up cessation support, preferably within the first week after
the quit date.
In July 2009, the FDA issued a warning after reports that some patients attempting
to quit smoking while using varenicline or bupropion experienced unusual changes
in behavior, depressed mood, worsening of depression, or had thoughts of suicide.
This has prompted recommendations that health-care providers elicit information
about a patient’s psychiatric history prior to prescribing varenicline or bupropion to
closely monitor changes in mood and behavior during the course of treatment.
However, updated recent safety studies examining very large databases (one
database of N = 119,546, one database of N = 35,800) regarding safety have
shown no difference in neuropsychiatric side effects between varenicline or
bupropion as compared to NRT and no increased risk of depression. Another
prospective study showed no adverse events when treating participants with
current or past major depression and also showed higher abstinence rates for the
varenicline group as compared to placebo at weeks 9 to 52 (20.3% versus 10.4%, p
<0.001). Varenicline should be considered a viable cessation pharmacotherapy for
cancer patients.

Motivational interviewing-based smoking cessation intervention was delivered over
a 3-month period, consisted of multiple contacts with a trained counselor, and
provided supplementary material tailored to cancer patients with NRT. The control
group received brief advice to quit and generic supplementary material. Quit rates
did not differ by treatment group (5% to 6% at 3-month follow-up), but the
intervention group was significantly more likely to report attempts to quit smoking.

Research Considerations: “…Advance understanding of models to increase access
to cessation support and increase efficacy of tobacco cessation methods for cancer
patients….Preventing relapse and evaluating the safety of transition to alternative
products such as e-cigarettes is equally important and increasingly complex with
the addition of new tobacco-related products.”


The relatively recent introduction of electronic cigarettes (i.e., e-cigarettes, e-cigs,
nicotine vaporizers, or electronic nicotine delivery systems [ENDS]) is noteworthy.
These electronic or battery-powered devices activate a heating element that
vaporizes a liquid solution contained in a cartridge, and then the user inhales this
vapor. Levels of nicotine as well as other chemical additives and flavors in the
cartridge are uncertain and vary according to the brand. Although there are no
research studies that have evaluated the potential harmful effects of the use of e-
cigarettes for cancer patients, organizations such as the World Health Organization
have already expressed concerns about the safety of these increasingly popular
products. To date, e-cigarettes have not been approved by the U.S. Food and Drug
Administration (FDA) as therapeutic devices to aid in quitting smoking. Readers are
referred to a recent editorial on the use of e-cigarettes by cancer patients; however,
it will likely be several years before evidence-based health information is available.
{Last citation from DeVita.}

Cummings KM, Dresler CM, Field JK, et al. E-cigarettes and cancer patients. J Thorac
Oncol 2014;9:438–441. [PMID: 24736063]


Sklaroff RB. Tobacco Products Litigation (letter). JNCI 80:87, 8/3/88 {Disclosure}

Use of e-cigarettes, and the relationship to smoking. E-cigarettes were almost
exclusively used by smokers and ex-smokers. More than 1 in 10 (12%) of cigarette
smokers also used e-cigarettes, compared with 1 in 20 (5%) ex-smokers and almost
none of those who had never smoked. These findings reflect those from a “YouGov”
survey commissioned by Action on Smoking and Health (ASH); data on e-cig use
have also been collected as part of the “Smoking Toolkit Study.” E-cigarettes
were found to be used mainly as smoking cessation aids and for the
perceived health benefits (compared with smoking tobacco). Over half of e-
cigarette users said that their main reason for using e-cigs was to stop smoking, and
about one in five said the main reason for their use was because they thought they
were less harmful than cigarettes….Only one in 700 people who regularly
‘vape’ were not smokers previously.


The ACS [“E-cigarettes and the future of tobacco control”] commentary [for
professionals and patients] politicized “Risk Reduction” and poisoned the scientific
method; its author received travel-expenses to participate on a global tobacco
control policy advisory board from Pfizer [manufacturer of Chantix] and advocated a
“middle-ground” [].
Water-vapor was said, per the FDA, “to contain a variety of contaminants, including
some that are carcinogenic” [Ref. #10:]. Yet, only two
of the ~250 brands of E-cigs were scrutinized…in 2009. The word “carcinogen”
appears nowhere in the 8-page memo; an analysis thereof [“Are Electronic
Cigarettes Safe?”] discounted reasonable concerns
[]. Key-excerpts:

Diethylene glycol. You may have heard that the FDA found traces
(1%) of diethylene glycol in one “Smoking Everywhere” brand prefilled
cartridge. Diethylene glycol is a highly-toxic substance used in tobacco
processing (and in anti‐freeze), but it is NOT used to manufacture
electronic cigarette liquid. Because it used in tobacco processing,
cheaper, less refined nicotine may become contaminated with traces
of diethylene glycol. It can also be a by‐product of the manufacture of
low‐grade propylene glycol. It is the most likely explanation of how one
cartridge may have been contaminated. The other 17 cartridges and
other brands tested by independent labs were not found to have been
contaminated with diethyleneglycol. Many liquid manufacturers use
USP‐grade nicotine (the same as used in FDA‐approved nicotine
patches and gums) and USP propylene glycol and should not contain
any diethylene glycol.

Tobacco‐specific Nitrosamines. The FDA analysis found “tobacco‐
specific nitrosamines” in some of the samples tested. These
nitrosamines are created during the curing and processing of tobacco
and would be expected to be found, in trace amounts, in nicotine
extracted from processed tobacco. In tobacco smoke, they are found in
high concentration and are a leading cause of tobacco‐ related
cancers. These carcinogens were found in just trace amounts in the
electronic cigarette liquid and are found in other low‐risk smokeless
tobacco and nicotine products, including chew, snuf, patches, gum and
inhalers. A study at Oxford concluded that the highest levels of these
nitrosamines are found in the reaction of tobacco smoke and minimal
in NRTs. Levels of nitrosamines found in electronic cigarettes are at or
below those found in NRTs.

