Date December 11, 2023

Up in Smoke

The debate over vapes, nicotine pouches and the quest to reduce the global scourge of tobacco-related diseases and fatalities.

The Brown University School of Public Health has built an international reputation for producing impactful research on nicotine addiction and smoking cessation. Work pioneered at Brown by the Center of Alcohol and Addiction Studies starting in the 1980s advocated for a change in the nation’s attitude toward alcohol and tobacco dependence. Those efforts have expanded and flourished since the establishment of the School of Public Health a decade ago: Brown now boasts dozens of faculty members working to help people quit smoking. Among the leading scholars in this domain, Dr. Jasjit S. Ahluwalia and Dr. Jennifer Tidey, stand out as pioneering scholars and advocates for tobacco harm reduction.

With a portfolio of over 400 published manuscripts, Ahluwalia, professor of behavioral and social sciences and of medicine at Brown, ranks as the fourth-most prolific author worldwide in the field of smoking cessation. Tidey, the school’s associate dean for research and professor of behavioral and social sciences and of psychiatry and human behavior, is a national authority in tobacco regulatory science, working to provide the FDA with the information it needs to make evidence-driven and public health-centered policies for tobacco products.

Thanks in part to their decades of research and leadership, important progress has been made in curbing the prevalence of tobacco smoking. Indeed, cigarette consumption has been declining in the United States for approximately 60 years when the U.S. Surgeon General officially declared smoking a health hazard in 1964. And yet, despite great progress and the best efforts of public health practitioners, some key measures remain stubbornly unchanged.

The Unremitting Toll

Vector image of lungsCigarettes are as dangerous as ever. A single burning cigarette releases a staggering 7000 chemicals, some of which can be found in items like rubber cement, gasoline, nail polish remover, battery acid, hair dye, mothballs and insecticide. Others are key components in embalming fluid, rat poison, and rocket fuel. Among these chemicals, a minimum of 69 are recognized as cancer-causing agents by the American Lung Association. 

The result is roughly 480,000 deaths in the United States annually, with a global toll of approximating 8 million, according to the World Health Organization.

Dr. Ahluwalia finds this situation untenable, especially as the death toll has remained stubbornly consistent in the 30 years he’s been teaching, researching and writing about nicotine addiction and smoking cessation.

“Since 1992, my classes at Emory and now at Brown have emphasized that, despite a decline in prevalence, the annual toll of 480,000 American deaths due to tobacco-related causes remains unchanged after 30 years,” he said. “This unsettling stagnation, even amid a growing population, underscores the gravity of the issue. We have to care about the number of deaths, and it’s really unacceptably high. It remains the leading preventable cause of death in the United States, and soon to be the world.”

Harm Reduction Tools

One essential area of interest shared by Tidey, Ahluwalia, and investigators across the School of Public Health, is harm reduction—a set of tools aimed at minimizing the dangers of smoking, rather than focusing on prohibition.

As an advocate for evidence-based strategies to reduce smoking-related illnesses and fatalities, Dr. Ahluwalia sees a parallel to opioid overdose prevention. “There was some push and pull with opioid harm reduction strategies,” he said. “Methadone maintenance, safe needle exchange, and safe injection zones have gone through their own tough situations in Congress, state legislatures, the courts, and with the American public. But they are coming out on top because there’s some really profound evidence for the prevention of overdose, hepatitis, HIV, mental illness, and death.”

Vector image of a vapeFor people who smoke, cessation tools include nicotine gum, lozenges and patches, which have been available for decades. Users of smokeless tobacco products like Snus have a lower cancer and heart disease risk. Ahluwalia considers nicotine pouches, such as On! and Zyn, even safer. “These are essentially pure nicotine,” he said. “You put them in your mouth and after 20 to 30 minutes, you throw them away. Relatively speaking, they are very safe.”

The promise of these products to reduce tobacco exposure is hampered, however, by misunderstanding. “There’s so much confusion about these harm-reduction products, even among scientists,” Professor Tidey said. “But we know that combusted products like cigarettes and cigars are far more dangerous than e-cigarettes and nicotine pouches—things that don’t burn. What people don’t really understand is that it’s not the nicotine, it’s the chemicals from burning, the combustion of tobacco, that are deadly and cause cancer.”

Dr. Ahluwalia believes eradicating tobacco, not nicotine, should be our goal. Nicotine replacement products like pouches and vapes reduce the risk of disease and mortality and, he says, should be regulated and be widely available to adults.

