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Despite FDA Approval, E-cigarettes Need To Remain Banned in India [Responses]

Despite FDA Approval, E-cigarettes Need To Remain Banned in India [Responses]

Photo: skjev5280/Unsplash

  • Whether in cigarettes or e-cigarettes, nicotine is toxic – it is an addictive stimulant that, with long-term use, results in elevated BP and higher risk of heart attacks.
  • Vaping has the potential to introduce a large number of young individuals to a life-long nicotine habit, putting them on a highway to future tobacco abuse.
  • Tobacco cessation is of utmost public health importance, but vaping is not the way to achieve it, writes Dr Narayana Subramaniam, a surgical oncologist.
  • The Association of Vapers India issued a statement in response to the article; it is appended below the article, followed by the article’s author’s response.

The US Food and Drug Administration recently approved the marketing of e-cigarettes, reigniting a debate around the world, including in India, on whether the ban on e-cigarettes and vaping is justified.

Multiple groups in India have hailed this approval as an acceptance of the notion that vaping is a suitable alternative to smoking and in the best interest of public health. Those in favour of vaping have argued that it is a good tobacco alternative that will help people quit smoking. Those still opposed to the idea have contended that it is more dangerous than other tobacco alternatives, and warrants wariness for its appeal to adolescents and young adults, for whom it can become an addiction gateway.

To be sure, India needs to continue to ban e-cigarettes and their derivatives. Let’s take a considered look at why.

How vaping works

A ‘vape’ is a device that heats nicotine, flavouring substances and any other compounds to form an aerosol, which is inhaled through the mouth and exhaled via the mouth or nose. As such, the vape facilitates the delivery of these products to the lungs, and from there absorption into the bloodstream.

Vapes differ from cigarettes in their contents: they don’t contain tobacco, tar or other substances that are known to cause cancer. They do, however, contain other new components, like aldehydes, heavy metals and silicates which are toxic to humans, and are likely to cause lung damage in the long term.

Vapes, or e-cigarettes more broadly, have been traditionally marketed as an alternative to smoking – that they will help smokers address their nicotine craving while quitting tobacco. So e-cigarettes belong to the ‘harm reduction approach’ to tobacco cessation, which advocates alternate sources of nicotine delivery, such as gum or vaping.

Now, vaping is by no means safe. Although they are safer than cigarettes, because they exclude tobacco and other well-established carcinogens, nicotine is in itself toxic. It is a highly addictive stimulant that causes craving and withdrawal, with long-term use resulting in elevated blood pressure, higher risk of heart attacks and critical blood-vessel-narrowing in the limbs.

Other experts have also argued that vaping is a more efficient form of nicotine delivery – reducing the harsh sensation in the throat and mouth associated with smoking, thus resulting in more nicotine consumption.

Another major concern is the acute lung injury associated with e-cigarette use. Over a period of around eight months, starting in mid-2019, officials reported more than 2,800 cases of vaping-associated lung-injury in the US that were severe enough to cause hospitalisation or death. Although the exact cause was unknown, research by experts at the Centres for Disease Control and Prevention found strong links to a particular constituent of vaping fluid – vitamin E acetate – and possible contaminants, particularly in the bodies of those who were vaping marijuana products.

The conversation around legalising vaping has tended to revolve around its potential to help people stop smoking – but there are increasing concerns that vaping is attracting younger users, particularly those who have had no prior tobacco exposure.

The data is strongest from the US. The 2020 National Youth Tobacco Survey showed that almost a fifth of high-schoolers used e-cigarettes, with nearly 40% of them admitting use for more than 20 days in a month.

This exponential increase in e-cigarette use by the youth, which the US surgeon general called an “epidemic” in 2018, was likely fueled by marketing campaigns targeting younger consumers, manufacturers availing flavours like mint, menthol and chocolate, and – overall – ignorance. A Truth Initiative study in July 2021 found that two-thirds of e-cigarette users aged 15-21 years were unaware that the product contained nicotine.

Dual use is another major health concern – in which individuals use tobacco products like cigarettes along with e-cigarettes. Although the companies that manufacture e-cigarettes argue that the latter will help cease tobacco use, a NASEM report in 2018 found that among those aged 18-35 years, e-cigarette use was associated with more intensive cigarette use, and that those using e-cigarettes the previous year increased their odds of daily cigarette use by 67% and a diagnosis of tobacco addiction by 158%.

