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How good are ecigarettes at helping smokers quit?

https://simonchapman6.wordpress.com/2019/01/09/how-good-are-ecigarettes-at-helping-smokers-quit/

Any radio discussion of ecigarettes inevitably attracts evangelical callers wanting to tell their story of the miracle they have experienced:

“As a fortunate survivor of extended tobacco addiction, 40 years of a pack a day, I have not smoked a single bit of tobacco since I started vaping 5 months ago. I was able to finally give up tobacco after failed attempts at cold turkey, patches, and gum as NRT”

“I know about 200 people in our small town of 3000 that vape, and only about 3 of those still smoke some cigarettes, and those that do have cut consumption by about 90%.” [note here that a recent English analysis concluded “If use of e-cigarettes and licensed NRT while smoking acted to reduce cigarette consumption in England between 2006 and 2016, the effect was likely very small at a population level.”)

As I’ve previously summarised, there are many reasons why such testimonial statements are considered the weakest form of evidence in answering questions about whether ecigs are serious new entrants in the population-wide game of helping smokers to quit.

The obvious problems with individual testimonies are self-selection bias (people with a success story are far more likely to want to enthusiastically proselytise their story than the many who try and fail); lead time bias or “borrowing from the future” (some people who quit would have quit weeks or months later anyway, perhaps on their own or using another approach, thus artificially inflating the apparent importance of the method they used when they quit); and relapse.

Relapse is a major, much studied sequalae to quit attempts. Far more smokers relapse than quit permanently. Across all methods, relapse dominates, with the maximum rates occurring in the first month after an attempt (eg: see table below).

1.-screen-shot-2019-01-08-at-4.26.59-pm

This means that cross-sectional (“snap-shot”) surveys which report findings on what people’s smoking status is on the day they answered the survey questions have major limitations. Many people have inaccurate recall of their smoking and quit attempt histories and many people who report being ex-smokers on the day they answered the question would answer that they had returned to smoking if asked the same question a few weeks or months later.

For example, this study proposed that by 2014, 6.1m Europeans had quit smoking by vaping. But such “big” numbers often do not withstand scrutiny. The 6.1 million number comes from a cross-sectional survey where ex-smokers reported they used to smoke, then used e-cigarettes and now don’t smoke. Were it only that simple. This critique makes the key point that the survey questions would have allowed those who quit for only a short period to say they had stopped, when relapse is a major phenomenon and demands a longer-term view.

The critics also 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?”

Randomised controlled trials?

Well conducted randomised controlled trials are considered high quality evidence, but have major problems that make them difficult to generalise to “real world” settings. If you volunteer to participate in a trial, you are likely to have a disposition to want to help science and so will probably be very positive and diligent about following the study protocol – unlike the way many in real world conditions forget to take their drugs or relapse. Trial participants are regularly contacted by study organisers trained in cohort retention strategies. This regular contact can result in trialists wanting to please “the lovely research assistant who calls me up each week” and can artificially increase study group retention rates, again unlike real world use where no such influences occur.

And if you are heavily dependent on nicotine, enrolled in an RCT and allocated to a study arm with placebo nicotine, guess what? Your withdrawal symptoms will quickly let you know that you are not getting any nicotine, so your belief that the nicotine replacement (NRT or ecigs) you hope you are using might do the trick will instantly be in tatters, with undermining consequences for your quit attempt.

For all these (and several other) reasons, the most important forms of evidence about how people quit smoking are longitudinal cohort studies which use high quality participant selection protocols to best ensure that those being interviewed are a representative sample of the smoking population. With smoking cessation, the endemic problem of high relapse back to smoking makes it vital that we take a helicopter view across time of how long transitions in and out of smoking last, long term and permanent quitting, being the ultimate outcome of interest. The large body of evidence we have about relapse heavily underlines that “persistent abstinence” is of far more importance than a former smoker’s smoking status on a particular day, which can change quickly.

In 2018, two particularly important papers were published by US researchers using the longitudinal PATH ( Population Assessment of Tobacco and Health) data set.

Let’s take a close look at what they found.