Advice to patients was concomitantly flawed, including the claim of equal-efficacy
with the patch.
European Commission Puts Money Before Health With E-Cigarette Tax Proposals


The European Commission is considering hiking up tax on electronic cigarettes, even though
an official government report shows that they are not a gateway to smoking and in fact help
people quit tobacco.

A report by the Office of National Statistics showed that only 1 in 700 “vapers” were not
previous tobacco smokers, but despite this the Financial Times reports it has seen
documents which would drastically increase the price of e-cigarettes and further hinder their
take up.

Brussels Bureaucrats have asked excise duty analysts from across the EU to consider the
“best way to achieve fiscal equal treatment” between e-cigarettes and normal tobacco
products. Currently, because of the huge “sin taxes” imposed on tobacco products, and
partly due to their addictiveness, there is a large price difference with e-cigarettes being
much better value for money. The EU demands all member states impose a minimum of 57
per cent excise duty on every packet of cigarettes purchased in the EU, compared to an
average of 20 per cent, or the presiding level of VAT, on e-cigarettes.

Policy makers from across Europe met in Brussels yesterday to discuss whether these safer
alternatives, used by many smokers to help quit tobacco altogether, should be covered by
excise duty.

David Atherton, Chairman of Freedom2Choose, told Breitbart London: “If the health lobby
are so keen to reduce the harm of smoking then electronic cigarettes which have a quit rate
of 20 percent after one year as opposed to using the Pharmaceutical industry’s nicotine
patches, gum and drugs at 5 percent, then ‘vaping’ must be encouraged as much as
possible. The government should never ban vaping indoors and private enterprise
should also embrace electronic cigarettes, too.” He added that “ ‘second hand
[vaping] smoke’ is almost certainly harmless [and] most view smoking electronic [to be]
cigarettes as dangerous as drinking a cup of coffee.”

New E-Cig convert, Paul Nuttall who is deputy leader of UKIP, reacted sharply to news that
the European Commission is considering hiking up tax on healthier electronic cigarettes.

“I am a great fan of e-cigs and UKIP has been very supportive of the practice because it is
healthier and a source of jobs for innovative British companies. The British government must
stand up against these measures and UKIP undertakes to oppose any legislation from the EU
to put tax on electronic cigarettes. I have never seen a private pleasure that the EU does not
want to tax. Of course this move will hike up the cost of vaping e-cigarettes, and thus push
more people back to ordinary and less healthy cigarettes.

“This move unmasks the EU’s real intent of its Tobacco Directive which was to tax all
cigarettes more and help governments make more money. To paraphrase Ronald
Reagan, ‘The EU’s view of the economy could be sumed up in a few short phrases: If it
moves, tax it. If it keeps moving, regulate it. And if it stops moving, subsidize it.”

The World Health Organization has called for tighter controls on e-cigarettes and from 2016,
the Medicines and Healthcare Products Regulatory Agency is expected to license e-
cigarettes as a medicine in the UK.

It was hoped that, following the ONS report, there would be moves to rethink legislation and
liberalize laws surrounding vaping in the interests of public health. However, it would appear
that despite statistical evidence, the European Commission is ignoring sound advice and
putting the health of European Citizens at greater risk.

[PA bill bans smoking with kids in car]
Bill Godshall, Executive Director of Smokefree Pennsylvania [1926 Monongahela
Avenue, Pittsburgh, PA 15218 - 412-351-5880 -] has
published Tobacco Harm Reduction Updates [weekly] since 2010; all have been
posted at Illustrating the bulk of
data favoring e-cigs is only one week’s compilation of hyperlinks:


International case control study finds 3530 vapers who quit smoking were more
likely than 3530 dual users of e-cigs and cigarettes (whose average cigarette
consumption declined from 20 to 4 per day after onset of vaping) to perceive lower
risk of vaping, and to use 3 rd generation vapor products (while dual users were more
likely to use 1st and 2nd generation e-cigs); levels of nicotine use declined after onset
of vaping from a median of 18 and 17 mg/ml to 10 and 12 mg/ml for nonsmoking
vapers and dual users respectively.

2014 MN Dept of Health adult survey finds record low smoking rate (14.4%), e-cigs
used far more than NRT or prescription drugs for smoking cessation (45% vs 22% vs
10%) by smokers who tried to quit and by former smokers who quit in past year,
smokers 22 times more likely than never smokers (27.3% vs 1.2%) to use e-cigs; top
reasons for e-cig use were to reduce harm (78%), reduce cigarette consumption
(51%) and quit smoking (45%).

AVA: Vaping is Minnesota adults’ most popular method for quitting smoking
Montreal Chest Institute review says vaping helps hardcore smokers get off and stay
off; finds 43% (32/75) of smokers who tried quitting by switching to vaping had
remained smokefree from 3 months to a year later.

New study finds e-cig users not as dependent on nicotine as cigarette smokers,
finds long term e-cig users not as dependant on nicotine as long term nicotine gum

JF Etter – Electronic Cigarettes and Cannabis: An Exploratory Study

Nicotine and Tobacco Research ignores deadly cigarettes to devote entire issue to e-
cigs, e-cig opponents author most articles to confuse, scare, lobby for e-cig reg/bans

Correction: The Gallup Poll cited in last week’s THR Update was conducted in July
2013 (finding that 5% of US ex-smokers quit smoking with nicotine patches, 3% with
e-cigarettes, 2% with prescription drugs and 1% with nicotine gum)

Public Health Advocacy

Dave Sweanor: Big Tobacco’s Little Helpers (exposes how THR opponents have
protected cigarettes and enriched cigarette companies for decades)

Quebec Health Minister says vaping is a good way of kicking cigarette habit

Clive Bates: Keep calm it’s only poison (reveals that e-cigs accounted for just 0.06%
of calls to Poison Control centers in 2013, and just .15% in 2014)

