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September 3rd, 2015:

Why e-cigarettes have their own toxic dangers

A study of English quitters found those who used e-cigarettes were less likely to have successfully quit smoking after 12 months.

Wander into a vape shop in the mall or online, and you can find a smorgasbord of flavors: cotton candy, vanilla custard, even Unicorn Milk or Katy Perry’s Cherry.

Flashy flavors have helped e-cigarettes, designed to vaporise a nicotine solution, grow into an industry with an estimated $3.5 billion in annual U.S. sales. Less than a decade after the battery-powered devices were introduced in the United States, an estimated 10 percent of American adults and 13 percent of high school students “vape,” according to recent surveys.

While many users perceive e-cigs as safer than traditional cigarettes, some of the flavorings that make them so enticing may have their own toxic consequences.

A growing number of studies find that some of the liquids used in e-cigarettes contain flavorings whose inhalation has been associated with lung problems, ranging from irritation to a rare but serious lung disease. For example, diacetyl, a butter-flavored chemical, has been linked to dozens of cases of bronchiolitis obliterans, a life-threatening obstructive lung disease.

E-cigarettes are unregulated, but that may change. The Food and Drug Administration is considering a rule to extend its cigarette-regulating authority to e-cig devices. More than 7,700 e-cig flavors are being sold under more than 450 brands, with no labeling or testing requirements.

Jessica Barrington-Trimis, an epidemiologist at the University of Southern California who studies tobacco’s health effects, said that flavorings are particularly worrisome because they “have a history of being known respiratory toxins.” Barrington-Trimis, who spoke at an FDA panel looking into e-cigs in March, said that because the devices produce an ultrafine aerosol that goes deep into the lungs, their flavorings “are a natural target” for further investigation.

“We need to research this more to understand what chemicals are in these things and what these chemicals may be doing to the lungs of the user,” she said.

One of the first people to highlight e-cig flavoring concerns was a physician who uses e-cigarettes himself. Konstantinos Farsalinos, a researcher at the Onassis Cardiac Surgery Center in Athens, tested 159 sweet e-cig liquids, such as toffee, chocolate and caramel flavorings, and found that 74 percent of the samples contained diacetyl – the chemical associated with bronchiolitis obliterans – or a chemically similar substitute, acetyl propionyl.

Among the ones that tested positive, nearly half would expose users to levels that exceed recommended workplace limits for breathing the two chemicals, his 2014 study found.

Diacetyl is found naturally in butter, beer and other foods, and it is added to baked goods, candy and snack foods to impart a buttery or creamy taste. Although it is considered safe to eat, breathing it may not be.

In 2002, the National Institute for Occupational Safety and Health, reported that eight workers in a Missouri microwave popcorn plant had developed bronchiolitis obliterans after breathing diacetyl on the job. Half of them needed lung transplants, and five have died of respiratory causes, Kathleen Kreiss, a NIOSH expert in occupational respiratory disease, said in an e-mail. Dozens of cases of bronchiolitis obliterans – known in some circles as “popcorn lung” – have since been found at other food and flavorings plants.

Farsalinos, who has accepted some funding from the vaping industry, said he believes that e-cigarettes are safer than tobacco cigarettes. Acetyl propionyl and diacetyl are also naturally present in cigarette smoke, Farsalinos said, at levels higher than those he found in e-cigs.

Still, Farsalinos said, “these specific chemicals should be completely removed” from e-cigs. “Why? Because it’s a 100 percent avoidable risk.”

Some manufacturers avoid diacetyl. For example, Nicoventures, a division of British American Tobacco, does not use diacetyl in its nine e-cigarette flavorings, Sandra Costigan, a company toxicologist said in an e-mail.

The American Vaping Association, an advocacy group for the industry, believes that diacetyl and acetyl propionyl should not be added to e-cigarette flavorings, association president Gregory Conley said.

In 2012 the Flavor and Extract Manufacturers Association, which represents the U.S. flavorings industry, issued a list of 27 “high-priority” flavoring chemicals that, while safe in food, may pose a risk of respiratory injury and for which it recommends reducing inhalation exposure. The list includes chemicals found in e-cig liquids, such as diacetyl and benzaldehyde, which is used in almond and cherry flavors.

“When we saw flavors were being used in e-cigarettes, we wanted to put the word out right away that it’s a possibility that flavors being inhaled through an e-cigarette could also be harmful,” John Hallagan, the association’s senior adviser and general counsel, said in an interview.

“Flavors are not made to be inhaled,” he said. “In the absence of safety information, what we’re saying is we really need to pay attention to this from a safety perspective.”

