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Top medical journal gives airtime to Harm Reductionists

Highly regarded publications are currently giving prominent coverage to major voices of harm reduction through vaping. Although journalistic vape-bashing is still a major sport in the arena of public information, the tide is beginning to turn toward sensible harm reduction in the regulation of vaping devices.

The New England Journal of Medicine is one of the most prestigious medical publications in the land of apple pie, baseball, and hateful political campaigns. A recent issue has given a salient op-ed spot to pro-vaping medic David B. Abrams and his colleague, Nathan K. Cobb.

David Abrams directs the Schroeder Institute for Tobacco Research and Policy Studies in the Bloomberg School of Public Health at Johns Hopkins University in Baltimore, Maryland. He is a widely published harm reduction advocate, and was one of the signers of the now-famous "letter of 53" nicotine scientists to the WHO, arguing for sensible e-cigarette regulations (a letter that the WHO, of course, ignored). Nathan Cobb is an Assistant Professor at the same Institute, and an attending physician in the pulmonary department of nearby Georgetown University Hospital. The online version of the article also offers an audio tape of an interview with Cobb, the principal author.

Cobb begins with the anticipated points that well-crafted regulations, which are very much needed, can shape the evolution of a vaping product that is safe and consistent. Such 'refined nicotine products', he maintains, "could play the same role as NRT but at a truly national, population scale. Their use could shift smokers permanently away from lethal cigarettes to cleaner, safer nicotine products, saving innumerable lives." But without clear and moderate regulations, variants will arise "whose safety and addiction liability no longer approximate those of NRT products or current e-cigarettes and which therefore may offer far less harm-reduction potential."

But Cobb's analysis becomes much more refined, and offers a valuable distinction between e-cigs produced by Big Tobacco and those made by independents. He offers a subtle grasp of the differing economic motivations of various kinds of e-cig manufacturers. On the one hand, independent e-cig dealers "that sell only refined-nicotine products can build smaller yet profitable businesses by appropriating customers from Big Tobacco and retaining them only until they transition to complete cessation." No Big Tobacco company, on the other hand, "could tolerate the downsizing implicit in shifting from long-term addiction to harm reduction and cessation. If afforded the opportunity, tobacco companies may try to avoid disruption of their business model by marketing innovations designed to sustain high levels of addiction...."

A look at the science behind this distinction is worthwhile. The reason combustible cigarettes are so addictive is that they get nicotine into the blood stream by "alveolar deposition". Alveoli are the tiny structures in your lungs that transfer what you breathe into chemicals that go into your blood. NRTs and vaporizers deliver their nicotine through a "humectant", which is basically a moist substance that is absorbed, in much the same way a crème is absorbed when you rub it onto your skin. Alveolar deposition of nicotine gives you an instant buzz, and is very addictive as a result. Absorption via a humectant is more gentle, more gradual – and less addictive.

Dr. Cobb points out that some large, multi-national producers of combustible cigarettes have acquired patents on vaporizing systems that deliver nicotine through the alveoli, making them potentially as addictive as combustible smokes. This could "blur the boundaries" between different types of vaping products. Cobb argues that, given their economic motivation to keep people smoking, Big Tobacco could devise marketing strategies around these hyper-addictive e-cigs that would keep people addicted to nicotine, taken in either combustible or in vaporized form, turning "dual use" into a monster.

The public relations value of this point, one of them at least, is that it offers a clear scientific rationale for regulating Big Tobacco's e-cigs differently than those produced by independents. It will be increasingly difficult for vape bashers to say that the e-cigarette business is purely and simply a Big Tobacco effort. It is becoming crystal clear that Big Tobacco e-cigs and those produced by companies that don't sell combustible cigarettes are not only different, but diametrically opposed.

Cobb urges the FDA to "drive a wedge between regulated clean-nicotine products and the toxic combustible products that predominate today."