Coleman B et al, Tob Control 2018;0:1–10. doi:10.1136/tobaccocontrol-2017-054174

This important report on transitions in the vaping and smoking status of a nationally representative cohort of American adults aged 18+ who use electronic cigarettes (EC) provides rich data that greatly advances our understanding of the natural history of EC use.

If we examine the report’s data and consider the net impact of vaping on the critical goals of having vapers stopping smoking and vaping non-smokers not starting to smoke, the findings are very sobering and should give strong reason for pause among those advocating e-cigarettes as a game-changing way of stopping smoking.

The study reported on transitions between participants’ responses at Wave 1 and Wave 2, obtained 12 months later. At Wave 2, of the cohort of 2036 dual users (EC + smoking) only 104 (5.1%) had transitioned to exclusively using ECs and another 143 (7%) had quit both EC and smoking for a combined total of 247 (12.1%) who had persistently quit smoking. Of the 896 exclusive EC users at Wave 1, 277 (30.9%) had stopped vaping at Wave 2.

So together, 524 out of the 2932 EC users (17.9%) followed from Wave 1 might be considered to have had positive outcomes at Wave 2 (ie: quitting smoking and/or quitting EC).

The other side of the coin however, shows that of the 2036 dual users at Wave 1, 886 (43.5%) relapsed to using cigarettes exclusively. In addition, among the 896 exclusive ECusers from Wave 1, 109 (12.2%) had stopped vaping and were now smoking, with another 121 having resumed smoking as well as using EC (i.e. became dual users). Importantly, 502 of 896 (56%) exclusive e-cigarette users were those who had never been established smokers prior to using e-cigarettes. Alarmingly, of these 502 adults, 120 (23.9%) progressed from using only e-cigarettes to either dual use (54 or 10.8%) or smoking only (66 or 13.2%).

Taken together, 886 dual users in Wave 1 relapsed to become exclusive cigarette smokers in Wave 2, and 230 exclusive vapers in Wave 1 took up cigarette smoking in Wave 2 (dual use or exclusively cigarettes). Undoubtedly, these should be considered as negative outcomes.

The table below shows that for every person vaping at Wave 1 who benefited across 12 months by quitting smoking, there were 2.1 who either relapsed to or took up smoking. Most disturbingly, in this adult cohort nearly one in four of those who had never been established smokers took up smoking after first using EC. Concern about putative gateway effects of ECs to smoking have been dominated by concerns about youth. These data showing transitions from EC to smoking in nearly a quarter of exclusive adult EC users with no histories of established smoking should widen this debate to consider adult gateway effects too.

2018-colemantransitionssummary

By far the largest proportion of those with negative outcomes are those dual users who relapsed to smoking (886 or 43.5% of dual users). As the authors noted in their discussion, many of these were infrequent EC users, possibly involved in transitory experimentation at Wave 1. If we add the 902 who were still dual using at Wave 2, then 1788 of 2036 dual users (87.8%) in this sample might be said to have been held in smoking (dual using or exclusive smoking) 12 months later compared to 12.1% dual users who may have benefited by using ECs.

Commercial interests in both the tobacco and EC industries would be more than delighted with these findings. However, from public health harm reduction perspective these results argue against EC being a revolutionary effective harm reduction strategy, and point to their far stronger potential to both recruit smokers and hold many smokers in smoking.

Benmarhnia T et al American Journal of Epidemiology 2018 DOI: 10.1093/aje/kwy129

In a second paper using the PATH data, the authors considered persistent abstinence (not using tobacco for more than 30 days). The red highlighted section of the table below shows that those smokers who used ecigs (called ENDS in the table) had the worst persistent abstinence all-tobacco quit rates of any group in the cohort (5.6% of those who were vaping at the Wave 1 survey and 3.7% of those who too up vaping between Wave 1 and Wave 2). By far the most successful all-tobacco quit rate was for “no aid used” (ie cold turkey or unassisted cessation) with 12.5%.