Junk Science, Propaganda and Lies

NEJM junk e-cig study

NEJM publishes, touts junk e-cig study (funded by class action lawyers) to news
media (with embargoed press release) that repeatedly overheated a PV, falsely
assumed vapers do the same, falsely claimed some e-cigs may be more
carcinogenic than cigarettes
Clive Bates: Spreading fear and confusion with misleading formaldehyde studies

American Vaping Association / Smokefree Pennsylvania respond to NEJM embargoed
letter/press release falsely claiming some e-cigs can be more carcinogenic that
New e-cig study hypes formaldehyde fears based on faulty experiments

Konstantinos Farsalinos – The deception of measuring formaldehyde in e-cigarette
aerosol: difference between laboratory measurements and true exposure

Konstantinos Farsalinos – Verified: formaldehyde levels found in the NEJM study
were associated with dry puff conditions. An update http://www.ecigarette-

ACSH: Poorly-done e-cig vapor study gets big headlines but means nothing

Mike Siegel: New study reports high levels of formaldehyde in e-cigarette aerosols

Mike Siegel – Confirmed: Formaldehyde study conducted under implausible
conditions; conclusions invalid
Fergus Mason: Formaldehye strikes again (investigative journalist reveals authors of
NEJM study/letter received “philanthropy to support research” from Michael J. Dowd
and Patrick J. Coughlin, who appear to be attorneys Michael J. Dowd and Patrick J.
Coughlin from Robbins Geller Rudman & Dowd, a class action lawfirm involved in
past lawsuits against cigarette companies.
“Robbins Geller attorneys have led the fight against Big Tobacco since 1991. As an
example, Robbins Geller attorneys filed the case that helped get rid of Joe Camel,
representing various public and private plaintiffs, including the State of Arkansas,
the general public in California, the cities of San Francisco, Los Angeles and
Birmingham, 14 counties in California, and the working men and women of this
country in the Union Pension and Welfare Fund cases that have been filed in 40
states. In 1992, Robbins Geller attorneys filed the first case in the country that
alleged a conspiracy by the Big Tobacco companies.”
Jacques Le Houezec criticizes junk study on e-cigs in NEJM (in French)

Jacob Sullum: Does Formaldehyde make e-cigarettes worse than the real thing?
(exposes junk formaldehyde e-cig study published and touted by NEJM)

Greg Gutfeld: New e-cigarette study goes up in smoke

Joe Nocera: Is vaping worse than smoking?

News media further hype NEJM junk e-cig study touted by misleading embargoed
NEJM press release several days prior (whose goal was to generate fear mongering

David Peyton (coauthor of NEJM study) tells Oregon Public Radio he wanted to get
the results out as soon as possible, and to as wide as audience as possible.

David Peyton claims "Our research shows that when heated at higher temperatures,
e-cigarette juices can vaporize and form large amounts of ‘hidden formaldehyde,’
five to 15 times higher than the amount of formaldehyde in traditional cigarettes,”
but then criticizes NEJM tweet stating “Authors project higher cancer risk than

Big Pharma and FDA funded American Heart Association policy statement author
tries to inject more fear mongering claims about e-cigs and lobby for FDA deeming
reg/ban into news coverage of bogus NEJM letter, fails to ethically disclose AHA’s
conflict of interest

E-cig junk scientists and propagandists Pankow and Peyton to present at “The
Science of E-cigarettes” in Portland, OR on 2/25/15

CA Dept of Public Health lies about e-cigs

Gil Ross: California’s Public Health lies about e-cigarettes will kill smokers

Mike Siegel: California Dept of Health Services lies to the public about e-cigarettes

Michael Shaw – Scaring people about e-cigarettes: A public health disgrace
(criticizes false fear mongering claims about e-cigs by California DPH)

More junk science, propaganda and lies

NY Times publishes letter by Big Pharma shills Frank Leone and American Thoracic
Society that falsely claims there’s no evidence e-cigs are less hazardous than
cigarettes or that e-cigs can help smokers quit, falsely claims “evidence shows that
e-cigarettes may serve as a gateway to . . . tobacco”, and that “allowing their use in
locations where other smoking is prohibited . . . may actually prolong addiction to
tobacco”, fails to ethically disclose irreconcilable financial conflicts of interest..

Mike Siegel: Yet another public health practitioner publicly claims that smoking is no
more hazardous than vaping

Mike Siegel: American Thoracic Society physicians claim there is no evidence
smoking is more hazardous than vaping
NY Times publishes letter by Penn State’s Joshua Muscat that falsely claims e-cigs
aren’t safer than lethal cigarettes and that e-cigs increase nicotine addict, absurdly
claims FDA reg/ban would “likely” make e-cigs safer than cigarettes

Univ of Pittsburgh Cancer Institute director Nancy Davidson cluelessly or falsly
claims “we don’t have any idea” whether e-cigs are safer than cigarettes. Tribune-
Review headline and article repeat false and misleading fear mongering claims
about e-cigs.