The tobacco cessation argument is undermined by manufacturers’ profits being tied to continued use of the product – not reduced use. So it shouldn’t be hard to understand why the largest e-cigarette companies in the world are subsidiaries of the largest tobacco companies. Vaping has the potential to introduce a large number of young individuals to a life-long nicotine habit, putting them on a highway to future tobacco abuse.

Does vaping help stop smoking?

The answer to this question is still controversial. The World Health Organisation does not consider the use of e-cigarettes as a viable method to quit smoking, as there is inadequate evidence. A recent clinical trial involving nearly 900 people found that e-cigarette users were able to quit tobacco at nearly twice the rate of other nicotine replacement therapies (including nicotine patches and gum) after one year (18% v. 9.9%).

However, other research has shown that e-cigarette use improves smoking cessation only in highly-dependent smokers – suggesting that an individual’s degree of nicotine dependence affects this.

Paradoxically, novice users of tobacco, especially on the younger side, may end up with a heavier smoking habit when using e-cigarettes as a cessation tool.

It is notable that the proponents of vaping are the ones contending that vaping is a smoking cessation tool – and not the manufacturers themselves. The office of the Drug Controller General of India has said that it hasn’t received any applications in this regard.

For the vast majority of the population, the benefits of vaping do not outweigh the risks. On the pretext of being an alternative to smoking, e-cigarette use has increased exponentially in those younger than 25 years of age, likely due to deliberate and concerted marketing efforts by manufacturers.

Although vaping is free of tobacco, to suggest it is safe is misleading and untrue. Vaping is hardly a decade and a half old, so it is likely that the chronic respiratory diseases associated with vaping are yet to be fully appreciated. It may be less harmful than cigarettes, but is much more likely to be harmful than other nicotine replacement therapies. And the real-world consequences of this trade-off are almost impossible to determine at a population-level, and will need to be decided on an individual basis.

In places where it is legal and has been approved, vaping is more likely to work among younger adults who are heavily nicotine-dependent and among heavy smokers, and should not be used with anyone else. This nuance is probably also the reason for significant differences in public health policy on this matter, around the world.

A 2019 Public Health England report stated that e-cigarettes were 95% less harmful than smoking, while acknowledging the concomitant risk of youth initiation. A European Respiratory Society report in the same year said the risks of using e-cigarette remain largely unknown, and that that meant neither experts nor policymakers could claim it could be safer than conventional cigarettes (both after long-term use).

India banned the use and sale of e-cigarettes roughly a year ago, citing concerns of a potential smoking epidemic in the younger population. This was a prudent decision in the context of the incidence and pattern of tobacco use in India. India’s tobacco cessation policies have shown success among the youth: the estimated reduction in tobacco use among school children (13-15 years) was above 40% in the last decade.

Additionally, smokeless tobacco – in the form of paan, khaini, gutkha, zardha, etc. – is the pre-eminent form of use in the Indian subcontinent. We don’t know how e-cigarettes will impact this group of consumers. Note, however, that only 4.4% of the 13,000+ Indian adults aged 15-24 years in the 2016 Global Adult Tobacco Survey had heard of e-cigarettes. It is difficult to imagine, then, as to how they might consider e-cigarettes to be an effective cessation tool.

Tobacco cessation is of utmost public health importance, but vaping is not the way to achieve it. There is insufficient data on their long-term effects and on tobacco abstinence – even as a growing body of data and research is showing  that e-cigarettes are statistically more likely to become an avenue for millions of adolescents to develop nicotine addiction, at an unprecedented rate, than to be a way to kick the habit.

As a result, legalising vaping and e-cigarettes will undo decades of efforts to control tobacco use, especially in the younger demographic. We need to better understand the longer term effects of vaping, identify who exactly it will benefit and over which other smoking cessation therapies, and how we can prevent it from compounding our existing tobacco-related public health crisis. After that, and if our hypotheses of today are borne out, we need to formulate a good and properly enforceable policy. Until then, e-cigarettes, vapes, etc. should remain banned.

Dr Narayana Subramaniam is a head and neck surgical oncologist at Sri Shankara Cancer Hospital and Research Centre, Bengaluru.