When we multiply these quit rates by the numbers of smokers using each quit method, the yield of persistent quitters is even starker (see the second table below derived from the data in the table immediately below).

blog-table

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So in this major national cohort of US smokers, not only did EC use produce the lowest rate of persistent abstinence from tobacco use after one year compared to all other quit methods, but EC’s contribution to population-wide tobacco abstinence was utterly dwarfed by all other methods (10.9% v 89.1%). The much-denigrated and neglected unassisted cessation approach quietly ploughed on, continuing its massive historical dominance of how most ex-smokers quit, contributing 1.5 times more quitters than all other methods combined.

Nearly 2 million U.S. adult nonsmokers vape

Download (PDF, 98KB)

E-cigarettes: A win or loss for public health?

Download (PDF, 645KB)

Science and Technology Select Committee evidence on e-cigarettes

State-Specific Prevalence of Tobacco Product Use Among Adults — United States, 2014–2015

Download (PDF, 158KB)

Demand for novel nicotine/tobacco products and prospectively predict future use

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California targets candy-flavored tobacco as teen ‘gateway’ to cigarette smoking

More teens are turning to fruit- and candy-flavored tobacco, raising concerns that sweetened e-cigarettes and cigarillos are a gateway to nicotine addiction. A California anti-tobacco campaign targeting teens has ramped up in high schools and at a recent state Capitol rally on Kick Butts Day. Claudia Buck cbuck@sacbee.com

http://www.sacbee.com/news/local/health-and-medicine/article140622513.html

At the checkout counter, the flavors are sweet and enticing: Banana Smash. Twisted Berry. Berry Honey. Cherry Dynamite.

They aren’t in the candy aisle but on the tobacco shelf, often sold in 99-cent two-pack mini-cigars or liquid cartridges for e-cigarettes.

While fewer young Americans are puffing on cigarettes, more teens are using flavored tobacco, typically by vaping with electronic cigarettes or smoking tiny cigars known as cigarillos.

This year, there’s a renewed push to banish flavored tobacco products, which health officials and others fear are luring the next generation of nicotine addicts by targeting teens and kids.

The sweetened flavors are “a gateway to traditional cigarette smoking,” said Scott Gerber, a wellness program director with the Alameda County Office of Education, who attended a recent anti-tobacco state Capitol rally with a handful of high school students from Berkeley and Fremont. Tobacco companies, he said, “are targeting young people with cherry, strawberry, piña colada flavors. … Gummi bears? That’s a youth-friendly flavor, not an adult-friendly flavor.”

Gerber was among about 250 high school students and chaperones who attended the anti-tobacco rally, chanting slogans and carrying signs with messages such as “We want to see a new light, not a lighter” and “We want 7,700 flavors of ice cream, not tobacco!” The rally was part of national Kick Butts Day, co-sponsored by the California Youth Advocacy Network and the Campaign for Tobacco-Free Kids.

In 2014, 73 percent of high school students and 56 percent of middle school students who used tobacco products in the past 30 days reported using a flavored tobacco product, according to the federal Centers for Disease Control and Prevention.

Wheatland High School student Angelina Hom, 15, who belongs to a campus group called SOWHAT (Students Of Wheatland High Against Tobacco), said she’s seen the negative impacts of tobacco firsthand in family members and hopes more of her peers get the message to avoid tobacco.

Convenience stores near her Northern California school have prominent displays of brightly colored, fruity-flavored tobacco products positioned close to the checkout counter, she said. “You go to pay for your food and there’s a wall full of of tobacco and cigarettes. It targets kids into thinking it’s cool.”

E-cigarettes are the most commonly used tobacco product among middle and high school teens in California. An estimated 217,000 Californians between the ages of 12 and 17 currently smoke traditional cigarettes or e-cigarettes, according to state health officials.

In stores, although tobacco products by law must be behind glass, it’s not unusual to find Swisher Sweets, candy-flavored cigarillos sold in two-packs for less than a dollar, sitting near candy bars and snacks, at eye level of young customers.

