San Francisco has a decidedly selective way of policing healthy living. It curbs smoking by banning it nearly everywhere. Yet it still allows tobacco and marijuana sales, gives away syringes to addicts and wants to open drug-injection facilities. City politicians go after Big Soda with glee, but mostly stay out of the way of the more powerful alcohol lobby.

Some of those seeming contradictions make practical sense. Others do not.

This latest one is flat-out ludicrous: Embarrassed that the No. 1 vaping company is prospering on port property, city leaders are in a legal fury. The city attorney and a member of the Board of Supervisors have proposed to bar e-cigarette firms from renting city property and, more sweepingly, block the sale of e-cigarettes in the city.

The stated rationale, of course, is a concern for public health. After all, vaping companies prey on a young audience with candy-flavored offerings and a hip, streamlined device. For other users, e-cigarettes are sold as a pathway from the chemical harms of tobacco, though the danger of nicotine addiction remains.

E-cigs are no fad, with the big tobacco company Altria in December buying a 35 percent share of Juul, based on Pier 70, giving the company a value of $38 billion. This city, an ostensible temple of clean living, is home to the leading edge firm in the vaping game — and yet the proposed measures can’t chase it out of town as long as its lease runs.

That annoying reality no doubt is stoking the latest legislation. But the crusade needs a reality check. It’s not as if reasonable steps are not being taken to study vaping and restrict its appeal to youth. The city cracked down on flavored e-cigarettes through a ballot measure last year. The federal Food and Drug Administration is entering the picture with its own limitations aimed at curbing sales.

Vaping is a tempting public villain. Manufacturers should be treated with skepticism about claims that vaping is a benign habit. What vaping doesn’t deserve is a dose of shortsighted demonizing that does little to change the bigger picture of tobacco abuse and other health dangers the city is loath to confront.

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Prior to announcing his resignation last week, FDA Commissioner Scott Gottlieb had made ending teen vaping a central goal of his tenure. Determined to eliminate what he frequently termed an “epidemic,” regulators have not only exaggerated the magnitude of the problem, but also threatened retailers with regulatory repercussions. The source of the problem lies elsewhere.

For e-cigarette opponents eager to protect children, there is no regulatory burden too big to impose. On Wednesday Gottlieb delivered on his promise of “vigorous enforcement steps” against tobacco retailers that sell to underage customers. He announced a draft compliance policy with these expectations: “some flavored e-cigarette products will no longer be sold at all…other flavored e-cigarette products that continue to be sold will be sold only in a manner that prevents youth access… some flavored cigars will no longer be sold.”

Last week Gottlieb set the stage by calling out the management of Walgreens, as well as other national gas station and convenience stores such as Exxon, 7-Eleven, and Walmart. Using tough language, he described the FDA’s “boots-on-the-ground presence across the country,” noting the “historic milestone of conducting … one million tobacco retailer inspections” since 2010, which resulted in tens of thousands of warning letters, nearly 20,000 penalties, and 145 “no-tobacco-sale orders.”

Federal data reveals important information, however, that conflicts with the FDA announcement and the perception that teen vaping is a pervasive problem. The Centers for Disease Control and Prevention’s 2017 National Youth Tobacco Survey shows that only about 12 percent of American high school students used e-cigarettes in the past month. Even if the CDC’s observation – based on unpublished data – is correct about a vaping increase in 2018, it doesn’t confirm an epidemic. Nearly 70 percent of the students who vape – but do not smoke – used e-cigarettes five days or less during that 30-day period, a pattern called “party” or “weekend” vaping, not regular, daily consumption.

Another federal survey, dubbed “Monitoring the Future,” reveals more critical teen epidemics: alcohol and marijuana use. Thirty percent of high school seniors use alcohol and 18 percent report being drunk in the past month. Similarly, 22 percent of students report using marijuana – a level that’s remained steady since 1995. In contrast to vaping, considered to be 95 percent safer than smoking and not impacting judgment or inhibitions, teens too often die from accidents related to marijuana and alcohol consumption.

Despite the FDA’s finger-pointing at retailers, only a tiny fraction of American teens who have used e-cigarettes bought them on their own. The FDA’s own survey data backs this up. The Population Assessment of Tobacco and Health (or PATH) survey collects detailed information about teen tobacco use. It reveals that fewer than 10 percent of current teen e-cigarette users – defined broadly as having taken at least one puff in the past 30 days – “bought them myself.” In short, most teens aren’t getting e-cigarettes from retailers willing to break the law for an extra buck. Instead, they get e-cigarettes the old-fashioned way – through friends.