AVI responds

After the publication of Dr Narayana Subramaniam’s article, The Wire Science received a statement from the Association of Vapers India (AVI). The substantive portions of the statement are reproduced below (the full text is too long). It is followed by the author’s response to it.

1. Vaping is not safe, contains toxic elements

Let perfect not be the enemy of good. Even as no one claims vaping to be 100% safe, it is significantly (~95%) less harmful than smoking, which it substitutes. High mortality and morbidity from smoking means this can be the difference between longer life and near-certain death for millions of Indian smokers.

The concept of harm reduction to treat addiction behaviours is well-established in illicit drugs control, where after decades of a failed coercive war to eliminate drug use, the focus has expanded to reducing harms from it. We fail to understand the logic for repeating the same mistakes and not applying these risk-reduction approaches to tobacco control which involves a lot more lives.

We welcome more research into vaping e-liquids to ascertain possible harms and to guide policymaking, and also support the framing of standards (which, incidentally, don’t currently exist for Indian smokeless tobacco, the most used tobacco products in our country). It should however be noted that the mere presence of elements is not an indicator of harm, as everyday goods, including medicines, also contain many toxic compounds but under the prescribed threshold.

A study found toxic exposure from vaping is comparable to environmental air, and poses significantly lower passive risk – second-hand smoking kills 800,000 people every year. A 3.5-year study published in Nature found daily e-cigarette users who had not smoked before showed no vital changes compared to non-smokers. It should also be noted vaping technology is improving rapidly and is expected to become safer in future, preventing and even reversing harm from smoking.

2. Nicotine is itself toxic

It is astounding how many people, including medical professionals, are ill-informed about nicotine despite its global impact. Repeated studies, including in India, have found majority of physicians mistakenly believe nicotine leads to cancer and heart and respiratory diseases. To be clear, nicotine, though habit forming, is not a carcinogen. There is an urgent need to decouple nicotine from smoking, as both pose significantly different levels of risk. Nicotine is also part of pharmaceutical cessation therapies such as gums, patches and sprays, which the WHO wants included in the list of essential medicines and has also approved of their long-term use.

Therefore, instead of misdirecting the ire against nicotine, the focus should be on mitigating harms from its use, and more specifically on the delivery mechanisms – smoking being at the highest end of the harm spectrum and NRTs on the lowest, and vaping, nicotine pouches and snus towards the lower end – with policymaking encouraging moving current users down the harm continuum by allowing them to choose from a bouquet of options that suit their individual needs.

Use of recreational nicotine is not a crime anywhere in the world and is not likely to be anytime soon. It is therefore imperative that there be available the least harmful ways of consuming it. Banning safer alternatives perpetuates harmful nicotine use, ensuring we reach the dubious milestone of 1 billion projected tobacco deaths this century.

3. Acute lung injury associated with e-cigarette use is a major concern

According to the US Centres for Disease Control (CDC), 82% of those hospitalised reported using cannabis products, while the US FDA put out a specific statement warning against the use of THC-containing products. The cause identified by CDC, Vitamin E acetate, is a thinning agent used to make cannabis e-liquids vapable. Therefore, to cite cannabis products as a reason to ban nicotine vaping is a dishonest misdirection, and in India, use of marijuana is already prohibited, while no one has called for banning of combustible cigarettes because they are also used in smoking weed.

It is also worth noting that these were illegal, black-market products and not the legal toxicology profiled ones as cannabis legalisation is not uniform across the US, which further highlights the need for regulation and standards. Additionally, this false panic has set back smoking cessation efforts globally, with the US itself witnessing a rise in cigarette sales for the first time in 20 years. Discouraging smokers from proactively reducing risk is not good public health policy, nor is a ban.

4. Exponential increase in e-cigarette use by the youth in the US

This is a wildly incorrect and misleading statement. While 40% is a striking figure, it is a percentage of a low total and most were former smokers. As pointed out in a recent paper signed by 15 past presidents of the influential SRNT:

E-cigarette‒driven increase in nicotine product use among high-school students is not associated with an increase in population-level dependence.89 Among tobacco-naïve youths, in addition to low vaping prevalence (9.1% in the past 30 days in 2020) and frequency (2.3% vaping ≥ 20 days in the past 30 days),91 small percentages exhibited signs of nicotine dependence.90

