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Smoking causes one in ten deaths globally, major new study reveals

Efforts to control tobacco have paid off, says study, but warns tobacco epidemic is far from over, with 6.4m deaths attributed to smoking in 2015 alone

https://www.theguardian.com/society/2017/apr/05/smoking-causes-one-in-ten-deaths-globally-major-new-study-reveals

One in 10 deaths around the world is caused by smoking, according to a major new study that shows the tobacco epidemic is far from over and that the threat to lives is spreading across the globe.

There were nearly one billion smokers in 2015, in spite of tobacco control policies having been adopted by many countries. That number is expected to rise as the world’s population expands. One in every four men is a smoker and one in 20 women. Their lives are likely to be cut short – smoking is the second biggest risk factor for early death and disability after high blood pressure.

The researchers found there were 6.4m deaths attributed to smoking in 2015, of which half were in just four populous countries – China, India, USA, and Russia.

Major efforts to control tobacco have paid off, according to the study published by the Lancet medical journal. A World Health Organisation treaty in 2005 ratified by 180 countries recommends measures including smoking bans in public places, high taxes in cigarettes and curbs on advertising and marketing.

Between 1990 and 2015, smoking prevalence dropped from 35% to 25% among men and 8% to 5% among women. High income countries and Latin America – especially Brazil which brought in tough curbs on tobacco – achieved the biggest drops in numbers of smokers.

But many countries have made marginal progress since the treaty was agreed, say the authors of the study from the Institute of Health Metrics and Evaluation at the University of Washington in the US. And although far more men smoke than women, there have been bigger reductions in the proportions of men smoking also, with minimal changes among women.

Senior author Dr Emmanuela Gakidou said there were 933m daily smokers in 2015, which she called “a very shocking number”. The paper focused only on those who smoke every day. “The toll of tobacco is likely to be much larger if we include occasional smokers and former smokers and people who use other tobacco products like smokeless tobacco. This is on the low end of how important tobacco is,” she told the Guardian.

There is much more that needs to be done, she said. “There is a widespread notion that the war on tobacco has been won but I think our evidence shows that we need renewed and sustained efforts because the toll of smoking in 2015 is much larger than most people would think, so we absolutely have a lot more to do. We need new and improved strategies to do it and a lot of effort and political will.”

Traditionally there have been far fewer women smoking around the world than men, but it was a huge problem for both, she said.

“There are some really worrisome findings – for example in Russia female smoking has increased in the last 25 years significantly. There are also some western European countries where about one in three women are smoking. So it is true globally that a lot fewer women smoke than men but there are some countries where it is a big problem for women,” she said.

Dr Kelly Henning of Bloomberg Philanthropies, which is committed to tobacco control and co-funded the study with the Bill and Melinda Gates Foundation, said: “I think the study highlights the fact that the work is not finished on tobacco. The good news is the decline in daily smoking among men and women … however there are still many smokers in the world and there is still a lot of work to do. I think we have to keep our eye on the issue and really do more.”

Countries with some of the highest death tolls such as China and Indonesia “really don’t need those health problems – they have so many other issues they are trying to address. But tobacco control is critically important in those places,” she said.

“China has more than a million deaths a year from smoking related diseases and China is only beginning to see the effects of their high male smoking rate. That is only one instance of what is expected to become an extremely major epidemic,” she said.

Writing in a linked comment, Professor John Britton from the University of Nottingham said: “Responsibility for this global health disaster lies mainly with the transnational tobacco companies, which clearly hold the value of human life in very different regard to most of the rest of humanity.” British American Tobacco, for instance, sold 665bn cigarettes in 2015 and made a £5.2bn profit.

“Today, the smoking epidemic is being exported from the rich world to low-income and middle-income countries, slipping under the radar while apparently more immediate priorities occupy and absorb scarce available human and financial resources,” he writes. “The epidemic of tobacco deaths will progress inexorably throughout the world until and unless tobacco control is recognised as an immediate priority for development, investment, and research.”

Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015

Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015

http://thelancet.com/journals/lancet/article/PIIS0140-6736(17)30819-X/fulltext?elsca1=tlpr

Summary

Background

The scale-up of tobacco control, especially after the adoption of the Framework Convention for Tobacco Control, is a major public health success story. Nonetheless, smoking remains a leading risk for early death and disability worldwide, and therefore continues to require sustained political commitment. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) offers a robust platform through which global, regional, and national progress toward achieving smoking-related targets can be assessed.

Methods

We synthesised 2818 data sources with spatiotemporal Gaussian process regression and produced estimates of daily smoking prevalence by sex, age group, and year for 195 countries and territories from 1990 to 2015. We analysed 38 risk-outcome pairs to generate estimates of smoking-attributable mortality and disease burden, as measured by disability-adjusted life-years (DALYs). We then performed a cohort analysis of smoking prevalence by birth-year cohort to better understand temporal age patterns in smoking. We also did a decomposition analysis, in which we parsed out changes in all-cause smoking-attributable DALYs due to changes in population growth, population ageing, smoking prevalence, and risk-deleted DALY rates. Finally, we explored results by level of development using the Socio-demographic Index (SDI).

Findings

Worldwide, the age-standardised prevalence of daily smoking was 25·0% (95% uncertainty interval [UI] 24·2–25·7) for men and 5·4% (5·1–5·7) for women, representing 28·4% (25·8–31·1) and 34·4% (29·4–38·6) reductions, respectively, since 1990. A greater percentage of countries and territories achieved significant annualised rates of decline in smoking prevalence from 1990 to 2005 than in between 2005 and 2015; however, only four countries had significant annualised increases in smoking prevalence between 2005 and 2015 (Congo [Brazzaville] and Azerbaijan for men and Kuwait and Timor-Leste for women). In 2015, 11·5% of global deaths (6·4 million [95% UI 5·7–7·0 million]) were attributable to smoking worldwide, of which 52·2% took place in four countries (China, India, the USA, and Russia). Smoking was ranked among the five leading risk factors by DALYs in 109 countries and territories in 2015, rising from 88 geographies in 1990. In terms of birth cohorts, male smoking prevalence followed similar age patterns across levels of SDI, whereas much more heterogeneity was found in age patterns for female smokers by level of development. While smoking prevalence and risk-deleted DALY rates mostly decreased by sex and SDI quintile, population growth, population ageing, or a combination of both, drove rises in overall smoking-attributable DALYs in low-SDI to middle-SDI geographies between 2005 and 2015.

Interpretation

The pace of progress in reducing smoking prevalence has been heterogeneous across geographies, development status, and sex, and as highlighted by more recent trends, maintaining past rates of decline should not be taken for granted, especially in women and in low-SDI to middle-SDI countries. Beyond the effect of the tobacco industry and societal mores, a crucial challenge facing tobacco control initiatives is that demographic forces are poised to heighten smoking’s global toll, unless progress in preventing initiation and promoting cessation can be substantially accelerated. Greater success in tobacco control is possible but requires effective, comprehensive, and adequately implemented and enforced policies, which might in turn require global and national levels of political commitment beyond what has been achieved during the past 25 years.

Funding

Bill & Melinda Gates Foundation and Bloomberg Philanthropies.

Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015

Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015

http://thelancet.com/journals/lancet/article/PIIS0140-6736(17)30819-X/abstract

Summary

Background

The scale-up of tobacco control, especially after the adoption of the Framework Convention for Tobacco Control, is a major public health success story. Nonetheless, smoking remains a leading risk for early death and disability worldwide, and therefore continues to require sustained political commitment. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) offers a robust platform through which global, regional, and national progress toward achieving smoking-related targets can be assessed.

Methods

We synthesised 2818 data sources with spatiotemporal Gaussian process regression and produced estimates of daily smoking prevalence by sex, age group, and year for 195 countries and territories from 1990 to 2015. We analysed 38 risk-outcome pairs to generate estimates of smoking-attributable mortality and disease burden, as measured by disability-adjusted life-years (DALYs). We then performed a cohort analysis of smoking prevalence by birth-year cohort to better understand temporal age patterns in smoking. We also did a decomposition analysis, in which we parsed out changes in all-cause smoking-attributable DALYs due to changes in population growth, population ageing, smoking prevalence, and risk-deleted DALY rates. Finally, we explored results by level of development using the Socio-demographic Index (SDI).

