11 Dec

Why Can’t Scientists Agree on E-Cigarettes?

Earlier this year, Michael Gove claimed Britain’s had enough of experts. Now I don’t agree with Gove on much, but when it comes to e-cigarettes, he may have a point. We’re bombarded with stories about these products, but most just add to the confusion, with perceptions of vaping risks rising year on year. Just recently the Sun informed us that experts are saying “e-cigs are just as bad for your heart as smoking fags”, but read a couple lines down and you’ll find other experts reasserting the claim that e-cigarettes are 95% safer than tobacco. So which is it? Why can’t the scientists agree? And will they ever?

Cochrane is a global non-profit group that reviews all the evidence on healthcare interventions and summarises the findings so people making important decisions – you, your doctor, the people who write medical guidelines – can use unbiased information to make difficult choices without having to first read every study out there. This week, the latest Cochrane review of e-cigarettes was published. While the conclusions are limited because there aren’t many high quality studies available yet, overall the evidence suggests that (1) e-cigarettes with nicotine can help people quit smoking, (2) they don’t seem to have any serious side effects in the short- to mid- term (up to 2 years), and (3) in some cases, switching to them leads to changes in your blood and breath that are consistent with the changes you’d see in people who give up smoking altogether.

This is good news. But other systematic reviews and studies have drawn very different conclusions, and I’m going to try to shed some light why that is.

Can e-cigarettes help people quit?

Our Cochrane review suggests they can. But a review published in the Lancet Respiratory Medicine earlier this year, which received a lot of attention, suggests they actually make it harder. The reason for this difference is the types of studies the authors include.

Randomized controlled trials are the best way to see if a treatment works. As Ben Goldacre, author of Bad Science, explains, by randomly assigning people to one intervention or another and measuring the outcome in the same way across both groups, you can rule out alternative explanations for differences between groups. The reviews that find e-cigarettes help people quit smoking only include randomized controlled trials. The studies that find that e-cigarettes stop people from quitting aren’t randomized controlled trials – instead they survey smokers and ask if they are using e-cigarettes. Then, some months later, they ask the same people if they are still smoking. We don’t know if the results from these studies reflect the effect of vaping, or if something else about the vapers makes it harder for them to quit. For example, it might be reasonable to imagine they are more dependent smokers, which is why they vape as well as using regular cigarettes. This would make quitting harder.

Are they safe?

The issue here isn’t so much the study type, but the way you ask the question. By ‘safe,’ do you mean completely without risk? No, they’re not – not much is. We’ve seen stories about people catching fire and puppies with nicotine poisoning. Plus, in general, it’s not a great idea to inhale chemicals into your lungs if you can avoid it. Experts basically agree on that – I’ve yet to come across a tobacco researcher or policy maker who would recommend you start using e-cigarettes if you aren’t already a smoker.

The crucial question here is – safe compared to what? Cigarettes are uniquely deadly. They kill one in two people who use them regularly. So, if you’re asking whether e-cigarettes are safer than regular cigarettes, most experts would, after briefly hesitating, lean on the side of yes. The hesitation is there because e-cigarettes are new to the scene. We don’t know their long-term safety profile, so we have to look for clues elsewhere – for example, studies that measure side effects of short-term use and studies about how e-cigarettes affect your blood, lungs and heart. Interpreting these measures is complicated. For example, a recent study found that vaping affects the same blood vessel in your heart as smoking regular cigarettes. This isn’t necessarily surprising – we know nicotine, the active agent in both, affects this vessel. We also know that nicotine isn’t responsible for the harms associated with smoking. So how to interpret these results? The gamut of expert reactions ran from “[e-cigarettes are] far more dangerous than people realise” to “vaping carries a fraction of the risk of smoking.” When it comes to long-term safety, experts are making their best guesses in the absence of solid data, and that’s where room for disagreement creeps in.

So what’s next?

The good news is there’s lots of research going on – finally. The most recent update of the Cochrane review found 26 studies in the pipeline that will help answer questions about the safety and effect of using e-cigarettes to quit smoking. The more studies we have looking at a question, the more certain we can be about the answer. The irony is that until we have the answer, narrow interpretations of the results of individual studies risk doing further harm, undermining public confidence in science and possibly discouraging quit attempts. Fundamentally, tobacco researchers on both sides of the argument want the same thing – to reduce death and disease. We’re in the same boat. If you’re reading this as a member of the public, please don’t be put off by the conflicting headlines – we all agree cigarettes are bad for you, most of us agree vaping is probably much safer than smoking regular cigarettes, and if you’re a smoker we all really want our research to help you to quit. Don’t let us get in the way.

