Australia’s Therapeutic Goods Administration (TGA) last week rejected an application to liberalise the scheduling of nicotine (see from page 71).
This prompted the predictable round of protests from proponents of e-cigarettes who have long touted them as the next public health wonder of the world, even as important as antibiotics.
But unlike antibiotics, which are heavily regulated, require a prescription, and must demonstrate both safety and efficacy to regulatory bodies, e-cigarettes and the liquids used in them are virtually unregulated.
Tobacco harm reduction has had a history of monumental failures. It started with the global multi-million dollar promotion of filters. One of these was the infamous asbestos-filtered “micronite filters” in Kent cigarettes. More recently, we saw the now outlawed consumer deceptions of the light and mild cigarette fiasco. And on the way we even had “reduced carcinogen” brands.
These were designed to keep people smoking and slow the mass exodus that began in the early 1960s. Millions did just that. Only quitting and the decreasing incidence of smoking (ie. never starting) have dramatically decreased the tobacco disease epidemic.
It would be wonderful if e-cigarettes were finally a harm reduction holy grail. But there are many reasons to remain cautious.
Here I look at 12 mantras about e-cigarettes that seem to have failed to impress the TGA.
1. Vaping is ‘95% less harmful than smoking’
A hand-picked group of 12 produced this magic number when asked to rank the health risks of 12 nicotine delivery products, including cigarettes. Several of the group had no research record or expertise in tobacco control; some had histories of financial connections with manufacturers of e-cigarettes and tobacco companies. There were no toxicologists, cancer or cardiovascular specialists among the authors.
The “95%” number was uncritically repeated in a Public Health England report, which even described e-cigarettes as “around 95% safer [not less dangerous] than smoking” (my emphasis). Incredulous toxicologists have since pointed out “there is no evidence for the 95% estimate”.
The extreme pro e-cigarette activist Carl Phillips, who has a long history of support from tobacco manufacturers, summed it up beautifully:
This specific point estimate (synonymous with “5% as bad for you as smoking”) has rapidly evolved into “fact” (in the political sense of that term). It is repeated in a large fraction of popular press reports and widely used in arguments, snipes, and broadsides from vaping advocates. It seems to have emerged from nowhere when the Public Health England report asserted the figure. That traced to what was actually a huge misinterpretation of what was only a made-up number, from one junk-science journal article.
Phillips may be unique in believing the number is closer to 1%. His supporters in the tobacco and vaping industries are probably very happy with the PR potential of that estimate.
2. Vaping is orders of magnitude less harmful than smoking
Because vapers don’t inhale smoke, with its toxic cocktail of carcinogens, irritants and carbon monoxide, this is almost certainly going to be the consensus when sufficient longitudinal data emerge, particularly when it comes to cancer. However, the already mentioned “group of 12” has claimed that “The paucity of evidence for serious harm to users of e-cigarettes over the years since they were first marketed in 2006, with millions purchased, in itself is evidence” of vaping being all but benign.
Even perceptive vapers have seen through this nonsense. It took several decades for the full effects of smoking tobacco to emerge. Worrying evidence about cardio-respiratory effects is already mounting. These highly respected researchers estimated the long-term effects of vaping may equate to 50% of the risk of cardio-respiratory harm that tobacco causes, what they call a “substantial” exposure.
Tobacco-caused cancers may well reduce in people who only vape. But cancer deaths represent only 37% of all tobacco deaths: cardio-respiratory deaths make up most of the rest.
3. Nicotine in vaping is benign
While some make facile comparisons of the risks of nicotine with drinking coffee, the International Agency for Research on Cancer recently noted “evidence has indicated the potential for nicotine to cause DNA damage” and “inhibit apoptosis, and stimulate cell proliferation and angiogenesis …”, declaring that evaluation of electronic cigarettes and nicotine is a “high priority”.
The recent US Surgeon General Report highlighted the adverse effects of nicotine on brain development in young people and in pregnancy. A recent study has further revealed previously unrecognised negative effects of nicotine, and vaping, on the heart.
4. Vaping has caused 6.1 million European smokers to quit
This factoid was megaphoned from a paper authored by a researcher with a history of funding from e-cigarette manufacturers. It was a secondary analysis of a cross-sectional survey since pilloried in the journal Addiction, where it was published. As any epidemiology student knows, causality can never be claimed from cross sectional studies. Among other criticisms, the critics asked:
How many of those who claim that they have stopped with the aid of e-cigarettes would have stopped anyway, and how many of those who used an e-cigarette but failed to stop would have stopped had they used another method.
They also noted the questions asked would have allowed those who quit for only a short period to say they had “stopped”.
Longitudinal studies with a minimum of 12 months follow-up of randomly selected cohorts have shown sobering results, a long way from the hype of vaping having the equivalent efficacy of antibiotics. One such follow-up reported:
Daily use of e-cigarettes while smoking appears to be associated with subsequent increases in rates of attempting to stop smoking and reducing smoking, but not with smoking cessation.
A companion paper reported daily use of tank-system (refillable) e-cigarettes were the only type of e-cigarette to show a significant improvement in smoking cessation. The very latest data from England show about half of daily e-cigarette users are also smoking (slide 9) and the rate at which English smokers have tried to stop is the lowest in 2016 (30.9%) than it has been since 2007 (42.5%) when the study began (slide 22).
This raises important questions about whether e-cigarettes may be keeping many smokers smoking, while helping others to quit.
5. Just cutting back smoking (rather than quitting) significantly reduces risk
It’s obvious, surely, if you don’t quit but only cut down the amount you smoke, the reduced smoking is going to reduce the harm you are doing? Obvious that is, until you actually look at very large studies that have looked at the death rates down the track in those who reduce but don’t quit.
First, two examples followed 479,156 men for 11 years and found no association between smoking reduction and all cancer risk but a significant decrease in risk of lung cancer, with the size of risk reduction “disproportionately smaller than expected”. Second, a study of 51,210 people followed from the 1970s until 2003 found no evidence smokers who cut down their daily cigarette consumption by more than 50% reduced their risk of premature death significantly.
Vaping advocate and Addiction editor Professor Robert West puts it succinctly:
I think as far as using an e-cigarette to reduce your harm while continuing to smoke is concerned there really isn’t good evidence that it has any benefit.
And as we saw earlier, a large proportion of people who vape, continue to smoke.