This is hardly an epidemic-level ‘exponential rise’ to justify banning vaping in India. Further, teen vaping has been continually declining in the US, including a major drop in 2020 and again this year, totalling to a whopping 60% decrease in two years, which indicates a fad than an epidemic. Teen use is an important concern but needs to be placed in context, as cited in a recent letter written by 100 experts, including from India, to the FCTC COP9 delegates:

Policymakers are rightly concerned about increases in youth ENDS use, notably in the United States. However, a deeper analysis of the US evidence, segmenting data by frequency of use and prior tobacco use, is revealing and reassuring. It shows that: (1) most adolescent vaping is infrequent, (2) that frequent use and nicotine dependence among tobacco-naïve users is rare, and (3) most frequent use is concentrated in those who have previously used tobacco.[25] [26]

Despite the rise in adolescent e-cigarette use, there has not been an increase in nicotine dependence.[27] The United States has seen an abnormally rapid decline in teenage smoking coinciding with the uptake of vaping.[28] [29] Some young people use ENDS to quit cigarette smoking or as an alternative to cigarettes.

As a result, vaping is displacing cigarette smoking among young people and established smokers.[17] [18] Though there are positive associations between adolescent ENDS use and subsequent smoking, these are unlikely to indicate a ‘gateway effect’. They are more likely to arise from common risk factors – risk-taking characteristics of the individual or their circumstances that incline them to both smoking and ENDS use.[30] [31] [32] [33]

In the UK where transitioning smokers to vaping has governmental sanction, according to the latest 2021 ASH survey, “Of 11-17 year old never smokers, 3.3% have tried e-cigarettes once or twice, 0.5% use them less than weekly, and 0.2% use e-cigarettes more than once a week.”

5. Vaping leads teens to smoking, the ‘gateway effect’

This has been for long a pet claim of prohibitionists but is not substantiated. Both the UK and the US where vaping is most prevalent now have the lowest recorded smoking rates among youth, which would not be possible if teen vapers were transitioning to smoking. In the US, youth cigarette smoking, at 5.8% in 2019, declined by 63.3% from 2011 to 2019 (compared to only a 17.4% decline from 2003-2011 when e-cigarettes were not widely used), suggesting that vaping is an exit ramp than a gateway to smoking.

An analysis of NYTS data found less than 1% of teen vapers were established smokers, punching big holes in the gateway theory.

No one would like the underage or youth to use any tobacco or nicotine product, but the reality is many do, and experimentation in this age group persists for many other risky behaviours. Keeping a less harmful smoking alternative banned does not serve even this group’s interests as they are guided towards trying out more deadly and addictive products.

Another harsh reality is that a ban, especially in a country like India with weak enforcement, is not effective and, among other problems, leads to creation of black markets with no safeguards to prevent sale to minors, nor for ensuring product and quality standards so that an EVALI-like mishap is not repeated. A carefully regulated market, with accurate awareness of harms, is more conducive to preventing teen uptake than an outright ban with no checks. Like they say about sex education, it is important to have the conversation with kids than leave them to figure it out through porn.

Lastly, after the initial hysteria there is now adequate consideration that teen vaping should be viewed in the context of the common liability model. Simply put, teens who are likely to vape are also likely to smoke, which does not indicate causality but on the contrary establishes that a ban on vaping will increase the likelihood of them smoking, which also explains the rapid decline in smoking through displacement by vaping. A recently published study by Brown and Harvard University researchers, titled High School Seniors Who Used E-Cigarettes May Have Otherwise Been Cigarette Smokers, reconfirms this trend.

6. Vaping does not help quit smoking, works only for highly dependent smokers

This is not supported by real-world data. Countries that have significant vaping presence – France, UK Canada, New Zealand and the US – have witnessed accelerated decline in smoking prevalence. More than 68 million smokers have switched globally in under a decade, despite the intense demonisation of vaping.

Apart from endorsements from 60 national and health bodies worldwide, the recent influential Cochrane Review finds e-cigarettes have the potential to displace smoking. Importantly, projections show transition away from combustibles to vaping over a 10-year period yields 6.6 million fewer premature deaths in the US with 86.7 million fewer life years lost, while curbing or demonising vaping can lead to more smoking, as also noted by the Royal College of Physicians (London):

However, if [a risk-averse, precautionary] approach also makes e-cigarettes less easily accessible, less palatable or acceptable, more expensive, less consumer friendly or pharmacologically less effective, or inhibits innovation and development of new and improved products, then it causes harm by perpetuating smoking.  Getting this balance right is difficult.