“Having it advertised as candy unlocks the door to the world of addiction,” said shopper Jenni Richardson, 24, in a midtown Sacramento convenience store where Swisher Sweets sit directly above the ice cream freezer case. A self-described recovering heroin addict, Richardson said tobacco products are dangerously addictive, noting it was far easier for her to quit narcotics than nicotine.

Last summer, the growth in e-cigarette use helped prompt California to toughen state tobacco laws, raising the minimum age for legally buying cigarettes and cigars from 18 to 21, the first change since tobacco control laws went into effect 144 years ago. Also for the first time, those laws now apply to e-cigarettes, which have become hugely popular for their myriad fruit and candy-scented flavors, with names such as Watermelon Krush, Apple Pie a la Mode and Blueberry Cotton Candy.

Some counties have banned all sales of flavored tobacco, including Yolo County, which prohibits sales in the county’s unincorporated areas, starting May 1. The intent was to deter use by youths, said Keri Hess, the county’s tobacco prevention youth coordinator.

“Lots of kids who use e-cigarettes would never dream of trying a regular cigarette because they say it tastes gross. They know the hazards of regular cigarettes and tobacco, but they don’t recognize the health hazards of e-cigarettes,” Hess said.

In Yolo County, 73 percent of stores carried e-cigarettes last year compared with 46 percent in 2013.

The state’s crackdown came as illegal sales of tobacco to minors were up last year by more than a third from 2015, according to the state Department of Public Health’s annual survey, which took place before the legal age was changed. Using teenage decoys trying to buy smokes, the annual survey found that 10.3 percent of 793 stores sold tobacco to underage buyers, the highest rate in eight years.

Citing research that shows brain development continues until around age 25, state health officials say nicotine is a “highly addictive neurotoxin” that can permanently damage adolescent and young adult brains.

“The younger people are when they start smoking or using nicotine, the more likely they are to become addicted,” said State Public Health Officer Dr. Karen Smith during a news conference last summer. Every year in California, she noted, 34,000 people die of tobacco-related diseases.

She said the surge of teens vaping with e-cigarettes is no accident, given the “aggressive marketing” and the proliferation of gadgets and flavors by tobacco companies. Calling them “enticing gateway products,” Smith said e-cigarettes are “fueling the addiction” to nicotine.

Since 2009, the U.S. Food and Drug Administration has banned the sale of cigarettes with fruit and candy flavors, part of federal efforts to reduce tobacco addiction among youths. More recently, the FDA is focusing on cigars and cigarillos (mini-cigars). In December, it issued warning letters to four tobacco companies, including Swisher International Inc., maker of Swisher Sweets, for selling cigars in “youth-appealing” flavors, such as grape, wild cherry and strawberry.

If the companies don’t take action, they could face civil penalties, criminal prosecution and seizure of products, according to the FDA.

“Flavored cigarettes appeal to kids and disguise the bad taste of tobacco, but they are just as addictive as regular tobacco products and have the same harmful health effects,” said Mitch Zeller, director of the FDA’s Center for Tobacco Products, in a statement. He said continued bans on flavored tobacco are essential to “protect future generations from a lifetime of addiction.”

To students at the recent state Capitol rally, the brightly colored packaging and sweetened flavors are “like candy,” enticing teens and kids to get hooked on nicotine at an early age, said Naphatsorn Kaewwanna, 18, a high school senior with the Asian American Drug Abuse Program in Los Angeles County.

“We should put a stop to it,” she said.

 

Twelve myths about e-cigarettes that failed to impress the TGA

Australia’s Therapeutic Goods Administration (TGA) last week rejected an application to liberalise the scheduling of nicotine (see from page 71).

http://theconversation.com/twelve-myths-about-e-cigarettes-that-failed-to-impress-the-tga-72408

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.