Dr. Mercola repeats false and misleading fear mongering claims about e-cigs

Amy Fairchild and Ronald Bayer: Smoke and fire over e-cigarettes (article about War
on E-cigs deceitfully portrays FDA’s deeming reg/ban as a “balanced regulatory
approach”, falsely claims “precautionary principle” was/is reason for decades of lies
and campaigns to ban snus and e-cigs by Big Pharma shills and other THR

Carl Phillips: In search of an honest tobacco harm reduction (THR) skeptic

US Federal

FDA appoints Robert Califf as FDA Deputy Commissioner for Medical Products and
Tobacco, has no tobacco policy or regulatory experience

Mike Seigel: New head of office of Medical Products and Tobacco at FDA has history
of pharmaceutical consulting

FAA warns airlines about miniscule fire risks of e-cig batteries (but not about far
greater fire risks of cigarette lighters, matches, cell phone or laptop batteries),
urges airlines to require e-cigs be carried only in aircraft cabin. Please note that US
DOT has NOT banned e-cig use on airlines (after proposing an airline vaping ban
back in 2011)

US Senator Bill Nelson (D-FL) reintroduces bill (S 142) to require child safety
packaging for e-cigarettes, referred to CST Cmte

Philip Morris argues $10.1 billion Price case should never have been certified (IL)


E-cig vendors and makers testify against Gov. Inslee’s proposed cigarette protecting
95% tax on vapor products at WA Senate Ways and Means Cmte hearing

WA bill (SB 5573) would impose 95% tax on vapor products, ban flavored vapor
products, ban internet sales of vapor products by WA retailers, and much more

R Street’s Ian Adams: Inslee’s vaping tax bad for taxpayers, public health

Indiana bill (HB 1235) would tax e-cigarettes at 24% of wholesale price, ban vaping
by falsely redefining smoking as including vaping, ban tobacco sales at pharmacies

Hawaii bill (SB 299) would protect cigarettes by taxing all e-cig products at 30%, by
appropriating tax revenue to Health Dept to lie about e-cigs, and by banning vaping
everywhere smoking is banned; would also increase minimum age for tobacco and
e-cig sales from 18 to 21

Hawaii bill (HB 349) would tax e-cigs same as cigarettes (i.e. $3.20/pack) by
redefining “cigarette” to include an e-cig, ban vaping by redefining “smoking” as
including vaping, violate MSA by redefining “cigarette” to include an e-cig

New Jersey carryover bills from 2014 (A 1944 & S 1213) would tax moist snuff at
$2.25/oz, increase OTP tax to 90%
E-liquid bans

Indiana Senate Commerce & Technology Cmte to hold 1/29/15 public hearing on bill
(SB 539) that would ban sale of ALL or nearly all e-liquid by requiring state permits &
Mississippi bill (SB 2587) would protect cigar-like e-cigs made by Big Tobacco by
banning most/all vape shops and most/all e-liquid sales, would require e-liquid
manufacturers to obtain permit from MS Dept of Health, would require all e-liquid
retailers in MS to obtain permit from MS Dept of Health, would allow Dept of Health
to reject permit application for many different reasons, would require child-resistant
packaging for e-liquid (but not for cigar-like e-cigs)

E-cig packaging restrictions

WA bill (SB 5477) would require child-resistant packaging for all vapor products

Wyoming bill (HB 174) would require child resistant packaging for e-liquid (but not
for cigalike e-cigs), ban tobacco use on school property, require Health Dept to
educate adult tobacco consumers about the continuum of risk of tobacco products,
require child resistant packaging for e-liquid

Internet sales ban/restriction

California bill (SB 24) would require all e-cig retailers to obtain license and comply
with most cigarette tax laws, would ban most Internet sales of e-cigs by CA vendors
(but not by out-of-state vendors) by requiring valid photo ID of all Internet
customers, which would prompt e-cig customers in CA to buy e-cig from out-of-state

Vaping bans

NY Gov. Cuomo proposes to protect cigarettes by banning vaping, banning sale of
flavored e-cigs

California State Senator Mark Leno introduces bill (SB 140) to protect cigarettes by
banning vaping, Big Pharma shills ACS, AHA, ALA to lobby for Leno’s bill
Despite no evidence that e-cigs have ever caused any disease, CA State Senator
Mark Leno absurdly claims "We're going to see hundreds of thousands of family
members and friends die from e-cigarette use just like we did from traditional
tobacco use.”

AVA: San Francisco Senator’s unjustified vaping ban would harm smokers

Connecticut bill (HB 6283) would redefine e-cigs as tobacco products, ban vaping
everywhere smoking is banned, require package warning labels that falsely claim e-
cigs cause diseases

Indiana bill (HB 1235) would tax e-cigarettes at 24% of wholesale price, ban vaping
by falsely redefining smoking as including vaping, ban tobacco sales at pharmacies

Hawaii bill (SB 299) would protect cigarettes by taxing all e-cig products at 30%, by
appropriating tax revenue to Health Dept to lie about e-cigs, and by banning vaping
everywhere smoking is banned; would also increase minimum age for tobacco and
e-cig sales from 18 to 21.

Hawaii bill (HB 349) would ban vaping by redefining “smoking” as including vaping,
tax e-cigs same as cigarettes ($3.20/pack) by redefining “cigarette” to include an e-
cig, violate MSA by redefining “cigarette” to include an e-cig

Smoking and vaping bans

Hawaii bills (HB 34 & SB 802) would wisely allow condominiums and housing
corporations to ban smoking, but would unjustifiably allow them to ban vaping as
Hawaii bill (HB 525) would ban all tobacco use and vaping at State Parks

Advertising restrictions

Connecticut bill (HB 6290) would require e-cigs to comply with cigarette advertising

Minimum Age Restrictions

WA AG Bob Ferguson wants to increase minimum age for all tobacco products and
e-cig sales from 18 to 21 even though cigarettes cause >99% of tobacco
attributable deaths.

WA bill (HB 1458) would increase minimum age for all tobacco and e-cig sales to 21

Hawaii bills (HB 587 & SB 1030) would increase minimum age for all tobacco and e-
cig sales to 21, define e-cigs as a “tobacco product”

Hawaii bill (HB 385) would increase minimum age for all tobacco and e-cig sales to

Punishing youth

Hawaii bill (SB 550) would ban possession of consumption of tobacco or e-cigs by
anyone under 18.


