Over the years, I’ve collected some glorious examples of the tobacco industry’s efforts to promote health and hose down public concern about the risks of smoking. There was Philip Morris’s effort in Australia in the 1980s to sell a sunscreen to protect us all from skin cancer. They thought it was a great idea to give it the same brand name as another of their products, Peter Jackson cigarettes, which like all cigarettes kill two in three of their long term users. Lung cancer prevention = bad; melanoma prevention = good. All got that? It was quietly and swiftly withdrawn when this little problem given some sunlight.

Then there was the time in 1999 that Philip Morris  listed itself in a corporate promotional brochure as sponsoring the Red Nose Day Foundation, Australia’s largest research charity supporting research on sudden infant death syndrome (SIDS). Sleeping in the prone position and exposure to tobacco smoke are the two most important, known risk factors for SIDS. The glossy brochure, resplendent with photographs of the company’s products including cigarettes, identified the charity as among “recipients of support or sponsorship from Philip Morris and its operating companies in Australia”. Red Nose Day organisers had obtained, for fundraising purposes, two giant Toblerone chocolate bars from Philip Morris’s Kraft corporate arm, not realising the then connection with the tobacco parent company.

On learning that Philip Morris was using the Toblerone donation as part of its efforts to promote its corporate image, the executive director of the Foundation complained that its name and cause had been misused and announced that the money raised would be returned as unwanted to Philip Morris.

World wide Philip Morris had aggressively disputed evidence that environmental tobacco smoking is harmful. Anne Jones, director of Action on Smoking and Health (Australia) commented at the time that Philip Morris claiming to support SIDS research was “about as offensive as Slobodan Milosovic donating to Kosovar refugee relief”

Promoting “light” cigarettes

When Philip Morris owned Kraft (Kraft has had no affiliation with Philip Morris or its spinoff Altria since 2007) its tobacco division was globally busy inculcating the idea that some cigarettes were less deadly than others. “Lights” was one of the magic words they and other tobacco companies branded these cigarettes with, until regulators outlawed it as misleading and deceptive and heavily fined them for knowing this for many years. There was no evidence “lights” were less deadly than any other cancer stick.

Before the curtain fell heavily on this deceptive conduct, Philip Morris used Kraft to help its efforts. Here’s an ad showing how “light” was used to directly imply healthy. Just the trick to use to imply the same healthier claims for cigarettes.

Smoking? Well what about …?

Tobacco companies have a long history of trying to mine research and expressions of public alarm about various risks to health to foment public confusion that “everything gives you cancer these days”, so why worry about just one risk, smoking? Perhaps the most florid example of this was a 20 page A-Z dossier of health risks from 1984. This was designed to be used as a crib sheet for tobacco industry employees to spray examples around in media interviews when the troublesome issue of the dire risks of smoking arose. Here’s a sample. You can read the rest via the link.

Cell phone tower electromagnetic radiation angst

Paul Adams (pictured above) was the chief executive of British American Tobacco’s head office in London for seven years until he retired in 2011. Adams presided over one of the world’s largest tobacco companies whose products today contribute to the global total tobacco death toll of 8 million smokers a year. We can safely assume he knew an awful lot about the health impact of his company’s business across his years at BAT. But in December 1993 he was very worried about another alleged health risk: electromagnetic radiation from a proposed transmission mast in his community and sent a personal protest letter to his local district health council.

Health risks from mobile phone towers or the phones themselves have never been demonstrated across the decades. It would be highly improbable that Adams did not use a mobile phone himself. Phones don’t work without transmission towers.

WiFi and Bluetooth

And in 2019, we come to Josh Fett, British American Tobacco’s Senior Regulatory Engagement and Campaigns Manager for Asia Pacific and Middle East. Fett tweeted two telcos “trying to figure out” if it was safe to use WiFi/Bluetooth around babies in the home.

Sarah White’s (then CEO of Quit Victoria) pertinent question below to Fett unfortunately went unanswered.

WiFi began being offered by communication providers from 2002 and by 2014 was being used in 25% of houses worldwide. Bluetooth began its rapid rise in popularity from 2004, going through seven different upgrades by 2016 as its provision and use became almost standard in lots of electrical equipment.

So across this time, hundreds of millions of neonates, infants, children and adults have received up to 17 years exposure by the time Fett asked his question.