6. Vape is just like water vapour and (often) nicotine

But let’s not forget some 8,000 beguiling often kiddie-friendly flavours in e-juice that help the nicotine go down (with apologies to Mary Poppins) have mostly been approved as food additives but have never been approved for inhalation. Here’s what the US flavouring industry said:

The manufacturers and marketers of ENDS [electronic nicotine delivery systems], and all other flavored tobacco products, and flavor manufacturers and marketers, should not represent or suggest that the flavor ingredients used in these products are safe because they have … status for use in food because such statements are false and misleading.
And then there’s the liquid propylene glycol in which the nicotine and flavour chemicals are vapourised. Dow Chemical, which manufactures it, says unambiguously, reflecting human data:

… breathing spray mists of these materials should be avoided. In general, Dow does not support or recommend the use of Dow’s glycols in applications where breathing or human eye contact with the spray mists of these materials is likely …
Vapers average about 200 inhalations a day, with this study finding a range of 6 to 611 puffs. That’s an average 73,050 deep lung bastings a year, and right up to 223,168. Like cigarette smoke, vape mist contains fine, ultra-fine and nanoparticles, including metals and silicate. It is anything but just like inhaling steam in a shower.

Put simply, we have no data on what happens to people’s long-term respiratory or cardiovascular health when they pull these nanoparticles deep into their lungs daily, over many years, at the above rates.

7. Nicotine-free cigarettes contain no nicotine

E-cigarette advocates were excited about a recent study reporting many US teens did not vape for nicotine, but for the flavours. In NSW, it is illegal to sell vape liquid containing nicotine. But a NSW Health random check found many samples contained it. Other examples in the US, and elsewhere, of alleged “non-nicotine” refills turning out to contain nicotine exist, hence the headline “‘Nicotine-Free’ E-Cigs Still Deliver the Juice”.

The US Food and Drug Administration (FDA) summed up:

Testing also suggested that quality control processes used to manufacture these products are inconsistent or non-existent.

8. Second-hand vape is harmless, so it should not be restricted

I’d rather sit next to a vaper than a smoker. But those vape clouds we see and then don’t see don’t just vanish. They can be measured. This study of a vapers’ meeting where 59-86 people were vaping found counts of PM2.5 airborne particles (fine particulate matter, 2.5 micrometers or less in diameter) 125-330 times higher than in the same room when empty. This is higher than particle concentrations recorded in bars where cigarette or waterpipe smoking are allowed. That will likely explain the other real-world experiences reported by vapers like this.

If vaping were allowed in bars, restaurants and planes, we all would face behaviour like this scene. Try imagining workable regulatory wording that would allow “discreet” vaping by a few, but prohibited exuberant “clouding” by a group of vapers drinking in a bar.

If vaping emissions were really benign, indoor vaping advocates should take courage and call for it to be allowed in classrooms, crèches, hospitals and neonatal wards. The fact they don’t rather suggests they know well such a position would be irresponsible.

9. There’s no good evidence for e-cigarettes being a gateway to smoking in young people

In England, this appears to be the case. But in the USA, there’s a rapidly growing body of evidence suggesting a possible effect. Centers for Disease Control data from 2015 demonstrate a concerning sudden cessation and plateau in the previous decline of US high school students smoking tobacco, while e-cigarette use is skyrocketing.

Smoking was plummeting in young people in the USA and UK long before e-cigarettes appeared. Today, more young people in the US are using nicotine than ever, which may signal health and brain developmental problems down the track.

10. E-cigarette explosions are overrated

E-cigarette advocates point out other lithium battery-powered items like mobile phones and laptops have exploded, so we should all calm down about dramatic explosions.

However, vapers have noted explosions tend to take place, not just during re-charging, but during use, leading to mounting reports from hospitals of terrible burns and injuries.

When mobile phones explode, we see global recalls as happened with the Samsung Galaxy Note 7. The lack of regulatory standards for e-cigarettes and their components stands in stark contrast to these other products. I’m very pleased e-cigarettes are banned on airlines, but wonder about what would happen if one exploded in stowed luggage.

11. Big Tobacco really wants its smoking customers to switch to e-cigarettes

If this was true, how do we then explain the companies continue to do all they can to wreck effective tobacco control policies like plain packaging, graphic health warnings and significant tobacco tax hikes?

In Hong Kong in December 2016 British American Tobacco was still lobbying against graphic health warnings. And Philip Morris was threatening Uruguay over its advanced tobacco control policies, until it lost its case at the World Bank’s International Centre for Settlement of Investment Disputes in 2016.

