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  <front>
    <journal-meta>
      <journal-id journal-id-type="publisher-id">JPHI</journal-id>
      <journal-title-group>
        <journal-title>Journal of Public Health International</journal-title>
      </journal-title-group>
      <issn pub-type="epub">2641-4538</issn>
      <publisher>
        <publisher-name>Open Access Pub</publisher-name>
        <publisher-loc>United States</publisher-loc>
      </publisher>
    </journal-meta>
    <article-meta>
      <article-id pub-id-type="publisher-id">JPHI-20-3163</article-id>
      <article-id pub-id-type="doi">10.14302/issn.2641-4538.jphi-20-3163</article-id>
      <article-categories>
        <subj-group>
          <subject>review-article</subject>
        </subj-group>
      </article-categories>
      <title-group>
        <article-title>From Smoking to Vaping:  What does Judaism have to Say?</article-title>
      </title-group>
      <contrib-group>
        <contrib contrib-type="author">
          <name>
            <surname>Akiva</surname>
            <given-names>Turner</given-names>
          </name>
          <xref ref-type="aff" rid="idm1841892588">1</xref>
          <xref ref-type="aff" rid="idm1841892372">*</xref>
        </contrib>
      </contrib-group>
      <aff id="idm1841891436">
        <label/>
        <addr-line>Affiliations</addr-line>
      </aff>
      <aff id="idm1841892588">
        <label>1</label>
        <addr-line>Chair and Professor, Department of Health Science, Nova Southeastern University, USA</addr-line>
      </aff>
      <aff id="idm1841892372">
        <label>*</label>
        <addr-line>Corresponding author</addr-line>
      </aff>
      <contrib-group>
        <contrib contrib-type="editor">
          <name>
            <surname>Lucio</surname>
            <given-names>Mango</given-names>
          </name>
          <xref ref-type="aff" rid="idm1842024460">1</xref>
        </contrib>
      </contrib-group>
      <aff id="idm1842024460">
        <label>1</label>
        <addr-line>Director Nuclear Medicine Service A.O. "S.Camillo-Forlanini" Piazza Carlo Forlanini,                     1 - 00151 Rome - Italy </addr-line>
      </aff>
      <author-notes>
        <corresp>
  Akiva Turner, <addr-line>Chair and Professor, Department of Health Science, Nova Southeastern University, USA</addr-line>. Email: <email>aturner1@nova.edu</email></corresp>
        <fn fn-type="conflict" id="idm1842526380">
          <p>The authors have declared that no competing interests exist.</p>
        </fn>
      </author-notes>
      <pub-date pub-type="epub" iso-8601-date="2020-01-22">
        <day>22</day>
        <month>01</month>
        <year>2020</year>
      </pub-date>
      <volume>2</volume>
      <issue>1</issue>
      <fpage>22</fpage>
      <lpage>26</lpage>
      <history>
        <date date-type="received">
          <day>03</day>
          <month>01</month>
          <year>2020</year>
        </date>
        <date date-type="accepted">
          <day>17</day>
          <month>01</month>
          <year>2020</year>
        </date>
        <date date-type="online">
          <day>22</day>
          <month>01</month>
          <year>2020</year>
        </date>
      </history>
      <permissions>
        <copyright-statement>© </copyright-statement>
        <copyright-year>2020</copyright-year>
        <copyright-holder>Akiva Turner</copyright-holder>
        <license xlink:href="http://creativecommons.org/licenses/by/4.0/" xlink:type="simple">
          <license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</license-p>
        </license>
      </permissions>
      <self-uri xlink:href="http://openaccesspub.org/jphi/article/1248">This article is available from http://openaccesspub.org/jphi/article/1248</self-uri>
      <abstract>
        <p>The author reviews rabbinic decisions about smoking from a historical perspective along with the positions of the medical community. The author then brings the current, though limited, rabbinic considerations about vaping given the current state of science, as well as possible discussions for the future, as more becomes known about the safety and health risks associated with vaping.</p>
      </abstract>
      <kwd-group>
        <kwd>E-cigarettes</kwd>
        <kwd>vaping</kwd>
        <kwd>smoking</kwd>
        <kwd>Judaism</kwd>
        <kwd>halacha</kwd>
      </kwd-group>
      <counts>
        <fig-count count="0"/>
        <table-count count="0"/>
        <page-count count="5"/>
      </counts>
    </article-meta>
  </front>
  <body>
    <sec id="idm1841753300" sec-type="intro">
      <title>Introduction</title>
      <p>Today a great deal is known about the harms of smoking and tobacco use. In the United States, the main cause of preventable disease, disability, and death is the use of tobacco. According to the Centers for Disease Control (CDC), “as of 2017, about 34 million US adults smoke cigarettes. Every day, about 2,000 young people under age 18 smoke their first cigarette, and more than 300 become daily cigarette smokers. Over 16 million people live with at least one disease caused by smoking, and 58 million nonsmoking Americans are exposed to secondhand smoke.” <xref ref-type="bibr" rid="ridm1841333460">1</xref> At the same time, huge strides have been made in preventing tobacco use.</p>