Vertical integration of smoking and death

In 2019, Philip Morris International set up a life insurance company. As a next step in its business model, this was just masterly! Sell highly addictive, lethal tobacco products to your customers and at the same time, get them to also pay you a life insurance premium. I couldn’t resist adding a few more suggestions in the tweet below. So many ways for one of the world’s largest and longest purveyors of cigarettes to get a place at health industry tables and representative groups!

You’re in the health care industry!

But I save the best for last. Below we see the UK’s Vaping Industry Association (UKVIA) proudly megaphoning the message given to its 2022 conference by UK Conservative MP Adam Afriyie. Afriyie was a member of the All Party Parliamentary Group for Vaping which  both received funding from UKVIA and  from November 2016 until 2020, even had UKVIA operating  as the Secretariat for the APPG for vaping. Afriyie wanted vape manufacturers and retailers to get it into their heads that they were not in the tobacco industry, not in the nicotine addiction industry but, yes, in the healthcare industry.

That would be the vaping industry whose products are now sounding all the health alarms you see in reviews like those shown here.

George Orwell would be having a field day if he was alive today.

Like all cultists, those who live and breathe vaping by telling everyone at every opportunity that it has saved them, embrace a set of fervent beliefs. Vaping theology is a set of sacrosanct, inviolable beliefs that all adherents repeat regularly at risk being cast out of the vaping temple by other true believers.

At the end of this blog are another 23 of these creeds, with many more in preparation. This one looks at a belief that is never far from the lips of those who patrol policy debates on vaping where proposals or evidence threaten in any way to inhibit their mission.

Common liability theory

The garlic-encrusted crucifix hoisted high at the first syllable of any vampire-like suggestion that vaping might act as training wheels for children and teenagers to take up smoking is known as the “common liability hypothesis”.  The hypothesis first gained modest prominence in debates about the “gateway hypothesis” in drug uptake research where crude post hoc ergo propter hoc (after, therefore because of)  reasoning has often insisted that  (for example) that those who try cannabis and then later start using narcotics because they first smoked dope

We all appreciate that if one thing follows another it often does not mean the first thing caused the second. Breast milk is often followed by infant formula, water, then by fruit juice and clamour for carbonated drinks, then later by alcoholic drinks.  So can we say meaningfully that breast feeding causes Coke and alcohol consumption? Obviously not.

But there are plenty of examples of where one thing very much does greatly elevate the probability of another, satisfying several causal criteria. Prison incarceration is followed so frequently by reoffending on release that responsible legal sentencing practice tries to avoid imprisonment whenever reasonable to prevent crime. Intoxication and speeding so greatly increase the odds of motor vehicle crashes that deterrence and penalties are set high in most governments’ policies.

The current national concern about untrammeled betting advertising is seeing huge concern about the Pied Pipers of betting trying to lure starting punters into seemingly benign little flutters whiile turbo-charing promotions for multi betting. A classic example of gateway engineering.

Yes, there are always confounding factors that can be highlighted in such examples, but these seldom exonerate the critical role of an earlier variable (eg incarceration, drinking before driving).

When it comes to vaping and smoking, there are some entirely relevant observations. Both involve inhaling and exhaling nicotine through cylindrical delivery systems. Both involve the often rapid onset of signs of nicotine dependence in users. Both share a word (cigarette/e-cigarette) that seems to point to a similarity. Both involve repeated hand-to-mouth movements and a richly semiotic repertoire of holding and gesturing. Both see clouds of smoke or vapour billowing from their users, sometimes in clever displays. Both very frequently start in early teenage years. For some, both are important accoutrements of the passage from childhood to early adulthood, richly signifying and often peer group reputationally rewarding rebellion against parental controls and school rules.

With vaping and smoking, the common liability hypothesis posits that those children who vape and then subsequently start smoking would have mostly taken up smoking even if vaping had never been invented. It argues that kids who smoke in today’s smoking denormalised social environments have a propensity to be rebellious and so are also likely to take other risks: they vape, they smoke, try illicit drugs, have sex early, miss school, graffiti walls and so on. With the vaping “leading to” smoking debate, common liability adherents point to these propensities for kids who vape to be more likely to smoke simply because smoking is one of a constellation of adult-disapproved behaviours that bring peer status and petty prestigious notoriety to those seeking such distinction.

Nobel prize winning (2000) neuroscientist  Eric Kandell and his wife have described a molecular basis for nicotine being a gateway drug whereby nicotine in one form primes the brain to make it more susceptible to using other forms of nicotine. 

