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I did my last residency journal club on the effects of taxes on smoking and vaping: https://onlinelibrary.wiley.com/doi/10.1111/add.16002

The article's conclusion was that increasing taxes on one of those things decreased use of the item which was taxed, but increased use of the other product (a substitution effect). That is to say, people picked smoking or vaping, whichever was cheaper, but they weren't dissuaded from tobacco use.

This supports the harm reduction argument. I might prefer that no one used tobacco, but that is a very difficult outcome to achieve.

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I think sleep is an under-discussed problem with e-cigs.

While I totally grant that they are safer than cigarettes in all kinds of ways, I have seen more and more patients who wake up at night, sometimes multiple times, in order to vape. It has become an ingrained sleep association and I have little doubt this is a bigger issue than we realize if millions of people are doing it.

This gets into one of the big drawbacks of e-cigs, which is their ability to be used discretely, including taking a drag or two in the middle of the night without waking up your spouse with the smell of tobacco (a story I've heard innumerable times).

I was a smoker in college and quit when I realized I couldn't keep up the habit in medical school. One of the biggest aides in quitting smoking is the offensive smell of tobacco, the fact that it is obvious when you use it, and the difficulty of covering it up. If I had vapes in college I'm certain I would have continued using it straight into medical school. Maybe that would have been OK all things considered and wouldn't affect my health much (aside from increasing my concentration from the nicotine). But maybe it does? It just seems to be something worth considering.

If they haven't developed these already, I think it would be good to have self-tapering e-cigs for those who want to quit. Easy to program in dosing and number of puffs per hour or however you want to schedule it.

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I don’t think this article can be interpreted and assessed on its own, absent part 2 that will deal with the teens and “gateway” aspect. Cuz I don’t think the concern is with smokers who switch from cigarettes to E-cigs; the concern is with kids who go from nothing to E-cigs. It would appear (anecdotally) with the various bubble-gum flavoured e-juices and general marketing tenor, that the “young” demographic are being targeted. It would seem premature (and likely impossible) to demonstrate safety among E-cigs in young people, especially since these products have only been around a relatively short period of time.

Again, pending what evidence is brought to bear in part 2, it seems the author is being overly harsh on public health types who have to weigh the potential benefits to current smokers vs the potential risks to current non-smokers (with the latter cohort being a much larger one).

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I don't doubt the benefit in smokers. My concern is for the youth that are vaping in ever rising numbers. In our attempt at harm reduction, are we creating a generation of nicotine addicted children? What will be the lasting impact of this? This is why vaping is getting a bad rap, not the harm reduction related to smokers. Two totally different considerations.

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Exactly. The young folks consider it “safe” and yet nicotine addiction is as it ever was. We are just fooling ourselves if we think we are doing kids a favor by promoting “safer” addictive chemicals.

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I will always agree in the reduction of harm between tobacco and vape; however with so many different vape formulas - especially those one doesn’t have info on - there’s still harm. The best benefit is abstinence of course. When it comes to risks and harm reduction with any nicotine product - given the issues associated with nicotine use, I think that the difference in “harm reduction” is akin to a .44 magnum versus a .22.

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What a surprise, our public health officials have failed us yet again. I am sensing a theme.

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A Sally Satel article on Sensible Medicine! I'm so happy to see this substack tackling the subject of vaping.

I stopped smoking in 2009 with an ecig and never smoked again. I still vape regularly.

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Finally common sense. Both my parents smoked when I was growing up.I wish vaping had been an option then. I hate smoking but no one is banning cigs. (Prohibition worked well didn't it) People who want to ban vaping and/or flavors never have to defend facts and the real alternatives. Thanks for explaining the real choices and why we must defend giving people freedom to choose the least harmful path.

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Thank you, Sally. This kind of posting is why I am so loyal to substack and embrace this platform. I am a pediatric pulmonologist and a great opponent to tobacco smoking. My mother died of complications related to COPD. There are many in the pulmonology community who have a moralistic approach to tobacco and its variants, including vaping. There is a real hatred and tendency to demonize the tobacco industry. This is reflected in the bias in the statements of the AHA and ALA referenced here.

One unmentioned health concern is that some young people have figured out how to instill into their vaping device other substances. including THC. The contaminants themselves have reportedly caused acute lung injury in anecdotal reports. Thus, young people should be discouraged from using the vaping tool to inhale other chemicals.

I look forward to part II.

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They use that platform to vape buprenorphine too. A lot more than most care to realize.

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Feb 14, 2023Liked by Adam Cifu, MD

You have to wonder if much of this heavy-handed miscommunication/information comes from a place of moral judgement. Putting h this in the context of harm reduction makes so much sense.

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Yet another reason to hold federal health agencies in contempt.

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