05 Jun

Majority of Vapers Have Quit Tobacco – Survey

More than half of the estimated 2.9 million people in the UK who use e-cigarettes have given up smoking tobacco, a survey suggests.

But many people overestimate the relative health risks of vaping, which may have contributed to a slowdown in the numbers turning to e-cigarettes. Nine million people in the UK still smoke tobacco.

The number of people vaping or using e-cigarettes has quadrupled in the past five years, the annual Smokefree GB survey by Action on Smoking and Health (ASH) found, with many people turning to them for help with quitting or cutting down on smoking tobacco.

For the first time, more than half of vapers said they had quit smoking. Most of the remainder continued to both vape and smoke tobacco.

Ann McNeill, professor of tobacco addiction at King’s College London, said the finding was encouraging. “This year’s Ash survey finds that around 1.5 million vapers are ex-smokers, for the first time a larger number than those who continue to smoke,” she said.

“This is encouraging news as we know that vapers who continue to smoke continue to be exposed to cancer-causing chemicals. The message for the 1.3 million vapers who still smoke is that they need to go further and switch completely.”

But vaping’s rate of growth has slowed considerably in the past couple of years, and the survey found many people overestimated the health risks of vaping compared with tobacco.

In 2015, Public Health England concluded vaping was about 95% less harmful than smoking. But more than a quarter of respondents (26%) said they believed e-cigarettes were equally or more harmful than the traditional equivalents, with only 13% saying they were much less harmful than smoking.

Deborah Arnott, the chief executive of Ash, said: “It’s excellent news that the number of vapers who have quit smoking is continuing to grow, but there are still 9 million smokers compared to only 1.5 million vapers who don’t smoke at all.

“The rapid growth in e-cigarette use has come to an end while over a third of smokers have still never tried e-cigarettes, saying the main reasons are concerns about the safety and addictiveness of e-cigarettes. It’s very important smokers realise that vaping is much, much less harmful than smoking.”

The findings were based on an online survey by YouGov of 12,969 adults, weighted to be representative of the UK adult population.

14 Sep

Banning E-Cigarettes Will Be A Drag On Public Health

This week, the Victorian Legislative Council debates the draconian legislation to have electronic cigarettes regulated as tobacco products, under the Tobacco Amendment Bill 2016. Although well meaning, this legislation is misguided. It will help perpetuate smoking and have an overall negative effect on public health.

If passed, the legislation will restrict the sale, supply, display and use of e-cigarettes as if they were tobacco products. It will be illegal to vape in designated smoke-free areas in Victoria. Even advertisements to encourage smokers to switch to vaping will not be allowed.

A recent comprehensive review of e-cigarettes by the prestigious UK Royal College of Physicians recommended that e-cigarettes be promoted as widely as possible as a substitute for smoking in the interests of public health. So why are we effectively banning them in Victoria?

Fear and misinformation

The new laws are based on fear and misinformation. E-cigarettes are not tobacco products. They do not contain tobacco, do not burn and do not release smoke. Almost all of the harm from smoking is caused by the smoke, and nicotine has relatively minor health effects, except in pregnancy. E-cigarettes provide the nicotine that smokers are addicted to but with very low levels of harmful chemicals. According to recent comprehensive reviews by Public Health England and the Royal College of Physicians, e-cigarettes are unlikely to exceed 5 percent of the harm from smoking tobacco.

There is also clear evidence that e-cigarettes are helping many people to quit. Studies of early models which deliver low nicotine levels are at least effective as nicotine patches and newer models are substantially more effective. A recent study in the journal Addiction estimated that over 6 million smokers had quit smoking using electronic cigarettes in Europe alone.

According to the Victorian Minister for Health, e-cigarettes will act as a gateway to smoking for young people and ‘renormalise’ smoking. However, 10 years of experience in the UK, US and Europe suggests that the opposite is true — that e-cigarettes may be reducing adolescent smoking rates. Although many adolescents experiment with e-cigarettes, overseas studies have found that regular use is almost exclusively confined to young people who already smoke. Furthermore, in the US, only 20 percent of adolescent vapers use nicotine.