As a schoolboy, I smoked, got older kids to buy me alcohol, got suspended from school for buying beer on a school drama tour in year 11 and was the first in my year to have sex. I would have probably scored high on any scale of risk-taking a social psychologist might have pushed in front of me.

There have now been at least four systematic reviews/meta-analyses of the fast-emerging research literature on whether vaping increases the likelihood of taking up smoking.

Soneji et al (2017) JAMA Pediatrics: (9 studies) “The pooled probabilities of past 30-day cigarette smoking at follow-up were 21.5% for baseline past 30-day e-cigarette users and 4.6% for baseline non-past 30-day e-cigarette users.” (ie 4.7 times higher)

Baenziger et al (2021) BMJ Open (25 studies) “comparing e-cigarette users versus non-e-cigarette users, among never-smokers at baseline the OR for smoking initiation was 3.19 (95% CI 2.44 to 4.16, I² 85.7%) and among non-smokers at baseline the OR for current smoking was 3.14 (95% CI 1.93 to 5.11, I² 91.0%). Among former smokers, smoking relapse was higher in e-cigarette users versus non-users (OR=2.40, 95% CI 1.50 to 3.83, I² 12.3%).”

O’Brien et al (2021) BMC Public Health (14 studies) “our meta-analysis calculated a 4.06 (95% confidence interval (CI): 3.00-5.48, I² 68%, 9 primary studies) times higher odds of commencing tobacco cigarette smoking for teenagers who had ever used e-cigarettes at baseline, though the odds ratio were marginally lower (to 3.71 times odds, 95%CI: 2.83-4. 86, I² 35%, 4 primary studies) when only the four high-quality studies were analysed.”

Chan et al (2021) Addiction (11 studies) “a significant longitudinal association between vaping and smoking [adjusted odds ratio (aOR) = 2.93, 95% confidence interval (CI) = 2.22, 3.87]. Studies with sample sizes < 1000 had a significantly higher odds ratio (OR = 6.68, 95% CI = 3.63, 12.31) than studies with sample sizes > 1000 (OR = 2.49, 95% CI = 1.97, 3.15).”

All of the above reviews found that non-smoking children who had vaped at baseline had significantly increased odds of smoking cigarettes at follow-up, compared with those who had not vaped.

Yet in a recent editorial in Addiction, Pesko et al say that the public and health-care professionals pointing to the evidence in these reviews must be “confused”, writing:

“significant evidence now exists that this association between vaping and smoking is not causal, which is a source of confusion for the lay public and health-care professionals. Survey data show youth cigarette use declining steadily despite vaping increasing. When past-30-day youth e-cigarette use rates were as high as 32.9% in 2019, youth smoking rates should have been rising if the SG’s statement that ‘e-cigarette use is associated with the use of other tobacco products’ represents a causal relationship. Instead, by 2021 the youth cigarette use rate fell to a record low 1.9%.”

So why not settle the question with a randomised controlled trial?

All the studies reviewed in the four reviews above were observational longitudinal studies. In the first week of epidemiology training, every student is required to write out 1000 times at pain of death that “association does not equal causality” and play the sport of finding unwarranted causal inferences in observational study reports like those reviewed above.  It’s only in randomised controlled trials that authors are  given a gold pass to start suggesting causality.

Randomised controlled trials (RCTs) are venerated in medical and behavioural science because an important goal of randomisation is to disperse biases randomly across trial participants. Randomisation  theoretically eliminates confounding factors that may play dominant roles in determining outcomes, even ahead of the influence of the key intervention variables of interest (eg vaping vs NRT or unassisted cessation in evaluating the effectiveness of ways of quitting).

Because variables like age, sex, education, smoking in one’s family and peers, or personality traits like determination, self-efficacy or parenting styles are seen as likely to be important in how a person traverses decisions to smoke, drink or take drugs, randomisation — particularly in large trials — is designed to randomly spread the allocation of such variables across different arms of a trial (ie those receiving  an active drug – here, nicotine vapes – and those not vaping), in theory thus eliminating their influence.

But of course there will never be a randomised trial of vaping in children. No research ethics committee is ever likely to consent to such a trial because it would mean that researchers would be requiring randomised trial volunteer minors to start using highly addictive nicotine vapes. With smoking rates in early teens fast approaching zero in some nations like the USA, Canada, Australia, the UK and New Zealand,  imagine the outcry if a research group wanted to risk addicting nicotine naïve children to nicotine.