A randomised control trial found vaping is twice more effective than NRTs in helping smokers quit. Vaping is now the most used means of quitting smoking in the UK, its government has said.

The claim that vaping works only for the highly dependent is another attempt at confounding. While there would not be such large scale and widely prevalent switch if vaping was working only for a small subset of smokers, it is also worth noting that just as with NRTs, as the cited study itself points out, those most likely to try vaping are people more concerned about their dependence on smoking and its consequences, which says nothing about the potential or effectiveness of vaping to replace smoking, and the reduction of harms.

Unlike NRTs however, vaping because it is pleasurable and non-medicalised leads to accidental quitting among smokers, a significant public health gain.

7. Dual use is a concern, there is continued nicotine use

Other transition and cessation products such as gums also involve a period of dual use as smokers gradually wean off, but this has never led to calls for banning them. Instead of encouraging smokers to continue the journey down the harm spectrum by sticking to vaping and incrementally making it a bigger portion of their nicotine intake, a feature of switching is being manufactured into a problem.

In this context it is helpful to understand that vaping is not intended to be a complete cessation mechanism – though it does makes it easier to quit as nicotine outside of combustible cigarettes is less addictive just like in gums/patches, and it is common for vapers to gradually move to lower nicotine strengths, and some eventually quit – but a safer substitute to smoking.

Prohibitionists argue complete nicotine cessation is the only valid outcome, while harm reductionists point out this is not in consonance with the lived reality for millions of smokers and tobacco users. In use for 12,000 years, people consume nicotine for a myriad of reasons, some to address pyschosocial needs. Majority also find it difficult to quit, and many don’t want to despite the massive negative consequences.

Under these circumstances, the complete cessation model is a) not realistic, b) extremely difficult to achieve (the number of smokers globally has remained the same, over a billion, since 2000 despite WHO-led multinational efforts to curb use), and c) often leads to coercive policies that do more harm.

It is therefore time to consider more humane harm reduction measures wherein the focus expands to limiting harm from nicotine use than insisting on complete cessation, which is known among many tobacco users as the unilateral “quit or die” approach. Continued use of nicotine, if not accompanied by significant harms, is a moral problem than of public health, whose focus should squarely be on reducing related deaths and disease.

8. Long-term harms are not known

It is good to be reminded how ancient this argument sounds when we have developed, tested and approved vaccines and inoculated billions in less than two years, with assurances from the world’s most credible bodies they carry low long-term risk. The reason everyone got behind them is because by weighing relative harms, the cost of not vaccinating far outweighs the small long-term risk from vaccination. This same principle applies to vaping, more so when smoking kills nearly twice more people annually than covid has so far.

E-cigarettes have been around for 15 years and we know enough about them to ascertain their long-term risk, even as the technology itself will become better and safer over time. Public Health England in its 2021 review update noted: Long-term health effects of EC use are unknown but compared with cigarettes, EC are likely to be much less, if at all, harmful to users or bystanders.

The ground reality is that a million Indians are dying from smoking every year, and millions more don’t have to die to satisfy the prohibitionists’ conditions. When a safer alternative is available, we can reasonably project its long-term risks, when the world’s top medical bodies including the US FDA have approved them, there is no reason to put the lives of millions of Indians at risk.

9. No cessation claim has been made to DGCI, hence vaping should not be legalised

It is important to note such simplistic views are offered by surgeons and physicians who deal with the health consequences of tobacco use but have little understanding of its causes and treatment unlike the psychiatrists and psychologists who are trained to deal with addiction, most of whom are pro-harm reduction.

Also worth noting is that the idea that ‘any means to curb smoking should lead to complete nicotine cessation’ is a moral framing, not a scientific one, which would be ‘any means to curb smoking should lead to favourable health outcomes’, a line that the US FDA has taken while approving nicotine vapour technology.

Cigarettes and bidis, which vaping aims to displace, are consumer goods, available at every corner of our country. For vaping products to make the cessation claim, they would have to undergo a lengthy medicalisation process involving costly trials and could still fail because they are not inherently meant as cessation but safer substitution products. Is reducing deaths and disease from tobacco use not a goal worth pursuing on its own without insisting on complete cessation from nicotine use?