North Dakota bill (HB 1133) would clarify that OTP does not include e-cigs


Hawaii bill (HB 244) would prohibit employers from job discrimination against
people who use tobacco products and vapor products

Plain Packaging

ASH UK praises cigarette plain packaging despite no evidence law would reduce
cigarette consumption or smoking, falsely claims “public health lobby delighted”

UK government proposes plain packaging cigarette law despite no evidence
Australian law reduced cigarette consumption or smoking, Parliament to vote before
May election

Oncogenic Viruses

Infection Site of Diseases in Immunocompromised Associated
Virus Diseases in Normal Hosts
Rate Persistance Hosts Cancers
High-risk human >70% Anogential Carcinomas of the cervix, penis, Increased incidence of same diseases 610,000
papillomavirus types mucosa, oral anus, vagina, vulva, tonsils, base
(e.g., HPV16) mucosa of tongue
Hepatitis B virus 2%–8% Hepatocytes Cirrhosis, hepatocellular Same diseases, increased incidence with 380,000
(HBV) carcinoma AIDS
Hepatitis C virus ~3% Hepatocytes Cirrhosis, hepatocellular Same diseases, increased incidence with 220,000
(HCV) carcinoma, splenic marginal AIDS
Infection Site of Diseases in Immunocompromised Associated
Virus Diseases in Normal Hosts
Rate Persistance Hosts Cancers
zone lymphoma
Epstein-Barr virus 90% B cells, Mononucleosis, Burkitt Increased incidence of same diseases, 110,000
(EBV, HHV-4) pharyngeal lymphoma, other non-Hodgkin lymphoproliferative disease, other
mucosa lymphoma, nasopharyngeal lymphomas, oral hairy leukoplakia,
carcinoma leiomyosarcoma
Kaposi’s sarcoma 2%–60% Oral mucosa, Kaposi’s sarcoma (KS), Increased KS, MCD incidence, primary 43,000
herpesvirus (KSHV, endothelium, B multicentric Castleman disease effusion lymphoma
HHV-8) cells (MCD)
Merkel cell 75% Skin Merkel cell carcinoma (MCC) Increased MCC incidence 1,500 (US)
polyomavirus (lymphocytes?)
Human T-cell 0.01%– T and B cells Adult T-cell leukemia/lymphoma, Unknown
leukemia virus 6% tropical spastic paraparesis,
(HTLV-1) myelopathy, uveitis, dermatitis

Chemical Carcinogens

Agents Industries Tumor Type
Lung Tobacco smoke, arsenic, asbestos, crystalline silica, Aluminum production, coal Squamous, large cell, and
benzo(a)pyrene, beryllium, bis(chloro)methyl ether, 1,3- gasification, coke production, small cell cancer and
butadiene, chromium VI compounds, coal tar and pitch, diesel painting, hematite mining, adenocarcinoma
exhaust, nickel compounds, soot, mustard gas, cobalt-tungsten painting, grinding in oil and gas
carbide powders
Pleura Asbestos, erionite, painting Insulation, mining Mesothelioma
Oral cavity Tobacco smoke, alcoholic beverages, nickel compounds, betel – Squamous cell cancer
Esophagus Tobacco smoke, alcoholic beverages, betel quid – Squamous cell cancer
Gastric Tobacco smoking Rubber industry Adenocarcinoma
Colon Alcohol, tobacco smoking – Adenocarcinoma
Liver Aflatoxin, vinyl chloride, tobacco smoke, alcoholic beverages – Hepatocellular carcinoma,
Kidney Tobacco smoke, trichloroethylene – Renal cell cancer
Bladder Tobacco smoke, 4-aminobiphenyl, benzidine, 2-napthylamine, Magenta manufacturing, auramine Transitional cell cancer
cyclophosphamide, phenacetin manufacturing, painting, rubber
Prostate Cadmium – Adenocarcinoma
Skin Arsenic, benzo(a)pyrene, coal tar and pitch, mineral oils, soot, – Squamous cell cancer,
cyclosporin A, azathioprine, shale oils basal cell cancer
Bone Benzene, tobacco smoke, ethylene oxide, antineoplastic agents, Rubber workers Leukemia, lymphoma
marrow cyclosporin A, formaldehyde

American Cancer Society Guidelines for the Early Detection of Cancer
/ american-cancer-society-guidelines-for-the-early-

Cancer-related check-ups. For people age-20 or older having periodic health
exams, a cancer-related check-up should include health counseling and, depending
on a person’s age and gender, exams for cancers of the thyroid, oral cavity, skin,
lymph nodes, testes, and ovaries, as well as for some non-malignant (non-
cancerous) diseases. The ACS recommends these screening guidelines for most

Lung. Low-dose helical CT-scans should be offered to high-risk patients [55 to 74
years of age] who are in fairly good health, but who have at least a 30 pack-year
smoking history AND are either still smoking or have quit smoking within the prior
15 years. {This must not encourage smokers to keep smoking, feeling 'safer'; they
must be reminded that smoking causes other cancers, vascular disease, and COPD.
Four Years After the National Lung Screening Trial, Lung Screening Uptake is 'Way
Too Slow' {
nlid=74726_481&src=wnl_edit_medp_honc&uac=194910BZ&spon=7 }

Colorectal cancer (and polyps). Starting at age-50 [or earlier in high-risk
groups], colonoscopy should be performed every decade; alternatives include
flexible sigmoidoscopy, double-contrast barium enema, or CT colonography (virtual
colonoscopy). Some may elect yearly guaiac-based fecal occult blood test (gFOBT),
yearly fecal immunochemical test (FIT), or stool DNA test (sDNA), every 3 years.

Prostate. Starting at age-50, men should talk to a doctor about the pros and cons
of testing for PSA; this conversation should be held with a doctor starting at age-45
for African Americans or for patients who have a father or brother who had prostate
cancer before age-65.

Breast. Starting at age-40 and continuing for as long as a woman is in good health,
annual mammograms are recommended; clinical breast exam (CBE) is warranted
about every 3 years for women in their 20s and 30s and every year for women 40
and over, and breast self-exam (BSE) is an option for women starting in their 20s
(reporting any change promptly to their health care providers). Some women –
because of their family history, a genetic tendency, or certain other factors – should
be screened with MRI in addition to mammograms. (The number of women who fall
into this category is small: less than 2% of all the women in the US.)