A 2013 study found that several cinnamon-flavored e-cig liquids contained a chemical, cinnamaldehyde, that researchers said was highly toxic to human cells in lab tests. A co-author of that study, Prue Talbot, a professor of cell biology at the University of California at Riverside, said the results corroborated online reports by e-cig users of problems related to cinnamon flavors, including swollen throats and mouth sores.

Another study examined 30 e-cigarette liquids and found that many flavors – including a cotton candy, a bubble gum and a French vanilla – contained aldehydes, a class of chemicals that can cause respiratory irritation, airway constriction and other effects. The 2015 paper described two flavors, a dark chocolate and a wild cherry, that would expose vapers to more than twice the recommended workplace safety limit for the aldehydes vanillin and benzaldehyde. Different brands and even different batches of e-cig liquids can contain different amounts of flavoring chemicals.

“There’s no going by the flavor names as to say what’s in it,” said James Pankow, a chemistry and engineering professor at Oregon’s Portland State University, one of the co-authors of the study.

The FDA’s proposed rule on e-cigarettes would restrict sales to young people and prohibit unsubstantiated health claims. If e-cigs are brought under the FDA’s regulatory authority, the agency would have to go through additional rulemaking to set standards on flavorings, FDA spokesman Michael Felberbaum said in an e-mail. The FDA prohibits adding flavorings, other than menthol, in traditional tobacco cigarettes.

Some e-cig companies are doing their own research on flavorings. Nicoventures, the British company, recently proposed a screening process to avoid liquid flavorings that are classified as respiratory allergens, carcinogenic, mutagenic or toxic to reproduction, among other criteria. The company has rejected diacetyl and acetaldehyde as flavorings and avoided developing a flavor that uses cocoa shell extract because of concerns that it might be a respiratory sensitizer, Costigan said in an e-mail.

“We wanted to demonstrate that they [flavorings] could be used responsibly even when there are limitations in data,” she said.

The company says that flavorings benefit public health by helping smokers transition away from combustible tobacco. However, the science isn’t settled yet on whether e-cigs help people quit tobacco cigarettes – or get them hooked. A recent study, for instance, found that ninth-graders who used e-cigs were about 2 1/2 times as likely as their peers to start smoking traditional cigarettes.

Conley, of the American Vaping Association, says e-cigarettes flavored with watermelon helped him stop smoking five years ago, and he will fight to keep flavorings on the market.

“There’s a reason why the gum, patch and lozenge have such pitiful success rates,” he said, referring to some common approaches to smoking cessation. “We have to avoid medicinalizing these products [e-cigarettes] and making them bland and boring,” he said.

Even if e-cigarette users are exposed to diacetyl, he asserted, the risk of harm is only a fraction of that from smoking tobacco, which causes 480,000 deaths per year in the United States, according to federal data.

Talbot, who conducted the cinnamon flavoring study, said the problem is that people are now “inhaling a product into their lungs, and we don’t currently know what the consequences or long-term health effects of that will be.” While it is true, she said, that e-cIgs contain fewer chemicals than the brew of 7,000-plus that are in traditional cigarette smoke, “it would only take one bad one.”

A Smoking Gun – Cancer-causing chemicals in e-cigarettes

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Why e-cigarettes have their own toxic dangers

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Health Group Challenges E-Cig Makers After Tests Find High Levels Of Toxic Chemicals In Most Products

A health watchdog group took legal action against some of the country’s largest e-cigarette manufacturers for failing to properly warn consumers about the risk of such products after tests show that most produce high levels of toxic chemicals.

The Center for Environmental Health conducted tests of 97 e-cigarettes and other “vaping” products from two dozen makers including Imperial Tobacco’s Vuse brand, NJoy, and RJ Reynolds’ blu brand for the report titled “A Smoking Gun: Cancer Causing Chemicals in E-cigarettes.”

The report – which the group claims is the first-ever large sampling of actual e-cigarettes and vaping products tested simulating real-world use – found that 50 out of the 97 e-cigarettes tested pose a serious cancer risk.

The products used in the tests were purchased at easily accessible businesses such as 7-Eleven, Rite Aid, online retailers, and vape stores in the Bay Area.

According to the report, 90% of the companies had at least one product that produced high levels of formaldehyde or acetaldehydeone or both, representing a violation of California safety standards.

unnamed (1)The two chemicals have been found to cause cancer and are also linked to genetic damage, birth defects and reduced fertility.

“The testing showed that 21 products produced a level of one of the chemicals at more than ten times the state safety standard, and seven products produced one of the chemicals at more than 100 times the safety level,” said CEH in a press release on Wednesday.

unnamed (2)While some consumers believe that nicotine-free e-cigarettes are safe, the CEH testing found high levels of the chemicals even in several of these varieties.