Because vapes mimic the smoking experience, they can be effective step-down tools from smoking. Both Tidey and Ahluwalia stress that vapes are not safe, but that they are significantly safer than cigarettes. “Compared to the 7000 chemicals in a cigarette,” Ahluwalia said, “e-liquids used in vapes generally consist of about five core ingredients: propylene glycol, vegetable glycerin, nicotine, water and flavoring.” 

Potential health problems associated with vaping occur after the e-liquid is heated, which leads to degradation and may be harmful. “And yet, even with this, they are still safer than cigarettes,” Ahluwalia said.

What people don’t really understand is that it’s not the nicotine, it’s the chemicals from burning, the combustion of tobacco, that are deadly and cause cancer.

Professor Jennifer Tidey
Woman smiling

A Gateway to Tobacco

But aren’t vapes a gateway to tobacco smoking? “Initially, there was a very real concern that vaping could be a gateway to cigarettes,” Ahluwalia said. “I was concerned about it. But it didn’t turn out to be true. The prevalence of cigarette smoking in young adults, especially in adolescence, is the lowest it’s been in recorded history, currently standing at around 3%, down from the previously recorded 5%. So the gateway never happened.”

Tidey agrees that the expected rise in smoking after the advent of e-cigarettes hasn't materialized. “There could be various factors at play here,” she said. “It’s possible that smoking simply isn’t as appealing among young people anymore, or perhaps the public health messaging about the dangers of smoking has been effective. But I see no substantial evidence to suggest a clear gateway effect between vaping and cigarette smoking.”

Vector image of pouchAhluwalia suggests that vaping is a gateway to its own consumption. Those who initiate vaping continue to do so due to its own appeal and addictive nature. In other words, people who vape aren’t putting them down and taking up cigarettes; it’s typically the other way around.

With regards to disposable vapes, there are substantial environmental drawbacks, along with youth strongly preferring these products. They contribute to plastic waste and their lithium batteries are environmentally toxic. Reusable vapes that use cartridges are somewhat more sustainable, Ahluwalia suggests, but still more needs to be done to improve these products. For example, JUUL has developed JUUL2, which is available in the United Kingdom, and has the capability to prevent illicit pods from working with their device, and has a novel age verification platform. “But despite the 35 million smokers in the U.S., the landscape of smoking cessation tools has seen little substantial innovation for nearly twenty years,” he said.

The FDA addressed the issue of tobacco and nicotine regulation in its 2017 strategy statement with a two-pronged approach. First, the agency aims to make cigarettes less addictive by reducing nicotine levels. Tidey and others at Brown have conducted a substantial number of clinical trials that provide the evidence base for this approach. Second, the FDA recognizes the need for more innovation in medicinal nicotine products like patches, gum and lozenges. 

“Medicinal nicotine products are out there but people don’t use them,” Tidey said. “They don’t like them. Maybe they get motivated and use them for a week, but then they stop. So what can we do to enhance the use of these therapeutic forms of nicotine, which, it should be said, are FDA-approved for smoking cessation? Research should be conducted to make them more attractive.”

Initially, there was a very real concern that vaping could be a gateway to cigarettes. I was concerned about it. But it didn’t turn out to be true. The prevalence of cigarette smoking in young adults, especially in adolescence, is the lowest it’s been in recorded history.

Professor Jasjit Ahluwalia
Man smiling

Ahluwalia expresses frustration that instead of new innovations in smoking cessation, we’re seeing a push to prohibit the tools we do have—not just flavors but nicotine replacement devices themselves—by well-meaning organizations like the Campaign for Tobacco-Free Kids and the Truth Initiative. He advocates against bans, as they tend to lead to black markets that introduce dangerous products to the public. Instead of bans, he emphasizes implementing evidence-based regulations that prioritize safety and public health.

“Everyone hates the tobacco industry,” he said. “But because we hate the tobacco industry so much, we’re conflating harm-reduction products with tobacco, and we are forgetting about the most important person - the person who smokes cigarettes”

“What is needed is a more nuanced message about relative risks,” Tidey said. “If you’re a non-smoker, don’t start vaping. But if you already smoke and can’t quit, move to a less harmful product. It’s a more nuanced message and harder to relay. You don’t want kids to think vaping is safe; at the same time, adults who smoke have internalized the negative messaging about vapes and are now reluctant to try harm-reduction products.”

Dr. Ahluwalia underlines the importance of allowing scientific evidence to shape our approach to addressing smoking-related issues. “Do we stand on a self-proclaimed moral high ground and undermine the tools that can help,” he asked, “or do we genuinely commit to saving and enhancing lives? We practice harm reduction with methadone, seatbelts, helmets, speed limits, condoms, alcohol - why should tobacco be any different?”