Cervical. Starting at age-21 (regardless of whether she has been vaccinated
against HPV), the following schedule should be followed; some women–because of
their health history (e.g., HIV infection, organ transplant, DES exposure)–may need
modification. Women between ages 21 and 29 should have a Pap test every 3 years;
HPV testing should not be used in this age group unless it is needed after an
abnormal Pap test result. Women between the ages of 30 and 65 should have a Pap
test plus an HPV test (called “co-testing”) every 5 years; if this is not possible, they
should have a Pap test alone every 3 years. Women over age 65 who have had
regular cervical cancer testing with normal results should not be tested for cervical
cancer; once testing has been stopped, it should not be restarted. Women with a
history of a serious cervical pre-cancer should continue to be tested for at least 20
years after that diagnosis, even if testing continues past age 65.

Endometrial (Uterine). At the time of menopause, women should be told about
the risks and symptoms of endometrial cancer and encouraged to report any
unexpected bleeding or spotting to their doctors; some–because of their history–
may need to consider having a yearly endometrial biopsy.
5% to 7% of all lung cancers are attributable to asbestos; asbestos and tobacco
smoking act in synergy to induce lung cancer. Asbestos is considered one of the
major causes of malignant mesothelioma.

Cancer Control Journal 4(2) March/April 1997
Cancer Prevention: The Roles of Diet and Chemoprevention
By Peter Greenwald, MD, DrPH, and Sharon S. McDonald, MS
“Considerable evidence links dietary factors with cancer risk, but ongoing
investigation is needed.”

Background: Reduction of cancer risk by either preventing
carcinogenesis or stopping carcinogenesis in its early stages is a
logical approach for reducing the cancer burden, both for high-risk
individuals and for the general population. The areas of dietary
modification and chemoprevention show considerable promise as
effective approaches for cancer prevention and are a focus of research

Results: Diet and cancer studies show that, generally, vegetables and
fruits, dietary fiber, and certain nutrients seem to be protective against
cancer, whereas fat, excessive calories, and alcohol seem to increase
cancer risk. Chemoprevention research is closely linked to diet and
cancer research and represents a logical research progression.

Conclusions: Dietary epidemiologic studies have helped to identify
many naturally occurring chemopreventive agents. Currently,
randomized clinical prevention trials sponsored by the NCI include
dietary interventions (e.g., low-fat and/or high-fiber vegetables and
fruits) targeting breast and colorectal cancer, chemoprevention trials
using micronutrients (e.g., vitamin E, calcium, vitamin D) aimed at lung
and colorectal cancer, and chemoprevention trials testing the
effectiveness of pharmaceutical agents (e.g., tamoxofen, finasteride,
aspirin) for breast, prostate, and colorectal cancer.

'Bad luck' is leading cause of cancer
Scientists: Random gene mutations primary cause of most cancer


To the Editor [of the Mayo Clinic Proceedings]:

Regarding the pair of smoking-cessation pieces, neither the article [1] nor the accompanying
editorial [2] addressed the utility of electronic cigarettes, thereby invalidating all conclusions
therein…except for emphasizing the generic importance of translational research.

Specifically, the methodology employed in the article and the analysis thereof in the
editorial eschewed any citation of “vapes,” which have quickly justified having earned a
solid position in the anti-tobacco armamentarium; consider one conservatively-phrased
commentary [3], “E-cigarettes, with or without nicotine, were modestly effective at helping
smokers to quit, with similar achievement of abstinence as with nicotine patches, and few
adverse events. Uncertainty exists about the place of e-cigarettes in tobacco control, and
more research is urgently needed to clearly establish their overall benefits and harms at
both individual and population levels.”

Indubitably, use of e-cigs reduces the risk of serious illness caused by inhalation of tobacco
smoke; indeed, the only quasi-justifiable concern is whether they could serve as gateways
for adolescents and others to become smokers. Thus, a justifiable area of study could be
whether—just as pharmacologic and counseling initiatives can yield multiplicatively
beneficial effects—the combination of using e-cigs with other approaches could yield
outcomes superior to all other reported interventions.

A compilation of literally hundreds of articles detailing the rationale for e-cigs serving to
reduce tobacco-induced harm has been generated for years by my coauthor, Mr. Bill
Godshall, Executive Director of Smokefree Pennsylvania [4].

Another component of this challenge is reflected in the fact that only 4.8 % of patients
received the most effective therapy in the Kotz study; noting the capacity of “markets” to
allow consumers to choose what is most desired (in England, regardless of whether the
government sponsors specialized clinics), analysis of further interventions could easily
conclude that patients could successfully “kick the habit” by choosing to follow a self-
motivated pursuit of e-cigs, a novel modality that—absent governmental interference—could
continue to burgeon in popularity.

Regardless of what intervention is chosen, Hays properly advocated that it be conducted
under the aegis of a support system (physician, physician-extender and/or clinic); this is how
plans can be effectively reformulated. For example, improper use often leads to
ineffectiveness of nicotine gum; when smokers keep chewing after the addiction-urge has
passed, they may experience nausea and/or headaches from nicotine-overdose (as this
neurotransmitter continues to be released from the resin). Similarly, the efficacy of nicotine
patches may be dose-related.