What’s especially egregious about the FDA’s exaggeration is that it’s based on data manipulation. The FDA claimed that 22 percent of Walgreens stores engaged in illegal sales of tobacco products to minors since 2010; and 14 other national retail chains had violations of 15 percent-44 percent. These extremely large numbers, however, are the result of cumulative math over a nine-year period. A closer look at the data reveals that there was a 12 percent violation rate nationally in 2018 – a mere 1 percent higher than in 2015-2016.  And Walgreens’ rate was 9 percent, three points lower than the national average.

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Smoking is well-established as the cause of a number of serious health problems. Often, the burden of these side effects falls heavily upon the government – and more specifically, Medicaid. The government, therefore, has a strong incentive to take an active role in reducing the financial consequences of smoking.

Evidence suggests that electronic cigarettes can substantially reduce the health risks associated with tobacco cigarettes. In a newly updated policy study, Richard B. Belzer, an independent consultant to R Street in regulation, risk, economics and information quality, analyzes the expected savings to Medicaid in the first ten years after switching from traditional tobacco products to electronic cigarettes.

In the full study, Belzer examines and calculates the estimated savings that can be reasonably expected if a number of adult Medicaid enrollees switch. Over 25 years, he estimates that the savings to Medicaid will be approximately $2.8 billion per 1 percent of enrollees. The updated addendum estimates the savings for the first ten years after the switch from tobacco to electronic cigarettes at $410 million—where the median state saves approximately $5 million.

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In seven states and Washington, D.C., it is illegal for retailers to sell tobacco products to anyone younger than 21.

A bill that would make Maryland the eighth state to boost its age-of-consent for cigarette sales cleared an important hurdle Tuesday when the Senate Finance Committee voted 9-2 to advance a measure offered by the panel’s chairwoman, Sen. Delores G. Kelley (D-Baltimore).

The measure, which backers have dubbed Tobacco 21, includes the sales of so-called e-cigarettes, such as JUUL, whose sales have skyrocketed in recent years.

Health advocates high-fived one another outside the hearing room after the bipartisan show of support.

“What we’re really seeing right now is a public health epidemic,” said Laura Hale, head of the Maryland chapter of the American Heart Association. “Our youth are using these products at really high rates. … By raising the age to 21, just like we saw with alcohol, we kick it out of the high schools.”

“Tobacco 21 will save lives,” added Jocelyn Collins of the American Cancer Society’s Cancer Action Network.

At a bill hearing last month, retailers expressed concern that 18-, 19- and 20-year-old store clerks might not be allowed to sell cigarette products as the bill was originally drawn.

Companies that manufacture e-cigarettes are watching Maryland’s actions closely. They claim their products are frequently used by people who want to quit traditional cigarettes.

“Vapor products need to be thought of as a health tool, as a harm-reduction component that allows adult smokers to lead a healthier lifestyle by quitting cigarettes,” said David Pasch, a spokesman for Voices for Vaping, part of the Vapor Technology Association. “It doesn’t make any sense in the world to start taxing and doing other things to discourage people from buying vapor products, when they exist and need to exist to help adult smokers quit.”

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Public health officials’ goal should always be to build awareness of the risks associated with smoking and educate the public on the products that can help smokers quit. Yet the public health community has failed to build awareness of how switching to e-cigarettes can reduce the harm associated with smoking by as much as 95 percent, according to the Public Health England and multiple independent reviews.

This is a public health tragedy. Currently 38 million Americans are addicted to traditional combustible cigarettes, which puts them at higher risk for cancer as well as heart and lung disease. A new study shows e-cigarettes are nearly twice as effective as other methods in helping people quit smoking — and thereby significantly improve improve their health prospects. But many people simply don’t know of the e-cigarette option and its benefits.

In fact, when asked whether e-cigarettes are less harmful than traditional cigarettes, 53 percent of Americans in a new nationally represented poll of likely voters conducted by McLaughlin and Associates incorrectly responded “no,” and another 23 percent weren’t sure. A 2016 study published in the American Journal of Preventative Medicine found that even current smokers believed e-cigarettes to be equally or more harmful than traditional cigarettes, a misperception that could dissuade many of them from switching to less harmful e-cigarette products.