Findings

Worldwide, the age-standardised prevalence of daily smoking was 25·0% (95% uncertainty interval [UI] 24·2–25·7) for men and 5·4% (5·1–5·7) for women, representing 28·4% (25·8–31·1) and 34·4% (29·4–38·6) reductions, respectively, since 1990. A greater percentage of countries and territories achieved significant annualised rates of decline in smoking prevalence from 1990 to 2005 than in between 2005 and 2015; however, only four countries had significant annualised increases in smoking prevalence between 2005 and 2015 (Congo [Brazzaville] and Azerbaijan for men and Kuwait and Timor-Leste for women). In 2015, 11·5% of global deaths (6·4 million [95% UI 5·7–7·0 million]) were attributable to smoking worldwide, of which 52·2% took place in four countries (China, India, the USA, and Russia). Smoking was ranked among the five leading risk factors by DALYs in 109 countries and territories in 2015, rising from 88 geographies in 1990. In terms of birth cohorts, male smoking prevalence followed similar age patterns across levels of SDI, whereas much more heterogeneity was found in age patterns for female smokers by level of development. While smoking prevalence and risk-deleted DALY rates mostly decreased by sex and SDI quintile, population growth, population ageing, or a combination of both, drove rises in overall smoking-attributable DALYs in low-SDI to middle-SDI geographies between 2005 and 2015.

Interpretation

The pace of progress in reducing smoking prevalence has been heterogeneous across geographies, development status, and sex, and as highlighted by more recent trends, maintaining past rates of decline should not be taken for granted, especially in women and in low-SDI to middle-SDI countries. Beyond the effect of the tobacco industry and societal mores, a crucial challenge facing tobacco control initiatives is that demographic forces are poised to heighten smoking’s global toll, unless progress in preventing initiation and promoting cessation can be substantially accelerated. Greater success in tobacco control is possible but requires effective, comprehensive, and adequately implemented and enforced policies, which might in turn require global and national levels of political commitment beyond what has been achieved during the past 25 years.

Funding

Bill & Melinda Gates Foundation and Bloomberg Philanthropies.

Graphical health warnings on cigarette packs found effective

A recently completed sample based study done in Bangladesh claims that the health warning labels describing the harmful effects of tobacco products using text and/or pictures are found to be effective.

Health warnings on cigarette packages are among the most prominent sources of information about the harms of smoking and tobacco use.

Indeed, even in high-income countries where millions of dollars are spent on anti-tobacco mass media campaigns, smokers still report getting information about the risks of smoking from cigarette packages almost as much as from television, and much more than from other sources such as print media.

Therefore, in a country such as Bangladesh, where very little information about the harms of tobacco use appears on television and other broadcast media, warning labels on tobacco packages represent an even more important opportunity for informing the public about the harms of tobacco. Given their tremendous reach and frequency of exposure, health warnings are an extremely cost-effective public health intervention compared to other tobacco prevention efforts such as paid mass media advertising – these came out of a sample-based survey.

Findings from the survey revealed, 98.1% of the respondents opined that they supported the current practice of bothside for pictorial/graphical health warnings (GHW) and 77.5% respondent informed that they thought that the current use of GHW of 50% of the cigarette pack for warnings was good enough to demotivate and reduce the use of tobacco products. Considering up to 50% of the cigarette pack, around 89% were supporting this.

The findings revealed – about 72.7% of the respondents reported that they felt very unpleasant to see the pictorial warning on the tobacco packets (74.1% in urban and 72.7% in rural areas). The survey also reported that the pictorial warning was very realistic to 65.6% of the respondents and extremely realistic to 17.0% respondent (18.8% in rural and 15.3% in urban areas).

The psychological impact of GHW on the respondents was also examined. 13.9% of the respondents were extremely worried and 61.7% were very worried to see the pictorial warning on the cigarette package.

In summary, the study found that the graphical health warnings (GHW) were realistic to provide health-related information and are very effective in creating an unpleasant feeling and sense of worriedness among the smokers to aware them regarding the harmful effects of smoking.