Imagine further, the unlikely event that a study group was able to recruit a large number of parents who would give their full consent to their children being given vapes like this. Not even in the most totalitarian of political regimes would we find such behaviour condoned.

Knowing this, those who stridently insist that the available data on transitions to smoking in young vapers is associative but not causal, know that they will always be able to use this policy fire extinguisher and train their “association” hoses on the worrying fires of gateway claims. This is a devious game intended to perpetually dismiss concern about collateral damage to kids arising from policies that allow them very easy access to vapes.

Controlling for “propensity to smoke”

With RCTs out of the question (just as they are for example, with randomising drivers to get intoxicated to see if they really do have more crashes in real world conditions than those who’ve not consumed alcohol), the next best evidence available is when researchers control their analyses for the very ‘propensity to smoke’ factors gateway critics say are the real determinants of smoking uptake.

Here we have several studies which have set out to do just that. Let’s take two recent examples.

Using US PATH study data, Berry et al (2019) looked at 2 years follow-up of 12-17 year old non-smokers who were vaping and those who were neither vaping nor smoking.

They found that current e-cigarette users (cigarette non-current users) at baseline were 5 times more likely to become regular cigarette smokers at 1-year follow-up than non-vapers. However, this association was not significant at the second year of follow-up. In reaching this conclusion, the authors controlled  for variables known to be associated with progression to smoking in youth.

A second example is  a 2021 paper on the UK’s  huge Millennium Cohort. It found:  

“Among youth who had not smoked tobacco by age 14 (n = 9,046), logistic regressions estimated that teenagers who used e-cigarettes by age 14 compared with non-e-cigarette users, had more than five times higher odds of initiating tobacco smoking by age 17 and nearly triple the odds of being a frequent tobacco smoker at age 17, net of risk factors and demographics.” [my emphasis]

Most importantly, the paper also deflated the glib ‘kids who try stuff, will try stuff’ common liability theory dismissal of the concern that vaping acts as training wheels for later smoking uptake. In their analysis, the authors controlled for a rich constellation of ‘propensity’ factors that have been suggested to predict smoking uptake in youth. These included parental low educational attainment and employment status; parental reports of each child’s behaviour during the prior 6 months using the Strengths and Difficulties Questionnaire, with indicators of externalizing behaviours (i.e. conduct problems, hyperactivity, inattention; and internalizing behaviours (i.e. emotional symptoms, peer problems) parental smoking; whether a child spent time ‘most days’ after school and at weekends hanging out with friends without adults or older children present. Children, via confidential self-reports, indicated whether they had ever drunk alcohol (more than a few sips), ever engaged in delinquency (e.g. theft, vandalism) and whether their friends smoked cigarettes.

In a huge blow to common liability adherents the authors concluded:

“we found little support that measured confounders drove the relationships between e-cigarettes and tobacco use, as the age 14 e-cigarette and tobacco cigarette estimates barely changed with the inclusion of confounders or in matched samples. Furthermore, early e-cigarette users did not share the same risk factors as early tobacco smokers, as only half the risk factors distinguished e-cigarettes users from non-users, whereas age 14 tobacco smokers were overrepresented on almost all the antecedent risk factors. If there was a common liability, we would expect similar over-representation for users of both forms of nicotine.”

Pesko et al didn’t reference these inconvenient papers either.

Pesko et al’s paper was an editorial, not a systematic review, It cited none of the above reviews nor indeed any of the papers in those reviews, instead basing its glib dismissal of that evidence as “based on statistical association rather than clear evidence of causality”.

Instead it enlisted another old chestnut: that the gateway hypothesis conclusions are simply incompatible with the fall in smoking prevalence in youth when their vaping is rising. (“youth smoking rates should have been rising if the Surgeon General’s statement that ‘e-cigarette use is associated with the use of other tobacco products’ represents a causal relationship. Instead, by 2021 the youth cigarette use rate fell to a record low 1.9%”

This argument is frankly very feeble. I dealt with it in a 2018 paper with two colleagues in Nicotine & Tobacco Research. It relies on an assumption that the net population impact of any putative gateway effect of e-cigarette use would be larger than the combined net impact of all other policies, programs and factors which are responsible for reducing adolescent smoking prevalence (e.g. tobacco tax and retail price, measures of the denormalisation of smoking, exposure of children to adult-targeted quit campaigns, retail display bans, health warnings and plain packaging) and the important synergies between all of these.