      <p>However, the harms of tobacco use, particularly smoking, were not always known to the public.                 According to the American Cancer Society: </p>
      <p>(I). It wasn’t even until cigarettes were mass produced and popularized by manufacturers in the first part of the 20th century that there was cause for alarm. Prior to the 1900s, lung cancer was a rare disease. Turn-of-the-century changes though, gave way to an era of rapidly increasing lung cancer rates. New technology allowed cigarettes to be produced on a large scale, and advertising glamorized smoking. The military got in on it                    too – giving cigarettes out for free to soldiers during World Wars I and II. Cigarette smoking increased rapidly through the 1950s, becoming much more widespread. Per capita cigarette consumption soared from 54 per year in 1900, to 4,345 per year in 1963. And, lung cancer went from rarity to more commonplace – by the early 1950s it became “the most common cancer diagnosed in American                men. <xref ref-type="bibr" rid="ridm1841331084">2</xref></p>
      <p>Further, it was not until the late 1950s and into the early 1960s, after the completion of large scale studies, that the connection between smoking and cancer became widely accepted. While this change in scientific knowledge profoundly affected medicine and public health, it has also affected the rulings on the part of rabbinic decision makers regarding the religious permissibility or impermissibility of smoking or using tobacco products.  </p>
      <p>Rabbinic decision makers base rulings or  decisions on <italic>halacha</italic> (Jewish Law). <italic>Halacha</italic> is a body of codes and laws that come from the written and oral Torah. “The word <italic>halacha</italic> comes from a Hebrew verb which means to walk, to go, or to journey. <italic>Halacha</italic> guides an observant Jew in how to eat, sleep, drink, dress, conduct business, engage in various interpersonal and intimate relationships, as well in the Jew’s general conduct in all facets of life….” <xref ref-type="bibr" rid="ridm1841327412">3</xref> In the areas of health promotion, disease prevention and treatment, rabbinic authorities apply <italic>halacha</italic> to what is known in medical and public health science. <xref ref-type="bibr" rid="ridm1841335196">4</xref></p>
      <p>This article reviews the <italic>halachic</italic> decisions about smoking and how the outcome of these decisions have changed as the science has changed. It should be noted that the <italic>halachic </italic>basis for a decision does not change, but the facts to which it applies may change. Next this article sets forth current limited <italic>halachic</italic> discussions about vaping given the current state of science, as well as possible discussions for the future as more becomes known about the safety and health risks associated with vaping.</p>
      <sec id="idm1841749484">
        <title>Smoking and Halacha</title>
        <p>The Torah includes some broad, but important, statements about prevention and health. The Torah instructs Jews to “Guard your life exceedingly,”and                    to, “take care of yourself and guard your life                  exceedingly.”<xref ref-type="bibr" rid="ridm1841435628">5</xref><xref ref-type="bibr" rid="ridm1841186156">6</xref><italic>Halacha</italic> is most strict regarding risks for physical harm. For example, in the Talmud we are told that “one has a positive duty to remove and guard oneself of any life-threatening obstacle…..If one did not remove said obstacles, one has cancelled a positive commandment and transgressed (the commandment) "do not bring bloodguilt." <xref ref-type="bibr" rid="ridm1841186012">7</xref></p>
        <p>In the Talmud it also states, and was later codified,  that " Let a person never stand in a dangerous place, and say to himself that (the Heavenly minions) will perform a miracle for him and save him from harm for perhaps they will not perform a miracle for him, and even if they do perform a miracle for him, they deduct it from his merits” <xref ref-type="bibr" rid="ridm1841183204">8</xref> In a foundation text of Ashkenazi Chassidim,  it is put forth that if a person dies through his negligent actions, he will be judged for causing his own death.<xref ref-type="bibr" rid="ridm1841181044">9</xref> There is even a ruling that a behavior with a doubtful deleterious physical impact or outcome may still be prohibited. <xref ref-type="bibr" rid="ridm1841187668">10</xref></p>
        <p>To understand the application of <italic>halacha</italic> to, and <italic>halachic </italic>decisions about, tobacco, it is important to note that tobacco began to be chewed or smoked over 2,000 years ago. By the 1700s smoking had become widespread and a tobacco industry had grown to meet demand. During the 1920s, some of the first medical reports that linked smoking to lung cancer began to appear but did not gain media attention. This has been attributed to the influence of the tobacco industry. As has already been noted, it was not until the 1950s and 1960s that major medical reports widely reported that smoking could cause various illnesses. <xref ref-type="bibr" rid="ridm1841175652">11</xref></p>