A good news that the study uncovered was 75.8% respondents tried to reduce or quit smoking after seeing the pictorial warning on the cigarette packet. The rate is 76.3% in rural and 75.3% in urban areas. 83.5% respondents reported that they tried to reduce or quit smoking habit to see the pictorial warning. 74.8% recommended to include
GHW in Biri, Gul and Jorda.

Moreover, 64.2% respondents recommended that government should take initiative for mass awareness and 85.5% recommended for more visual media (TV) coverage.

FCTC cut smoking 2.5 per cent over 10 years; study

A decade of tobacco control efforts by the Framework Convention on Tobacco Control (FCTC) has reduced the global smoking rate by 2.5 per cent, according to an evaluation by the International Tobacco Control Policy Evaluation Project.

http://www.tobaccojournal.com/FCTC_cut_smoking_2_5_per_cent_over_10_years_study.54157.0.html

Although the international treaty, an adjunct of the World Health Organisation, has made substantial progress in combatting use of tobacco products, implementation of FCTC measures has fallen short of its objectives, according to the study. “While the progress of WHO Framework Convention on Tobacco Control has been remarkable, there are still far too many countries where domestication of the treaty and its implementation has fallen short,” said Dr Geoffrey Fong, a study author from the University of Waterloo, Canada. “One important cause of this is the tobacco industry’s influence, particularly in low- and middle-income countries.”

Conducted with assistance from WHO, the study analysed data from 126 countries and determined the smoking rate in those countries declined on average from 24.7 per cent in 2005 to 22 per cent in 2015. FCTC obligates 180 signatory countries to raise tax on tobacco products, create smoke-free public spaces, implement warning labels on packaging, ban advertising and support stop-smoking services.

Study explores alarming threat of emerging Asian tobacco companies to global health

There are already one billion tobacco smokers worldwide, and this number is likely to rise further with Asian tobacco companies poised to enter the global market, according to SFU health sciences professor Kelley Lee.

http://www.sfu.ca/sfunews/stories/2017/03/theloomingthreatofasiantobaccocompaniestoglobalhealth.html

“While companies like British American Tobacco and Philip Morris, traditionally known as ‘Big Tobacco’, have been rightfully targeted by tobacco control efforts to date, on the horizon are several companies based in Asia ‘going global’ with their business strategies,” says Lee, a Tier I Canada Research Chair in Global Health Governance.

“Their aim is to grow their share of the world market through increased marketing, new products and lower prices. This is likely to mean more smokers worldwide.”

Lee and her team are the first to study the global business strategies of Asian tobacco companies, recently published in a special issue of Global Public Health entitled, “The Emergence of Asian Tobacco Companies: Implications for Global Health Governance.”

Their aim in analysing companies in Japan, South Korea, China, Taiwan and Thailand was to document how these companies are shifting from a domestic focus to become aspiring transnational companies.

“Several of these companies have already started to export their brands to rapidly growing markets in Asia, Europe, the Middle East and Africa,” says Lee.

“Their success will mean a further increase to the already six million deaths caused by tobacco use each year.”

These new research findings suggest that globalization of the tobacco industry may be entering a new phase.

Rather than supporting the expansion of these companies as sources of profit, Asian governments need to recognize that far greater economic, environmental and social costs are being caused by this deadly industry.

The authors conclude that collective action by all countries, focused on the World Health Organization’s Framework Convention on Tobacco Control, is needed more than ever.

Lee sat down with SFU News to go over the five case studies that were examined in the special issue, and answered three questions about the findings:

What are the key factors behind the global business strategies of the five Asian tobacco companies?

Trade liberalization and tobacco industry lobbying pressured Asian countries to open their markets to transnational tobacco companies (TTCs) from the late 1980s. British American Tobacco, Philip Morris, R.J. Reynolds and other companies introduced new brands, marketing methods and undermined tobacco control measures to gain a major share of the market in Asia.

The loss of domestic market share also prompted Asian tobacco companies, in turn, to look abroad to grow their own foreign markets. Their global business strategies have borrowed many of the practices used by existing transnational tobacco companies.

Which global business strategies have Asian companies pursued?