This brings us to a key reason for wide adoption of vaping whereas NRT use has remained low despite being on the shelves for decades: vaping is a pleasurable and customisable alternative to smoking and does not require those looking to quit smoking to view themselves as needing medical intervention, which most smokers don’t. A solely medical pathway for e-cigarettes thus undermines their efficacy as a smoking cessation tool, apart from making them less accessible through increased costs and barriers to availability, while also limiting choices and innovation.

Though NRTs have begun trying to address consumer appeal by coming in flavours and varying nicotine strengths, they still suffer from medicalisation and are out of reach for most Indian smokers, leave alone bidi and khaini users. Allowing e-cigarettes to exist on a different pathway as consumer goods, as the US FDA has done, adds to the bouquet of options smokers have in quitting, rather than hurt cessation efforts.

That said, Australia recently legalised vaping through the prescription model such that vapers need to have a physician’s recommendation to import vaping liquids. This is by no means ideal, as it severely restricts access and makes vaping prohibitively expensive. In the UK, e-cigarettes are distributed through national stop smoking services, vape shops in hospitals, and now there is a move to give them medical certification so they can be prescribed through the National Health Service. Experts have largely welcomed the decision but raised questions of access. If both pathways coexist, a wider net can be cast to rope in current smokers.

10. India has done well on curbing tobacco use, doesn’t need vaping alternative

It is disheartening that the e-cigarette discourse is being framed only in the context of teen use, without regard for the country’s 110 million smokers who are at high risk of disease and premature death. Though there has been a 6% decline in tobacco use between 2010 to 2017 with the current prevalence at 29%, the absolute number of smokers has gone up and about a third of Indian men smoke.

This is therefore not just a problem of introducing teens to a new addiction, even though a significant number of them already use tobacco products, but of a massive Indian population. Crucially, cessation rates in our country are abysmally low, under 5%.

Most of India’s tobacco users come from poorer and rural sections with limited access to healthcare, such that they cannot afford to deal with the health consequences of tobacco use, even as the state struggles to provide them with meaningful cessation support that goes beyond the cursory and useless quitlines – behavioural counselling is non-existent, NRTs are unaffordable. Harm prevention by allowing users who can’t or don’t want to quit to avail less harmful delivery methods is thus vital in the Indian context.

A striking feature of India’s tobacco policy is its single-minded focus on cigarettes despite them being a small component (about 4%) of overall tobacco use. Even our tobacco law is named Cigarettes and Other Tobacco Products Act (COTPA). Cigarettes, despite being less harmful than bidis, are taxed at far higher rates, and smokeless tobacco (SLT), the most widely used form which causes 350,000 annual deaths, bears the least burden.

The intense risk-disproportionate revenue focus on cigarettes, which vaping replaces, perhaps explains the swift ban, more so when the state itself is directly invested in cigarette trade through its significant shareholding in the cigarette monopoly.

But it is another myth propagated by prohibitionists that vaping technology is not for the poor and rural smokers. Vaping devices (a battery, coil and liquid) are not high-end technology and can easily be made in India, providing jobs, ensure farmer livelihoods and reduce population-level harm, as a project supported by us found.

Snus and nicotine pouches meanwhile are an affordable risk-reduction alternative for India’s 200 million SLT users because of the similarity in intake method (also why vaping works better than NRTs for smokers) and are already being widely adopted across Africa and Asian nations. But this requires understanding the benefits of tobacco harm reduction.

Thus, in our view, instead of a knee-jerk and myopic ban which is ineffective, anti-people and does more harm than good, we should be considering humane, risk-proportionate regulation which puts India’s 27 crore affected people at the centre while incorporating safeguards to prevent uptake.

Author responds

The author of the original article responds to AVI’s statement:

I’m happy to respond to a rebuttal by Association of Vapers India (AVI) to my article. But at the outset, I should say that their text is a condescendingly worded press release in support of vaping. It uses multiple self-authored articles and unreliable links as ‘references’. Its use of references is also somewhat deceptive as they have been used out of context to rebut points that I’m not even making. My response follows:

1. “Vaping is not safe, contains toxic elements”

Here’s what I wrote:

“Vapes differ from cigarettes in their contents: they don’t contain tobacco, tar or other substances that are known to cause cancer. They do, however, contain other new components, like aldehydes, heavy metals and silicates which are toxic to humans, and are likely to cause lung damage in the long term.”