In the UK and US, there is no evidence that e-cigarettes are undermining the decline in smoking rates. In fact, as e-cigarette use is rising, adolescent and adult smoking rates are falling faster than ever before. It is quite possible that e-cigarettes are contributing to this rapid fall. Young people who experiment with e-cigarettes may otherwise have smoked if e-cigarettes were not available. It is obviously better for young people not to use e-cigarettes, but vaping is preferable to smoking and is likely to be 95 percent safer.

More research is needed before we have certainty about the risks and benefits of e-cigarettes. Like any new treatment, there is a possibility of unknown side-effects in the future. However, one thing we are sure of is that two out of three cigarette smokers will be killed prematurely by their habit and vaping can help many of them to quit.

Getting the regulatory balance right

E-cigarettes should be regulated, but in a balanced way that maximises the potential benefits to smokers while minimising the risk of negative public health effects. Regulation also needs to be proportionate to risk. It is irrational to apply severe restrictions to a much safer product while allowing widespread access to deadly cigarettes.

The proposed legislation is focussed solely on avoiding potential dubious risks but ignores the substantial health benefits to smokers. This legislation could have the unintended consequence of undermining a potentially life-saving technology. It will diminish the appeal of vaping relative to smoking and may even destroy the industry altogether, enhancing the unregulated black market.

The proposed total advertising ban on vaping is counterproductive. Carefully regulated advertising to adult smokers can inform them of the significant harm-reduction benefits of vaping and encourage them to switch. Appropriate advertising guidelines would avoid images of young people, targeting youth and non-smokers and glamorous or seductive advertising styles.

E-cigarettes should be given a competitive advantage over cigarettes to encourage switching. Allowing people to vape in some smokefree areas would help to make e-cigarettes more attractive and would reduce the risk of vaping ex-smokers having to use smoking areas with other smokers. Sales tax on e-cigarettes should be minimal to maintain a price advantage over deadly cigarettes.

Further appropriate regulations would ensure childproof containers with accurate labelling, no sale to people under 18 years, quality control and safety standards.

E-cigarettes represent a massive opportunity for Victorian smokers and have the potential for substantial improvements in public health. We cannot afford not to embrace them.

14 Sep

Australia’s Prohibition of E-Cigarettes is Out of Step With the Evidence

A new report by the Royal College of Physicians in the United Kingdom says electronic cigarettes (e-cigarettes) are much safer than smoking and encourages their widespread use by smokers. It concludes that e-cigarettes have huge potential to prevent death and disease from tobacco use.

The review identifies e-cigarettes as a valuable tool to help smokers quit. For those who are unable to quit with currently available methods, e-cigarettes can substitute for smoking by providing the nicotine to which smokers are addicted without the smoke that causes almost all of the harm. This approach is supported by the scientific and public health community in the UK and is consistent with a previous review by Public Health England, the government health agency.

E-cigarettes are the most commonly used aid to quit smoking in the UK. According to the new review, evidence available so far suggests e-cigarettes are at least as effective as nicotine replacement therapy, such as patches or chewing gum. More than one million people have quit smoking in the UK using e-cigarettes. Quit rates are likely to be even higher with professional counselling and with more advanced devices.

E-cigarettes have been available in the UK since 2007 as a general consumer product – with some additional restrictions on advertising and minimum age of sale. They’re used almost exclusively in the UK by smokers who are trying to cut down or quit smoking, or who have quit smoking.

Concerns About E-Cigarettes

In Australia, e-cigarettes containing nicotine are prohibited. Most Australian health organisations such as the National Heart Foundation, Cancer Council Australia and the Australian Medical Association take a very risk-averse approach based on potential harms. They say e-cigarettes could be a gateway to smoking for non-smokers; they may make the act of smoking socially acceptable again (renormalisation); there may be unknown long-term safety risks; and dual use may delay quitting.

The new review explores the evidence for these concerns and says they are mostly unfounded.

In the UK, there is no evidence e-cigarettes are a gateway to smoking. E-cigarette use is almost entirely restricted to current or past smokers. Use by children who would not otherwise have smoked appears to be minimal.

The report found no evidence to suspect the use of e-cigarettes renormalises smoking. On the contrary, smoking rates in the UK have been falling as e-cigarette use rises.

E-cigarette vapour contains some toxins and the report acknowledges some harm from long-term use cannot be dismissed. However, it supports the widely held view that the hazard to health is unlikely to exceed 5% of the risk of smoking, and may well be substantially lower. This level of harm is similar to nicotine replacement therapy and is likely to reduce with further technological advances. Similarly, the report concludes the harm to bystanders from vapour exposure is negligible.