Government supported consolidation, restructuring and rationalizing of domestic operations. This included shutting down facilities deemed inefficient, merging smaller concerns into larger ones and upgrading production capacity.

The companies also increased manufacturing, specifically for export to foreign markets, and engaged in new product development to create brands that have global appeal.

Moreover, there has been product innovation, including specially designed filters, flavourings, super slim cigarettes and electronic cigarettes, as well as foreign direct investment in the form of joint ventures, overseas manufacturing and leaf growing operations.

How globalized are Asian tobacco companies to date?

Japan Tobacco International was the first Asian tobacco company to successfully globalize, beginning in the late 1990s, supported by the Japanese government as part owners. Today, Japan Tobacco International is the third largest transnational tobacco company in the world.

Korea Tobacco & Ginseng is well positioned to become the world’s next transnational tobacco company given its active and successful pursuit of foreign markets since privatisation in 2001. The company is achieving rapid growth in eastern Europe, the Middle East and South Asia countries.

The China National Tobacco Company is by far the world’s largest tobacco company but to date has been largely domestically focused. Consolidation has been followed by a strong commitment by the state owned monopoly to “go global” over the next decade through exports, overseas manufacturing and leaf production.

Taiwan Tobacco and Liquor Corporation and Thailand Tobacco Monopoly have both expressed ambitions to globalize, but remain domestically focused and are more likely to become regional players in the foreseeable future.

Vapors Of High-Powered E-Cigarettes May Cause Cancer

http://www.sciencetimes.com/articles/10054/20170309/vapors-of-high-powered-e-cigarettes-may-cause-cancer.htm

People might have to stop powering their e-cigarettes to the highest level as scientists have found out that its vapors can cause cancer. There are significant levels of cancer-causing benzene in the vapors of those e-cigarettes in the highest power, stated Portland State University scientists.

The result of the study was published on March 8 in the online journal “PLOS ONE”. The chemistry professor James F. Pankow led the research team, reported EurekAlert. The level of benzene they found from the high powered e-cigarettes was thousand times higher than in the surrounding air. It also depends greatly on the device itself. If it is not at its highest level, the benzene levels are not that high.

When the e-cigarette fluid additive chemicals benzoic acid or benzaldehyde is present it added so much to the benzene levels. However, of course, the level of this is nothing compared to the level of a conventional smoke from a cigarette. Benzene is one component of gasoline. It is very bad for people.

It has been linked to a number of illnesses that are very grave and can cause death. Diseases like leukemia and bone marrow failure are few of the examples of diseases a person can acquire with benzene. Benzene is usually found in the urban areas where industrial emissions are very rampant plus fuel tank leaks. This chemical has been deemed as the largest single cancer-risk air component in the U.S.

Meanwhile, according to Science Daily, the smoke that conventional cigarettes release is affecting the natural healing process of lungs. The blocking then leads to chronic obstructive pulmonary disease or COPD. Cough, bronchitis and breathing difficulties are the major signs of COPD. The findings were published in “American Journal of Respiratory and Critical Care Medicine”. It was from the researchers at the Helmholtz Zentrum München, a partner in the German Center for Lung Research (DZL), and their international colleagues.

An individual with COPD does not heal its own lungs anymore. Researchers are now trying to find out why.

Vaping Is Less Terrible For You Than Cigarettes (Still Not Great For You, So Don’t Start)

Over time, people who smoke e-cigarettes seem to pile up fewer toxins in their bodies than people who smoke traditional cancer sticks.

https://www.fastcoexist.com/3068010/vaping-is-less-terrible-for-you-than-cigarettes-still-not-great-for-you-so-dont-start

Vaping devotees, you have been vindicated: In the first long-term study comparing e-cigarettes with regular old cigarettes, researchers found that e-cigs aren’t quite as bad for you as the tobacco they replace. In fact, transitioning to vaping may end up being a good way to help people quit smoking altogether.

The study, funded by Cancer Research U.K., found that people who switched from tobacco to e-cigarettes for at least six months “had much lower levels of toxic and cancer-causing substances in their body than people who continued to use conventional cigarettes.” The conclusion: e-cigarettes are less toxic than tobacco.