        <p>Well before these widespread medical reports, some European Jews believed that smoking aided in digestion and was either a benign or helpful habit. <xref ref-type="bibr" rid="ridm1841174284">12</xref> Given this, early <italic>halachic</italic> rulings did not address or prohibit smoking. However, there was much <italic>halachic</italic> discussion once it began to become known that there were some harmful risks associated with tobacco use.</p>
        <p>The European Rabbi, the Chofetz Chaim, wrote in the first part of the 20<sup>th</sup> century that ill or weak persons, even if addicted, were forbidden to smoke.   This was consistent with medical conclusions of that                time.<xref ref-type="bibr" rid="ridm1841171908">13</xref> Nevertheless, tobacco use was not prohibited for everyone and the Chofetz Chaim even wrote about the permissibility of smoking on Jewish holidays. <xref ref-type="bibr" rid="ridm1841169820">14</xref></p>
        <p>As the harms of smoking became more widely known, <italic>halachic</italic> deciders began to ponder whether it should be permitted. Early on the discussions revolved around an application of the Psalms verse “May G-d watch over the simpletons.” The Talmud applies this directive in certain cases, and it is invoked throughout the Talmud to allow what might not be permissible.  The assumption behind this directive is that if the masses were so accustomed to doing the activity that we rely upon G-d to protect them. For example, one major 20<sup>th</sup> century <italic>halachic</italic> source, Rabbi Moshe Feinstein, acknowledged the science linking smoking to harms,  but because the practice was so widespread, he relied              upon the above principle not to prohibit it. Others               objected to Rabbi Feinstein’s approach. For example, Rabbi Eliezer Waldenberg, believed that one could only apply “May Gd watch over the simpletons” if one could observe that many of those engaged in an unsafe activity were not harmed. <xref ref-type="bibr" rid="ridm1841165260">15</xref></p>
        <p>Regardless, rabbinic authorities will not establish a new decree if they believe that most of the community is unable to abide by it. This is related to the idea that the practice is so widespread. On the other hand, some have suggested that declaring smoking prohibited may not be a new decree as it falls under the existing decree to guard oneself or one’s life. <xref ref-type="bibr" rid="ridm1841165260">15</xref></p>
        <p>The Lubavitcher Rebbe, Rabbi Menachem Schneerson, being trained in engineering sciences,                took a related yet different approach. He posited                  that although cigarettes are dangerous, one day              technological advances may allow cigarettes to be manufactured with less risk to health. Thus, making a specific mandate might not be necessary. However, in their current form, he said, they are forbidden under the broader Torah mandates discussed above. <xref ref-type="bibr" rid="ridm1841165260">15</xref></p>
        <p>Even in earlier years when smoking was not <italic>halachically </italic>forbidden, it was <italic>halachically </italic>prohibited, however, to smoke if the smoke bothered others. <xref ref-type="bibr" rid="ridm1841161732">16</xref> Indeed, Rabbi Eliezer Waldenberg, a major rabbi and judge in Jerusalem, was insistent that if a smoker was asked to discontinue smoking by someone bothered, the smoker must stop. <xref ref-type="bibr" rid="ridm1841165260">15</xref></p>
        <p>Today many rabbis now declare smoking is prohibited. <xref ref-type="bibr" rid="ridm1841158636">17</xref> This because medical and public health professionals agree that smoking is a danger to health. In addition, smoking is no longer widely accepted in modern culture.  An extensive review of contemporary rabbinic opinions on the subject led the Rabbinical Council of America, one of the world’s largest  organizations of Orthodox rabbis, to conclude:</p>
        <p>Accordingly, this analysis must lead to the unambiguous conclusion that smoking is clearly and unquestionably forbidden by (halacha) and that this should be made known to all who care about the (Torah) and their health. A final note is in order: People who smoke are not (G-d forbid) doing so in an attempt to flout (halacha). In fact, most would dearly wish to quit, but shedding an addiction is no simple matter. While it is important to make clear that (halacha) prohibits smoking, it is also important not to condemn those who struggle with this issue. Rather we must offer our full help and support to aid them in their quest for physical and spiritual           health. <xref ref-type="bibr" rid="ridm1841158636">17</xref></p>
      </sec>
      <sec id="idm1841725292">
        <title>Vaping and E-Cigarettes </title>