Some may perceive the E-cig omission merely as a benign procedural oversight; yet, E-cig
advocates often encounter ill-advised, real-world political implications of such unjustified
glitches. For example, despite our well-documented and unrefuted testimonies [5],
Philadelphia passed two ordinances that essentially equate using vapes with tobacco
smoking. Consider the stridency of a conclusion drawn from another smoking-cessation
study [6]:

“Unsubstantiated overt and implied claims that alternative tobacco products [such as e-
cigarettes+ aid smoking cessation should be prohibited.” Such crass attempts to suppress
colloquy are antithetical to the tenets of the scientific discourse; condemnation thereof
corroborates the recommendation—shared with the authors of both of these Mayo pieces—
that further, intelligent, “efficacious” research be aggressively pursued…wherever it may

Robert B. Sklaroff, M.D., Department of Internal Medicine, Nazareth Hospital, Philadelphia
William T. Godshall, MPH, Smokefree Pennsylvania, Executive Director, Pittsburgh,

FDA shouldn't ban e-cigarettes
By Robert Sklaroff, Bill Godshall, & Stephen Gambescia

January 11, 2017

Surprisingly, the FDA's finalized regulations that will ban the sale of all currently marketed
vapor products on August 8, 2018 will actually threaten the lives of millions of vapers and
tens of millions of smokers. Electronic cigarettes could be the best harm reduction strategy
we've seen in quitting tobacco use since--well cold turkey.

Government regulators understandably are worried about flavorings in e-cigarettes, but the
"flavorings" are ubiquitous in many of our consumable products. They cite animal
experiments that claim nicotine can alter development of the cerebral cortex and the
hippocampus in adolescents. There are no human studies supporting either assertion,
however, and the basic science literature does not corroborate worriment about nicotine
(available over-the-counter, in patches and in gum).

That's why we recoil when commentators incessantly claim that more studies are needed
before vaping e-cigarettes could be deemed safe. Enough is known about health risks with
nicotine to issue reasonable and responsible warnings. Vaping is a far less harmful
alternative to smoking tobacco because, unlike cigarettes, they do not rely on combustion,
which leads to inhalation of deadly gaseous and particulate carcinogens.

Cessation programs have not achieved sustained remissions; thus, much effort is placed on
harm reduction and vaping is uniquely designed to achieve harm reduction. Because
smoking is physically and psychologically addictive, vaping satisfies both needs by mirroring
the ritual of handling a nicotine-delivery device. All this but with negligible harm.

Heavy handed regulation of electronic cigarettes-- as if it is a wolf in sheep's clothing-- is not
justified by biomedical and behavior sciences. Recent reports related to the energy source
may need further review.

Rather than becoming banned or excessively regulated by government, vaping should be
recognized as a public health measure that helps smokers quit and reduce smoking.



Robert Sklaroff, M.D., medical oncologist; Bill Godshall, M.P.H., executive director of
Smokefree Pennsylvania; and Stephen F. Gambescia, Ph.D., professor at Drexel University
have been active tobacco control advocates at the local, state, and national levels for 35
years. Dr. Sklaroff was the Branch Director of the Lower Northeast Philadelphia Branch of
the American Cancer Society, Mr. Godshall was Director of Professional and Public Education
for the Western Pennsylvania Region of the American Cancer Society, and Dr. Gambescia
was Vice-President of the Southeastern Pennsylvania Affiliate of the American Heart
Association; all served as officers of the Coalition for a Tobacco-Free Pennsylvania.

Vaping is an Effective Tobacco-Risk Reduction Methodology

By Robert Sklaroff, Bill Godshall, & Stephen Gambescia

The Surgeon General recently joined tobacco control groups to condemn vaping, claiming
this was another attack on public enemy number one.

This time, however, public health advocates need to assess and reject the “mission creep”
by these federal and nonprofit agencies.

And, as the new Administration pledges to slash many harmful regulations, it should include
FDA’s recent vapor product regulation, which was touted as another important measure to
protect children from Big Tobacco and nicotine.

Over the years, clinicians, behavioral scientists, and researchers have offered a sundry of
ways to help addicted smokers to cut down on or, ideally, to quit smoking. Other than price
hikes and indoor smoking bans, those approaches have had humbling success.

While not an elixir, a smoking reduction and abatement kit has come along, in the form of
vaping, that satisfies the addiction by delivering nicotine, but sharply reduces the harm
caused by inhaling cigarette smoke dozens or hundreds of times every day.

Because smoking is physically and psychologically addictive, some researchers think e-
cigarettes satisfy both needs by mirroring the ritual of handling a nicotine-delivery device.
Studies have found vaping to be more effective than other cessation techniques — drugs,
counseling, psychotherapy, hypnosis, etc. — because of their capacity to yield sustained

Since 2010, adult cigarette smoking has declined by 25%, while youth smoking has
plummeted by 50%, due in part to vaping. But 30 million hard-core adult-smokers remain
addicted to cigarettes, which cause 99% of all tobacco morbidity, disability, mortality and
healthcare costs.

The 2015 National Health Information Survey found that 2.5 million adult vapers had quit
smoking, and 5 million vapers were still smoking. In addition to helping many smokers quit,
vaping has also emerged as the best strategy for sharply reducing cigarette consumption by
smokers who continue to smoke.

Concomitantly, the risk associated with vaping e-cigs is negligible, save for a few reports of
battery fires, largely due to consumer ignorance or negligence that can be reduced by
better consumer education and repeal of FDA’s regulation that has banned sales of all new
safer vapor products in the US since August.

Since cigarette smoking causes virtually all tobacco diseases and deaths, it was counter
intuitive that health groups lobbied Obama’s FDA to extend cigarette regulations to vapor
products, which bans their sales to adults in the US since they weren't on the market in
2007. Vaping advocates rightly suspect that these nonprofits have exhibited “mission
creep” as they abandoned their public health goals by lobbying to ban vaping and vapor
products, which protects deadly cigarettes and smoking cessation drugs (whose
manufacturers funded the health groups) from future market competition.

As a result, this double-edged empowerment sword emboldened the FDA to issue Deeming
Regulations that will ban the sale of virtually if not all vapor products to US adults on August
8, 2018, unless overturned by the Courts, repealed by Congress, and/or rescinded by the
new Administration.

Even the Surgeon General’s report acknowledged “among adults, e-cigarettes are
considered a far less harmful alternative because, unlike traditional cigarettes, they do not
rely on combustion, which leads to inhalation of deadly carcinogenic particles, and 480,000
deaths each year.”