The study followed 181 participants over a six-month period. The participants were split into five groups: “combustible” cigarettes users, e-cigarette users, users of nicotine replacement therapy (NRT) like patches or gum, and people who smoke combustible cigarettes while also using either e-cigarettes or other NRT products.

Most studies up until now, as noted in the report, have examined the toxins in the actual vapor of the e-cigarette and compared that to the toxins in tobacco. But because the actual absorption levels of substances from e-cigarettes are not known, this may not be an accurate way to determine actual toxicity. Also, different vaping devices may deliver differing amounts of chemicals to the body.

This study instead examined the levels of toxins and carcinogens in the body over time, and found that they are lower in users of e-cigs than in regular smokers, and comparable to those found in people using other NRTs.

This is a big deal. While taking up vaping from scratch is still a bad idea, regular smokers who switch to e-cigarettes could do themselves considerably less harm than if they keep smoking tobacco. Ideally, e-cigarettes would be, like nicotine patches, used as an aid to eventually wean yourself off nicotine altogether, but even if you switch permanently to vaping, you’ll be healthier.

Vaping is still a young phenomenon—e-cigarettes were only patented in 2003—and the research is still scant. Even this study only looks at 181 individuals, and is funded by an organization that has a vested interest in reducing cancer. But really, it seems that pretty much anything is better for you than smoking. Apart from sitting down, that is.

E-cigarettes may pose the same or higher risk of stroke severity as tobacco smoke

Electronic cigarette (e-cigarettes) vaping may pose just as much or even higher risk as smoking tobacco for worsening a stroke, according to a preliminary study in mice presented at the American Heart Association’s International Stroke Conference 2017.

https://eurekalert.org/pub_releases/2017-02/aha-emp021517.php

Researchers found:

Mice exposed to e-cigarette vapor for 10 days or 30 days had worse stroke outcome and neurological deficits, than those exposed to tobacco smoke.

E-cigarette exposure decreased glucose uptake in the brain. Glucose fuels brain activity.

Both e-Cig and tobacco smoke exposure for 30 days decreased Thrombomodulin (anti-coagulant) levels.

From a brain health perspective, researchers said, electronic-cigarette vaping is not safer than tobacco smoking, and may pose a similar, if not higher risk for stroke severity.

Use of e-cigarettes is a growing health concern in both smoking and nonsmoking populations. Researchers said rigorous studies are needed to investigate the effects of the nicotine exposure via e-cigarettes on brain and stroke outcome.

Ali Ehsan Sifat, Graduate Student/Research Assistant, Department of Pharmaceutical Sciences, Texas Tech University Health Sciences Center, Amarillo, Texas.

E-cigarettes users have lower carcinogen and toxin levels than smokers, study finds

Although this is a relatively small study, as the authors acknowledge, it indeed helps to elucidate some clarity on some central issues. One such issue is that that the study contributes to confirming that the continued use of both e-cigarettes and tobacco cigarettes, i.e. “dual use”, does not appear to significantly reduce the harms of smoking. Arguably, this is not “news”. One very large longitudinal study (1), followed 24 959 men and 26 251 women, aged 20–49 years, screened for risk factors of cardiovascular disease in the mid-1970s, screened again after 3–13 years, and followed up throughout 2003. The authors of this substantial longitudinal concluded that:

http://www.bmj.com/content/356/bmj.j651/rr

“Long-term follow-up provides no evidence that heavy smokers who cut down their daily cigarette consumption by >50% reduce their risk of premature death significantly. In health education and patient counselling, it may give people false expectations to advise that reduction in consumption is associated with reduction in harm.”

In retrospect, therefore, it have been somewhat misleading for an important evidence review like the 2014 Cochrane Review of E-Cigarettes (2) to make one of its primary outcome measures: a 50% reduction in tobacco consumption. Some observers are still, erroneously and misleadingly, publically claiming that “when people vape, they smoke less, even if they don’t manage to quit altogether. In other words, harm is reduced” (3). This claim, in fact, does smokers a significant dis-service.