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A randomized, controlled trial found that e-cigarettes may be more successful at assisting with smoking cessation than nicotine replacement products. However, questions remain about the safety of e-cigarettes, as they have not been evaluated by the US Food and Drug Administration (FDA).

In this UK-based study, smokers who were interested in quitting were randomly assigned to either nicotine replacement products—provided for free for 3 months—or an e-cigarette starter pack. Both groups also received standard weekly behavioral support for a minimum of 4 weeks.

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A major new study provides the strongest evidence yet that vaping can help smokers quit cigarettes, with e-cigarettes proving nearly twice as effective as nicotine gums and patches.

The British research, published Wednesday in the New England Journal of Medicine, could influence what doctors tell their patients and shape the debate in the U.S., where the Food and Drug Administration has come under pressure to more tightly regulate the burgeoning industry amid a surge in teenage vaping.

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The debate over the potential harms and benefits of vaping has raged on for years. But the results of a large trial in the UK have provided the pro-vaping side its biggest win yet. It found that people trying to quit smoking were almost twice as likely to succeed over a year’s time if they used electronic cigarettes compared to people who stuck to typical nicotine replacement therapy.

The study, published in the New England Journal of Medicine on Wednesday, recruited nearly 900 smokers in the UK. All of the smokers had gone to dedicated centers to help them quit. There, they were randomly assigned one of two interventions.

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For those who want to kick their smoking habit, switching to electronic cigarettes may offer better odds of success than nicotine patches, lozenges or gum, new research suggests.

The finding follows a small year-long study that tracked about 120 British smokers enrolled in a National Health Service smoking cessation program.

“E-cigarettes provide nicotine, which is important when someone is trying to quit smoking,” said study author Dunja Przulj. “Going ‘cold turkey’ with no nicotine can make it difficult to deal with nicotine withdrawal symptoms. Having some kind of nicotine replacement improves your chances of quitting,” she explained.

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For those who want to kick their smoking habit, switching to electronic cigarettes may offer better odds of success than nicotine patches, lozenges or gum, new research suggests.

The finding follows a small year-long study that tracked about 120 British smokers enrolled in a National Health Service smoking cessation program.

“E-cigarettes provide nicotine, which is important when someone is trying to quit smoking,” said study author Dunja Przulj. “Going ‘cold turkey’ with no nicotine can make it difficult to deal with nicotine withdrawal symptoms. Having some kind of nicotine replacement improves your chances of quitting,” she explained.

“In our study, smokers used e-cigarettes much like other nicotine replacement treatments. They were asked to set a ‘quit day,’ and advised to use their e-cigarette regularly throughout the day, and whenever they felt they needed it,” Przulj added. “Everyone was encouraged to try and avoid smoking any normal cigarettes.”

In the end, study results suggested that “e-cigarettes would almost double your chances of quitting at one year compared to nicotine replacement [products],” she reported.

Przulj is a research health psychologist with the Health and Lifestyles Research Unit at Queen Mary University of London.

For the roughly 15 percent of Americans who smoke, the U.S. Food and Drug Administration has not approved e-cigs as a means for quitting.

But as a practical matter, the investigators noted that more American smokers chose e-cigs as a cessation tool than FDA-approved treatments.

In the British study group, a total of 79 smokers were enrolled in an “e-cig group” and given a refillable e-cigarette to use. The remaining 44 smokers were given a three-month supply of any approved nicotine replacement product they wanted.

In the end, the investigators found that while nearly 10 percent of the nicotine replacement group were not smoking traditional cigarettes a year later, that figure nearly doubled, to 18 percent, among those using e-cigs to quit.

The study team acknowledged, however, that prior research has demonstrated that when nicotine replacement products are paired with prescription medications — such as the nicotine receptor blocker Chantix (varenicline) and/or bupropion — one year abstinence rates are the same or higher as the e-cig results.

What’s more, 80 percent of those in the study’s e-cig group were still using e-cigs at the one-year mark. This compared with just 9 percent of those in the nicotine replacement products group by that point.

So, might encouraging smokers to rely on e-cigarettes to help kick their habit raise the risk that quitters just end up swapping out one form of nicotine addiction for another? Przulj thinks that’s a risk definitely worth taking.

“E-cigarettes are at least 95 percent less risky than cigarettes,” she said, “and so even if someone is still using an e-cigarette, the benefits outweigh any cons.”

In fact, “doctors should encourage any smokers to try e-cigarettes,” Przulj suggested, “especially if they have tried other methods before and these have not been helpful.”

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