Many e-cigarette users continue to smoke as well for a period of time (dual use) but there is no evidence this has reduced the number of smokers who quit. Indeed, dual use is often a transitional phase and many users will go on to quit completely as is the case of smokers concurrently using nicotine replacement therapy. A recent study found dual use reduces smoking intake and is less hazardous.

Implications for Australia

Australia has a comprehensive tobacco control policy including high tobacco taxes, mass media campaigns and smoke-free policies that stimulate quit attempts. However, smoking is highly addictive and most of Australia’s three million smokers try and fail repeatedly to quit, even with existing therapies

Based on the UK experience, e-cigarettes could assist many Australian smokers to quit or could replace cigarettes with a much safer source of nicotine. This could potentially save many thousands of lives each year.

As established smokers are more likely to be socioeconomically disadvantaged or to have mental health problems, the burden of disease falls disproportionately on these groups who have higher levels of addiction to nicotine and greater difficulty quitting.

The precautionary position taken by Australian health organisations and governments is not supported by the available evidence and overseas experience. The growing evidence for safety and effectiveness of e-cigarettes significantly outweighs any potential risks to public health.

A rational, evidence-based approach would be to make e-cigarettes available in Australia as consumer products and to encourage their use while minimising uptake by people who would not otherwise have used nicotine products. Ongoing monitoring and appropriate proportionate regulation would help minimise any risks.

E-cigarettes represent a massive opportunity for Australian smokers and have the potential for large-scale improvements in individual and public health, and social inequality. We cannot afford not to embrace them.

14 Aug

If Teens Are Going to Smoke, Better it Be an E-Cigarette

Opponents of e-cigarettes claim that they are acting as a gateway to smoking for young people. However, 10 years of experience in the UK, US and Europe suggests that the opposite is true — that e-cigarettes may be reducing adolescent smoking rates.

Experimentation is a normal part of adolescence and many will try e-cigarettes, mostly out of curiosity. However, it is rare for non-smoking youth to become regular e-cigarette users. In the United Kingdom, less than 0.2 per cent of youth have never smoked “vape” regularly and there is no evidence of progression from vaping to smoking. Regular e-cigarette use is almost exclusively confined to young people who already smoke.

According to a recent comprehensive review by the respected Royal College of Physicians in the United Kingdom “e-cigarettes are being used almost exclusively as safer alternatives to smoked tobacco, by confirmed smokers who are trying to reduce harm to themselves or others from smoking, or to quit smoking completely”.

Another argument claimed to support the gateway effect is the idea that adolescents will become addicted to nicotine from using e-cigarettes and then progress to more dangerous tobacco products for a better nicotine hit. However, the great majority of adolescent e-cigarette users do not use nicotine. In the US, only 20 per cent of adolescent users used nicotine in 2015.

As e-cigarette use by adolescents is rising in many countries, adolescent smoking rates are falling faster than ever. For example, in the US, the National Youth Tobacco Surveys found that e-cigarette use by high school students rose from 1.5 per cent to 13.4 per cent from 2011 to 2014. However, conventional cigarette smoking fell from 15.8 per cent to an all-time low of 9.2 per cent during the same period, the most rapid rate of decline on record. If a gateway mechanism is operating, an increase in smoking rates would be expected.

It is quite possible that e-cigarettes are contributing to this rapid fall in adolescent smoking rates. Young people who experiment with e-cigarettes may otherwise have smoked if e-cigarettes were not available. Using an e-cigarette which may be more enjoyable and socially acceptable may prevent taking up the more harmful behaviour. It is obviously better for young people not to use e-cigarettes, but vaping is preferable to smoking and is at least 95 per cent safer.

Furthermore, there is evidence from the US that banning the sale of e-cigarettes to minors may increase adolescent smoking rates. Two large studies found that banning the sale of e-cigarettes to minors led to a significant increase in adolescent tobacco smoking rates compared to states without such bans.

In addition, some young people use e-cigarettes to help them quit smoking as do adult smokers. E-cigarette bans remove this treatment option altogether.

It is important to monitor electronic cigarette uptake for any potential risks. However, this new technology has the potential to save millions of lives and, according to the Royal College of Physicians, should be widely encouraged in the interests of public health.