For example, the report found one nicotine-free product produced acetaldehyde at more than 13 times the state legal safety threshold and formaldehyde at more than 74 times the threshold.

“Anyone who thinks that vaping is harmless needs to know that our testing unequivocally shows that it’s not safe to vape,” said Michael Green, Executive Director of CEH. “This is especially troubling given the reckless marketing practices of the e-cigarette industry, which targets teens and young people, and deceives the public with unfounded health and safety claims.”

In its legal claims, the group alleges that e-cigarette manufacturers are breaking California’s consumer protection laws.

“Our legal action aims to force the industry to comply with the law and create pressure to end their most abusive practices,” Green says.

According to the legal actions, the companies can resolve the issues if they agree to a binding agreement that recall products already sold, provide clear and reasonable warnings for products sold in the future, and pay an appropriate civil penalty based on violations.

E-Cigarette bans warranted amidst scientific uncertainty

With NSW passing laws restricting the sale of electronic cigarettes and accessories to people under 18, Wendy Zukerman takes a look at the science: are e-cigarettes a great way of helping smokers quit or a dangerous new moneymaking attempt from the tobacco industry?

The sale of electronic cigarettes to minors is now banned in New South Wales after new anti-e-cigarette laws came into effect this week.

According to NSW Health Minister Jillian Skinner, the legislation was a priority for the government. ‘Following our re-election in March, we moved immediately to ban the sale of e-cigarettes and e-cigarette accessories to minors,’ she says.

There is no question that taking a puff on an e-cigarette is less dangerous as taking a puff on a cigarette.

After decades of anti-tobacco messages and smoking laws, e-cigarettes are fast becoming big business. Data out this year from the Centre of Disease Control found that two million students in the US have used them.

‘In the US now, there are more kids who are vaping than who are smoking,’ says Simon Chapman, a professor of public health at the University of Sydney.

Meanwhile, the American Heart Association’s Policy statement notes that unregulated e-cigarette use ‘has the potential to erode gains in smoking cessation and smoke free laws’.

Things might not be so black and white, though. Some scientists advocate the use of e-cigarettes as a tool to wean people off tobacco.

E-cigarettes use a battery to heat up a liquid, usually propylene glycol or glycerol. Often the liquid contains nicotine. When the concoction is heated it turns into an aerosol that can be inhaled. The product provides the user with the nicotine buzz of a cigarette without burning tobacco.

Many e-cigarettes are also sold with a choice of flavours such as apple, strawberry and bubblegum. With sharp memories of Fred Flintstone being used to pimp cigarettes to children in the 1950s, these seemingly child-friendly flavours have rubbed health experts up the wrong way.

Still, e-cigarettes are safer than smoking tobacco. ‘There is no question that taking a puff on an e-cigarette is less dangerous as taking a puff on a cigarette,’ says Stanton Glantz, professor of medicine at the University of California in San Francisco.

This is because the toxicity of a cigarette largely stems from the thousands of chemicals released when tobacco burns—a process that doesn’t occur in the electronic version.

A review conducted by Glantz and colleagues and published last year found that the level of toxic compounds in e-cigarettes can be hundreds of times lower than those found in regular cigarettes.

However, while they’re less dangerous than tobacco, e-cigarettes are unlikely to be harmless. ‘The danger of cigarettes is so stratospherically high,’ says Chapman. ‘It’s like comparing the 15th highest mountain in the world to Mount Everest.’

Professor Stanton Glantz, agrees: ‘You’re inhaling a lot of toxic chemicals when you use an e-cigarette.’

The heating devices in e-cigarettes can emit heavy metals. Additionally, when the temperature of propylene glycol rises past a certain point it can form the toxic chemical formaldehyde.

Glantz is also concerned about ultrafine particles produced once the liquid inside an e-cigarette is heated. ‘Those ultrafine particles are themselves dangerous,’ he says.

According to Glantz, these particles, which are about 1/50th the width of a human hair, can move through the air sacs in the lungs and into blood. Once in your system, Glantz says, these products cause inflammation, which can trigger systemic biological processes that affect the blood and the lining of the arteries, increasing the risk of cardiovascular disease.

Currently, however, there is little evidence that the tiny particles in e-cigarettes specifically cause any of these problems.

‘It’s extrapolating from what we know about ultrafine particles in general,’ says Glantz.

E-cigarettes are a relatively new product, and there are no long-term studies into their health effects. This is particularly problematic given that many of the diseases associated with conventional cigarettes, such as cancer and heart disease take a long time to develop.