The reference AVI shared ( was written by authors who disclose funding from e-cigarette companies, and claims that it is safer than smoking. This does not rebut anything that I wrote.

The second reference, of a study from Nature, was also industry-linked and involved only nine participants over two and a half years. Most lung injuries from inhaled heavy metal particles and other chemical agents can take decades to manifest. There are literally dozens of studies on animal models and case reports with humans of how these components cause lung injury – either acute or chronic.

2. “Nicotine itself is toxic”

I never called it carcinogenic. Nicotine is definitely toxic and bad for health. Here is another study reiterating what I wrote. The AVI response is confounded: it seems to be rebutting a claim that “vaping is as bad as smoking” – which I didn’t say.

3. “Acute lung injury associated with e-cigarette use is a major concern”

I specifically said in my article that  e-cigarette or vaping use-associated lung injury (EVALI) was from additives. By ignoring this, the AVI rebuttal makes it seem like I intentionally misled readers on this point.

4. “Exponential increase in e-cigarette use by the youth in the US”

Here is an article published by the Journal of the American Medical Association explaining how recent trends aren’t reliable since schools were closed for COVID-19. AVI also claims the denominator for the 40% claim in my article was small: “The 2020 National Youth Tobacco Survey showed that almost a fifth of high-schoolers used e-cigarettes, with nearly 40% of them admitting use for more than 20 days in a month.”. The denominator was 7,000 high-school students and the data was from 2020, with the paper published in June 2021. So not outdated – and another obfuscation.

5. “Vaping leads teens to smoking – the ‘gateway effect’”

This issue is far from settled except in the minds of vaping proponents (see here, here and here). Their argument that “fewer young smokers means there won’t be a gateway effect” is rubbish. The studies looking at smoking prevalence and vaping incidence in the youth are completely different from each other and from completely different populations, so you can’t conflate the results.

6. “Vaping does not help quit smoking, works only for highly dependent smokers”

I didn’t say it doesn’t work. I said the data suggests that it should be used for highly dependent smokers, which is what researchers also say, since it is unequivocally the most risky smoking cessation tool. “Decrease in smoking rate means increase in vaping rates” is supposition, not fact. Every major paper states this.

Reduced smoking can also be due to a host of other policies like taxation, statutory warnings on products, restriction in sale to youth and multiple other factors. To not acknowledge this is dishonest. The Cochrane Review, which AVI has cited, doesn’t say that vaping can replace smoking – it says vaping is more likely to be effective than other nicotine replacement therapies, but AVI has misrepresented this.

7. “Dual use is a concern, there is continued nicotine use”

AVi has advanced no rational argument against this claim. The medical concern here is that more vaping leads to more nicotine addiction, and eventually more smoking – if they don’t quit. There is evidence to support this – same as with the gateway theory.

8.Long-term harms are not known”

Again, AVI makes a comparison with cigarettes, saying vapes are better. But this was not the point of my article at all.

9. “No cessation claim has been made to DGCI, hence vaping should not be legalised”

This is not what I said. My point was, and is, that the easiest way to get approval for vapes would be cessation within a clinical context – but in the limited context of this point, it is apparently no longer the issue. AVI’s contention is just another free-choice whataboutery that compares vapes to cigarettes.

10. “India has done well on curbing tobacco use, doesn’t need vaping alternative”

Again, not what I said. I wrote that if youth start vaping and end up on tobacco, it will undo the progress India has made thus far. The AVI claims that the Indian rural population will benefit from vaping without any evidence. The reference article is an opinion piece written by an AVI member that has no real world data and relies solely on supposition based on alleged studies he conducted but never described or published.

As such, AVI’s response has no scientific value, uses lots of sketchy websites and industry-sponsored articles as gospel truth, and misrepresents many things that I had written in my article. Their claims are half-truths and unscientific. I have said repeatedly that vaping may help heavy smokers quit – but it needs to be introduced in the context of an appropriate framework into the market, and not willy-nilly.

Their rebuttal to my article, and my response here, doesn’t change this requirement. I stand by all the references that I have cited in my article. I never said tobacco was better or that tobacco shouldn’t be banned as well, which no one seemed to infer except AVI and some angry vapers.

This article was originally published on October 25 and was republished on November 1, 2021, with the AVI’s statement and the author’s response to it.

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