In explaining the “potential harm” of vaping, government entities note the flavorings and
cite animal experiments that claim nicotine can alter development of the cerebral cortex
and the hippocampus in adolescents.

But there are no human studies supporting either assertion.

Flavorings vary widely among e-cigs and are ubiquitous in retail products, and the basic
science literature does not corroborate worriment about nicotine, which is available over-
the-counter (as are gum, patch and lozenges) and by-prescription (as nasal-sprays and

Seemingly forgotten in the war on vaping and tobacco is the fact that nicotine is recognized
by the human body as a neurotransmitter, for the two main cholinergic receptors are
nicotinic and muscarinic; these nerves are firing — constantly, automatically, physiologically
— regardless of how much nicotine is absorbed from the environment.

Simply put, vaping delivers neither cancer-causing tar nor artery-clogging carbon-monoxide.
Instead, they create water-vapor with a little bit of flavoring that can be controlled no
differently than other consumable product in this country.

Furthermore, the Surgeon General found no proof that e-cigs serve as a gateway to smoking
cigarettes, a view that corroborates government statistics finding teens have largely
replaced cigarette smoking with vaping — no public health harm there.

Even better, the 2016 NIDA funded Monitoring the Future youth drug survey found “Across
the board declines in past 30-day use of cigarettes, e-cigarettes & other tobacco products
by young people,” including a 29% decline since 2014 in “past 30 day” e-cig use among 8th,
10th and 12th graders.
We should be reminded that public health measures remain well-grounded in the biomedical
and behavioral sciences, with cigarette smoking remaining “Public Enemy Number One,” the
major cause of preventable disease, disability and death in America.

Rather than pursue reflex-action to demonize, ban, regulate and/or tax, vaping should be
recognized as a disease prevention public health intervention.

There are many serious health problems the FDA and Surgeon General can guard Americans
against. Lifesaving vapor products are not one of them.

Robert Sklaroff, M.D., medical oncologist; Bill Godshall, M.P.H., executive director of
Smokefree Pennsylvania; and Stephen F. Gambescia, Ph.D., professor at Drexel University
have been active tobacco control advocates at the local, state, and national levels for 35

{Accepted for publication by The American Thinker.}

Three E-Cig Ads Banned for ‘Glamourising tobacco’

Three adverts for e-cigs have been banned from British TV by the Advertising Standards
Agency (ASA) on the grounds that they glamourise tobacco, despite not being a tobacco
product. The ruling came just over a month after the first ‘vaping’ advert was aired.

Two of the adverts, both made by VIP electronic cigarettes, drew over 200 complaints.
Neither show regular tobacco cigarettes being smoked. Nonetheless, the Agency ruled
that the adverts indirectly glamourized smoking and were therefore unsuitable for
British television under existing rules, City AM has reported.

Before the original vaping advert was aired, The Committee of Advertising Practice drew
up a list of six requirements that it and any other vaping adverts would need to meet.
They stipulated that the adverts must be “socially responsible” and not “feature
characters that are likely to resonate with youth culture or appeal to under 18s”; they
must not include “the use of a tobacco product”; must not “contain health or medicinal
claims”; and that they must not “claim or imply that the product can act as a smoking
cessation device,” nor “undermine the message that quitting tobacco use is the best
option for health.”

In addition, the Committee also advised that adverts must state that the products
contain nicotine, if applicable, and could not make claims that e-cigarettes can be used

A spokesman for the ASA said: “We considered that the manner in which the vapour
was exhaled and the heightened focus on this action created a strong association with
traditional tobacco smoking.

“Because the ads presented it, as the central focus of the ads, in a sultry and glamorous
way, we considered that they indirectly promoted the use of tobacco products.”

A third advert, made by VIP electronic cigarettes was also banned after attracting seven
complaints, on the grounds that it promoted e-cigarettes as an alternative to smoking
regular tobacco products. “We considered that the man’s statement could encourage
non-smokers to take up using e-cigarettes and we therefore concluded the ad was
irresponsible”, the ASA said.

But campaigners have pointed out that part of the appeal of e-cigarettes is that they
offer a tobacco free alternative to smokers who want to quit. They accused the ASA of
overstepping their remit in order to affect the behaviour of the public.

Simon Clark, director of the smokers’ group Forest, told Breitbart London: “The rules
on e-cigarette advertising were relaxed to encourage their use by existing smokers.

“The great appeal of e-cigs to many smokers is the fact that they replicate the act of
smoking. To encourage smokers to switch advertisers must be allowed to show people
exhaling vapour. Failure to do so will greatly reduce their effectiveness.

“The ASA has no right to ban an advertisement on the spurious grounds that, indirectly,
this may encourage people to smoke tobacco. Where’s the evidence this is happening?
There isn’t any.

“Not for the first time an unelected, out of touch quango has sided with public health
zealots whose primary interest is controlling our behaviour and restricting our freedom
to choose between a range of legal consumer products.

“I hope the e-cigarette companies appeal this ridiculous decision and win.”

Adult Smoking Habits in Great Britain, 2013

The proportion of the GB adult population who smoke cigarettes has fallen by more than
a half in the last 40 years, from 46% in 1974 to 19% in 2013. Not only have fewer people
taken up smoking, but more of those who did smoke have quit

Women accounted for the fall on the previous year - the proportion of women who
smoke cigarettes fell from 19% to 17% between 2012 and 2013. There was relatively little
change in this proportion for men

Unmarried people were almost twice as likely to be cigarette smokers as married people

The proportion who smoke cigarettes was higher amongst unemployed people, people
working in routine and manual occupations and those with lower level educational
qualifications. These are all factors associated with poverty

E-cigarettes are almost exclusively used by smokers and ex-smokers.
Almost none of those who had never smoked cigarettes were e-cigarette