Surely, if they were sincere here, they should be pleased governments are trying to get smokers to quit? Philip Morris has been running targeted advertising campaigns with major youth appeal. And new evidence collated from its own documents demonstrates its interest in e-cigarettes, as long ago as 1990, was only ever for them to be used as a complement to cigarettes.

Big Tobacco has heavily invested in e-cigarettes, with all major tobacco companies now having them in their portfolios. The big picture here is that Big Tobacco wants people to smoke and vape, not vape instead of smoking.

12. Leading public health agencies encourage ‘light touch’ regulation

This is mostly the case in England, but very much not the case in many other nations. Advocates constantly point to two e-cigarette “friendly” reports from the UK Royal College of Physicians and Public Health England, which had several common authors.

But 18 nations ban e-cigarettes outright, with more having various degrees of restrictions. Among leading agencies with strong concerns about e-cigarettes are the US Surgeon General, the World Health Organization, the FDA, 31 mostly major health agencies that petitioned the FDA to regulate e-cigarettes, Australia’s National Health and Medical Research Council and now the TGA.

E-cigarettes have been generating a huge wave of research interest over the past few years. The next decade promises to throw the light of much needed evidence on many of the issues above. In the meantime, the Australian TGA’s caution should be respected.

Local Anti Tobacco Advocate Busts E-cigarette Myths

http://www.caledonianrecord.com/features/health/local-anti-tobacco-advocate-busts-e-cigarette-myths/article_65ee5497-ed23-5131-b69d-a503312368c3.html

According to a recently released report by the US Surgeon General, research has confirmed that there has been a significant increase in electronic cigarette (e-cigarette) use in recent years. Just last year alone, in 2015, the increase of electronic cigarette use has more than doubled particularly among our youth (ages 11 – 14), adolescents (ages 15 – 17) and in our young adults (ages 18 – 25) with more than 3 million youth in middle and high school using electronic cigarettes within the past 30 days. A cash cow for the tobacco industry, these numbers are increasing daily. More than 85 percent of electronic cigarette users ages 12 – 17 use flavored e-liquids, which come in a large variety of flavors, and are especially appealing to youth. And the flavors are the leading reason for youth use, according to the Surgeon General’s report.

Tobacco companies have been ramping up their marketing strategies to attract and cause young people to start using electronic cigarettes. In the United States, $3.5 billion dollars in sales is big business for the industry. Electronic cigarette manufacturers spent $125 million dollars in advertising their products with retail stores becoming the most frequent source of youth exposure to the tobacco industry’s advertising approaches. The tobacco industry has gone back to its old tactics that are much the same as the ones used to promote the conventional tobacco products.

Unlike the marketing campaigns of yesteryear, advertising approaches and themes today have a significant advantage with the use of internet and social media creating a more effective and wider outreach to attract youth and young adults, causing them to start using tobacco products at a much earlier age. In 2014, more than 7 out of 10 middle and high school students stated that they have been exposed to tobacco advertising. Research has shown that youth who use tobacco products like electronic cigarettes or chew, are most likely to go on to use other tobacco products like the traditional tobacco cigarette. In 2015, nearly 6 out of 10 high school cigarette smokers were also using electronic cigarettes.

The tobacco industry has claimed that electronic cigarettes are safer than the traditional tobacco cigarette. The tobacco industry has also claimed that the chemicals in e-liquids are not harmful to the user. The tobacco industry has suggested that electronic cigarettes can and may be used as a cessation tool to quit smoking. On the contrary, the newly released US Surgeon General’s report has confirmed these claims to be myths. The US Surgeon General’s report has busted these myths by saying;

The use of products containing nicotine poses dangers to youth, pregnant women, and fetuses. The use of products containing nicotine in any form among youth, including electronic cigarettes, is unsafe.

The liquid usually has nicotine, which comes from tobacco, flavoring; and other additives. Many electronic cigarettes contain nicotine, which is highly addictive. The nicotine in electronic cigarettes and other tobacco products can prime young brains for addiction to other drugs, such as cocaine and methamphetamine. Electronic aerosol is not harmless. The aerosol or vapor created by electronic cigarettes can contain ingredients harmful and potentially harmful to the public’s health.