Other reviews (4; 5) have highlighted, indeed, that even the so-called “light smoking” of only one to four cigarettes per day still risks producing significant harm, so, the results of this new study, in respect of dual use are, arguably, not that surprising. As the authors state, users of e-cigarettes must appreciate that, for there to be an appreciable benefit to their health, they need to fully switch away from tobacco cigarettes.

Unfortunately, it appears that, currently at least, the significant majority of e-cigarette users: firstly, either stop using them, finding that the devices fail to satisfy their cravings, are “not like smoking” a cigarette and are “messy fiddly devices” (6; 7); or, secondly, continue to dual use (8) along with tobacco cigarettes. Thus, the technology and chemistry involved needs to improve, if e-cigarettes are to fulfil the promise that some believe they have in truly competing with tobacco cigarettes.

The results here confirm, however, that a full switch to e-cigarettes, or nicotine replacement therapies, should significantly reduce exposure to the important cancer-causing toxins tested in this study – clearly, good news, in terms of cancer. However, the claim in the Cancer Research UK Press Release that “the long term effects of these products will be minimal” (9) is premature, and arguably, unscientific. The study could only test for a relatively limited number of the total of known relevant harmful substances: almost entirely related to cancer. It did not test for, for example, other important biomarkers, related to oxidative stress and the vascular system, that other studies using human subjects have (10), and which have indicated to expert toxicologists a “substantial exposure” and a concerning potential for harm, although, still less than from tobacco cigarettes (11).

Still other studies using human subjects, looking at different issues than this new study, have identified suppression of a significant number genes related to immunity and respiratory risks (12), and more recently, findings suggestive of inflammation and subsequent cardiac risk (13; 14).

This new study under review here, though helpful, is only part of the puzzle that is “e-cigarettes” – further, long term studies, following e-cigarette users for a prolonged period of time, tracking not just issues mostly related to cancer, but other specific respiratory and cardiac risks, are still required, before anyone can confidently claim that the harmful effects of switching purely to e-cigarettes are “minimal”. Further, as the authors indicate, it tells us nothing regarding the efficacy of e-cigarettes, which can currently only be described as either: very weak, at best (15): or detrimental to chances of cessation, at worst (16).

One of the observations regarding this new study is that, probably due to the predominant interests of the funder Cancer Research UK, its primary outcome measures were related to risks of cancer. Therefore, what the study did not consider are the potential cardiovascular effects of e-cigarettes, and the non-cancer respiratory effects. CDC data (17) demonstrates, importantly, that basically as many people die prematurely from the cardiovascular effects of smoking tobacco (160,000) as from cancer effects (163,700), so, if we then add on the premature deaths of the non-cancer lung disease (113,100), it becomes clear that the health effects of smoking are, unfortunately, very much more than those purely related to cancer.

‘‘All views are my own and do not necessarily reflect those of my employer”

1) http://tobaccocontrol.bmj.com/content/15/6/472.long
2) http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010216.pub2/full
3) http://www.theglobeandmail.com/opinion/the-health-hazards-of-vaping-are-…
4) http://circ.ahajournals.org/content/121/13/1518
5) http://tobaccocontrol.bmj.com/content/14/5/315.full
6) http://substanceuseresearch.org/wp-content/uploads/2017/01/Pleasure.pdf
7) https://academic.oup.com/ntr/article-lookup/doi/10.1093/ntr/ntw102
8) https://academic.oup.com/ntr/article-lookup/doi/10.1093/ntr/ntw102
9) http://www.cancerresearchuk.org/about-us/cancer-news/press-release/2017-…
10) http://journal.publications.chestnet.org/article.aspx?articleid=2518226
11) https://blogs.otago.ac.nz/pubhealthexpert/2016/07/04/what-does-recent-bi…
12) http://ajplung.physiology.org/content/311/1/L135
13) http://jamanetwork.com/journals/jamacardiology/article-abstract/2600166
14) http://www.atherosclerosis-journal.com/article/S0021-9150(16)31378-8/pdf
15) http://www.cochrane.org/CD010216/TOBACCO_can-electronic-cigarettes-help-…
16) http://www.thelancet.com/journals/lanres/article/PIIS2213-2600(15)00521-4/abstract
17https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/t…(15)00521-4/abstractco_related_mortality/index.htm

Competing interests: No competing interests