        <p>E-cigarettes contain nicotine as well as flavoring and other substances. E-cigarettes are electronic and produce an aerosol or vapor from heated liquid. According to the CDC, “E-cigarettes have the potential to benefit adult smokers who are not pregnant if used as a complete substitute for regular cigarettes and other smoked tobacco products.” However, they are not safe “for you, young adults, pregnant women, or adults who do not currently use tobacco products.” The CDC does note that there is still much to learn about the effectiveness of e-cigarettes for smoking cessation and about long-term health effects. <xref ref-type="bibr" rid="ridm1841158348">18</xref></p>
        <p>Much of the health concerns for youth have centered around the potential of nicotine harming the developing adolescent brain, including the parts of the brain that control attention, learning, impulse control and mood. Use of e-cigarettes may also lead to future addiction. Even for adults, “some of the ingredients in             e-cigarette aerosol could also be harmful to the lungs in the long-term. For example, some e-cigarette flavorings may be safe to eat but not to inhale because the gut can process more substances than the lungs.” There have also been reports, though rare, of e-cigarette batteries causing explosions and injury, as well some poisoning from ingesting the liquid or absorbing it through the skin and eyes. <xref ref-type="bibr" rid="ridm1841141756">19</xref></p>
        <p> More recently there have been outbreaks of lung illness associated with flavored e-cigarette usage, and the investigation is ongoing. As of December 27, 2019, the CDC has identified 2,561 hospitalized cases                   of e-cigarette or vaping use associated with lung injury in the United States and 55 deaths have been confirmed.<xref ref-type="bibr" rid="ridm1841138948">20</xref> In response to these lung illnesses the CDC did issue a health alert and has identified vitamin E acetate as a chemical of concern associated with lung injury, but at this point the CDC has not ruled out other chemicals of concern. <xref ref-type="bibr" rid="ridm1841138948">20</xref><xref ref-type="bibr" rid="ridm1841138516">21</xref></p>
        <p>As the risks still have not been shown in large studies, most of the <italic>halachic </italic>discussions, taking place before the CDC health alert and the reporting of cases of lung injury, have centered around the kashrus (i.e. kosher or non-kosher status) of the liquid in the                       e-cigarettes that turns into a vapor, the outcome being whether e-cigarettes need a <italic>hecher</italic> (kosher symbol) and be certified as kosher.  The issue is not the nicotine, but the flavoring used which may contain non-kosher animal fat. </p>
        <p>Normally one would need to eat or drink something for it to need a kosher symbol. This is                    why one can be injected with a vaccine containing                 non-kosher products since it is not being ingested. In the case of E-cigarettes one is inhaling a vapor not drinking the liquid. However, there were early <italic>halachic</italic> discussions regarding the inhalation of forbidden wine vapors <xref ref-type="bibr" rid="ridm1841137292">22</xref> These discussions have been applied to vaping leading to the following conclusions: </p>
        <p>Based on everything we have seen, it seems that there may be some considerations that could lead one to be stringent only as a stringency (i.e. require a kosher symbol). However, the basic ruling should be that it is permitted (no kosher symbol required). It seems that some Kashrus organizations today in the U.S. adopt the lenient approach, while others, such as the Chicago Rabbinical Council (C.R.C.), do require certification. <xref ref-type="bibr" rid="ridm1841133404">23</xref></p>
        <p>Less has been discussed by rabbis about safety at this date. At least one rabbi,  Rav Yosef Greenwald acknowledges that E-cigarettes may be useful and permitted for someone trying to quit smoking, but also notes they may contain some dangerous elements and concludes that one is not allowed to start vaping given the obligation to take care of one’s health. <xref ref-type="bibr" rid="ridm1841133404">23</xref> It should be noted that  Rav Greenwald wrote that opinion before the CDC issued its health alert regarding lung illnesses, and before some states and localities began to ban flavored E-cigarettes following an announcement by the President of the United states proposing a ban on flavored vape products. Given this new possible connection between E-cigarettes and a very debilitating lung illness, which may lead to death in some cases, the <italic>halachic</italic> discussion may move from discussions of kashrus to those similar to the <italic>halacha</italic> of prohibiting or permitting tobacco use. Like with evidence for the hazards of smoking regular tobacco, large full-scale studies may take years for E-cigarettes. However, one would anticipate the <italic>halachic</italic> discussion will revolve around the current level of evidence for risk, evidence of benefit for current smokers, as well as prevalence of                  E-cigarette use in the community at large.</p>
      </sec>
    </sec>
  </body>
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        <mixed-citation xlink:type="simple" publication-type="journal">
          <fpage>http://matzav.com/holy-smokes-a-halachic-discussion-regarding-e-cigarettes</fpage>
        </mixed-citation>
      </ref>
    </ref-list>
  </back>
</article>