There have been no conclusive study results or evidence to confirm that electronic cigarettes are a possible cessation tool for those who want to quit smoking. On the contrary, there is sufficient evidence to substantiate that the use of electronic cigarettes promotes users to use both electronic cigarettes along with smoking the conventional tobacco cigarette and that can potentially place the user at risk for exposure to higher levels of nicotine in the body that may ultimately lead to acute toxicity and possible death from over-exposure to nicotine.

The US Surgeon General’s full report titled: E-Cigarette Use Among Youth and Young Adults, can be found on the Surgeon General’s official website: https://e-cigarettes.surgeongeneral.gov.

Brand Loyalty Low Among Teen E-Cig Users

Half of surveyed users did not know which brand they used

Half of teens who use e-cigarettes reported vaping no particular brand, and about a third reported using e-cigarette devices for substances other than nicotine, according to an analysis of recent survey data by researchers from the CDC.

The most commonly reported e-cigarette used by the middle school and high school students participating in the 2015 National Youth Tobacco Survey (NYTS) was the heavily promoted brand ‘blu’, manufactured by Fontem Ventures-Imperial Brands (formerly Imperial Tobacco Group).

Roughly one in four surveyed teen e-cigarette users (26.4%) reported using that brand, while 12.2% reported using the next most popular brand, ‘VUSE’, manufactured by R.J. Reynolds.

The survey results were reported Thursday in the CDC’s Morbidity and Mortality Weekly Report.

“Electronic cigarettes are now the most commonly used tobacco product among U.S. youths; in 2015, 5.3% of middle school students and 16% of high school students reported using e-cigarettes in the past 30 days,” CDC researcher Tushar Singh, MD, PhD, and colleagues wrote, adding that not much has been known about the brands preferred by teens and the substances used in e-cigarette devices.

The analytic sample of the 2015 NYTS included 4,021 students who reported ever using e-cigarettes, “even once or twice.” Respondents were asked what brands of e-cigarettes they had used, with eight specific brands listed, and whether they had ever used an e-cigarette device for vaping a substance other than nicotine.

Data were weighted to account for the complex survey design and to adjust for nonresponse. Prevalence estimates were also reported for the type of e-cigarette ever used, brands, and whether e-cigarettes were used for substances other than nicotine.

A total of 13.5% of sixth through eighth graders and 37.7% of ninth through 12th graders reported ever-use of e-cigarettes.

Among the adolescents reporting ever having used an e-cigarette, 14.5% used only disposable e-cigarettes, 53.4% used only rechargeable/refillable e-cigarettes, and 32.1% used both types.

Half of the student respondents (50.7%, representing 3.18 million teens) did not know the brand of the e-cigarette they had used.

Use of e-cigarettes for a substance other than nicotine was similar among middle school (33.7%) and high school (32.2%) users, and it was higher among males than females (37.3% of high school male e-cigarette users versus 26.2% of high school female respondents).

In a separate survey of high school age e-cigarette users in Connecticut, reported last year in Pediatrics, 18% of respondents reported using cannabis in an e-cigarette device.

“In the present analysis, it is unknown whether students who had used an e-cigarette for a non-nicotine substance had also used an e-cigarette for nicotine, which might underestimate nicotine use,” Singh and colleagues wrote.

“Nicotine content in e-cigarettes is of public health concern because exposure to nicotine is the main cause of tobacco product dependence, and nicotine exposure during adolescence, a critical period for brain development, can cause addiction, can harm brain development, and could lead to sustained tobacco product use among youths.”

Study limitations cited by the researchers included the self-reported nature of the survey, the limited number of specific e-cigarette brands included in the survey, and the lack of data on which substances other than nicotine were being used.

The researchers concluded that increased monitoring of product types, brands, and ingredients preferred by adolescent e-cigarette users is warranted, “to guide measures to prevent and reduce use of e-cigarettes among youths.”