Many nations have seen pleasing and continuing falls in adolescent smoking commence well before the advent of widespread vaping. Vaping is thus far from being the only factor responsible for declining smoking.

But this is the ridiculously  high bar that gateway critics demand that anyone suggesting gateway effects needs to jump over. If smoking is falling, the suggestion is that the uptake of vaping is causative. Note here too the ease with causal attribution from ecological data is invoked when it suits one’s purpose.

The combined impact of the abovementioned factors in preventing smoking uptake could easily mask considerable smoking uptake that might not have occurred in the absence of e-cigarettes. That uptake may not be big enough to reverse net falls in smoking prevalence which has seen hundreds of thousands of children and adolescents not take up smoking in nations where it has happened.

But the undeniable consistency in observational cohort studies, almost without exception, shows that if you don’t smoke and do vape, you are far more likely to smoke later, even when “propensity to smoke” factors are adjusted in studies which have done this.

To keep repeating these discredited slogans (“kids who try stuff, will try stuff”, “kids who are going to smoke, will smoke”) dignified by high-falutin’ hypotheses  like “common liability” that don’t survive first pass adjustment for their assumptions, discredits those who continue this narrative.

Other blogs in this series

Vaping theology: 1 The Cancer Council Australia takes huge donations from
cigarette retailers. WordPress  30 Jul, 2020

Vaping theology: 2 Tobacco control advocates help Big Tobacco. WordPress 12 Aug, 2020

Vaping theology: 3 Australia’s prescribed vaping model “privileges” Big Tobacco WordPress Feb 15, 2020

Vaping theology: 4 Many in tobacco control do not support open access to vapes because they are just protecting their jobs. WordPress 27 Feb 2021

Vaping theology: 5 I take money from China and Bloomberg to conduct bogus studies. WordPress 6 Mar, 2021

Vaping theology: 6 There’s nicotine in potatoes and tomatoes so should we restrict or ban them too? WordPress 9 Mar, 2021

Vaping theology: 7 Vaping prohibitionists have been punished, hurt, suffered and damaged by Big Tobacco WordPress 2 Jun, 2021

Vaping theology: 8 I hide behind troll account. WordPress 29 Jun, 2021

Vaping theology: 9 “Won’t somebody please think of the children”. WordPress 6 Sep, 2021

Vaping theology: 10: Almost all young people who vape regularly are already smokers before they tried vaping. WordPress 10 Sep, 2021

Vaping theology: 11 The sky is about to fall in as nicotine vaping starts to require a prescription in Australia. WordPress 28 Sep, 2021

Vaping theology: 12 Nicotine is not very addictive WordPress 3 Jan 2022

Vaping theology 13: Kids who try vaping and then start smoking,would have started smoking regardless. WordPress 20 Jan, 2023

Vaping theology 14: Policies that strictly regulate vaping will drive huge
numbers of vapers back to smoking, causing many deaths. WordPress 13 Feb, 2023

Vaping theology 15: The government’s prescription vape access scheme has failed, so let’s regulate and reward illegal sellers for what they’ve been doing. WordPress 27 Mar 2023

Vaping theology 16: “Humans are not rats, so everybody calm down about nicotine being harmful to teenage brains”. WordPress 13 Jul, 2023

Vaping theology 17: “Vaping advocates need to be civil, polite and respectful” … oh wait. WordPress 3 Oct, 2023

Vaping theology 18: Vaping is a fatally disruptive “Kodak moment” for smoking. WordPress Oct 30, 2023

Vaping theology 19: Vaping explosions are rare and those who mention them are hypocrites. WordPress 17 Nov, 2023

Vaping theology 20 : Today’s smokers are hard core nicotine dependent who’ve tried everything and failed – so they need vapes. WordPress 14 Dec, 2023

Vaping theology 21: Australia’s prescription vapes policy failed and saw rises in underage vaping and smoking. WordPress 10 Jan, 2024

Vaping theology 22: “Prohibition has never worked at any point for any other illicit substance”. WordPress 17 Mar 2024

Vaping theology 23: “84% of the Australian public are opposed to the way the government will regulate vapes” WordPress 2 Apr, 2024

Vaping Theology 24: “Tobacco control advocates are responsible for vape retail store fire bombings and murders. WordPress 27 May, 2024