‘We are going to have to wait a while to know precisely how bad they are,’ says Glantz.

Still, scientific opinion is divided when it comes to just how fearful we should be of the potential dangers. Dr Lynne Dawkins, leader of the Drugs and Addictive Behaviours Research Group at the University of East London, acknowledges that there are harmful chemicals in e-cigarettes, but says we need to put that into perspective, particularly since e-cigarettes are likely to be less dangerous than conventional cigarettes.

‘There are harmful chemicals in everything: in the air we breathe, in the food we eat, in the nail polish aroma that we put on our toe nails,’ says Dawkins, who has received funding from several electronic cigarette companies.

Simone Davis, who works for Liberty Flights, an e-cigarette company, says that in the face of uncertainty her company chooses products that are ‘approved for human consumption’.

But Chapman warns that there is an important difference between inhaling and consuming products. ‘These have not been approved for inhalation, let alone 200 times a day, 365 times a year,’ he says.

For example, the butter-flavoured chemical diacetyl is often added to foods such as popcorn. It has also been found in butterscotch flavoured e-cigarettes. While approved for human consumption, diacetyl can cause a rare but serious and irreversible lung condition called bronchiolitis obliterans, or ‘popcorn workers lung’ when inhaled.

There’s also a debate about whether nicotine itself is dangerous. Dawkins describes nicotine as ‘a mild stimulant, like caffeine really’. While Glantz says that nicotine ‘actually changes the physiology of the brain and inhibits a lot of normal neural development’.

According to Chapman, it’s hard to say whether nicotine is all that harmful on its own because most people who suck up high levels of nicotine over long periods of time are tobacco smokers—making it tricky to separate its effects from those of other chemicals. ‘We really don’t know enough to know about if it’s in itself dangerous,’ he says.

Meanwhile, uncertainty exists over whether e-cigarettes effectively pull smokers away from conventional cigarettes. ‘They can help people quit smoking,’ says Professor Chris Bullen from the University of Auckland, whose work has shown that e-cigarettes can be at least as effective as nicotine patches at helping people quit.

But Glantz has a different take. ‘The most dangerous thing about e-cigarettes is that they keep people smoking cigarettes,’ he says. To make his case, he cites different data from Bullen’s, which suggests that smokers using e-cigarette are less likely to quit.

Glantz says this could be because many countries let people use e-cigarettes in places they couldn’t smoke tobacco. ‘The main motivators, and one of the things that really helps people quit smoking, is smoke-free laws, and smoke-free homes,’ he says.

Chapman says he will await more evidence before making up his mind on the issue. ‘E-cigarettes could be a revolutionary breakthrough for smoking cessation, but at the moment the evidence on cessation is pretty disappointing, they are nothing like the hype is suggesting,’ he says.

E-cigarette study could propel law: Sen. Mark Leno seeks to classify vapor cigs as tobacco product

Mark Leno

A new study that health advocates say proves electronic cigarettes contain cancer-causing chemicals could help boost legislative efforts to regulate the increasingly popular, and highly debated, nicotine products.

The Oakland-based Center for Environmental Health released a study Wednesday that found high levels of formaldehyde and acetaldehyde in a majority of the most popular e-cigarettes — the nonprofit is also planning to file a lawsuit alleging these manufacturers violated California’s Proposition 65 by not warning consumers.

This study is the first-ever large sampling of actual e-cigarettes and found 90 percent of the major companies tested had a product with one or both of the chemicals known to cause cancer and that are linked to genetic damage, birth defects and reduced fertility, according to the center.

“For decades, the tobacco industry mounted a campaign of lies about cigarettes, and now these same companies claim that their e-cigarettes are harmless. Anyone who thinks that vaping is harmless needs to know that our testing unequivocally shows that it’s not safe to vape,” the center’s Executive Director Michael Green said in a press release. “Consumers need to know that the smoke from e-cigarettes is far less from harmless vapor, but is in fact a cancer-causing cocktail of toxic chemicals.”

Yet e-cigarette industry advocates argue the scientific testing of e-cigarettes needs to be refined and compared to combustible or traditional cigarettes, vapor products are less harmful, according to the Smoke Free Alternative Trade Association, or SFATA.

While scientists continue to probe the vapor products, state and city efforts to regulate where they can be used and how they’re distributed are underway.

State Sen. Mark Leno, D-San Francisco, recently authored a bill calling for the state to classify e-cigarettes as a tobacco product and consequentially, prohibit them from being used at a variety of public places such as schools, restaurants and on public transportation. Leno’s Senate Bill X2-5, is similar to one authored by state Sen. Jerry Hill, D-San Mateo, and would also require the liquid nicotine to be sold in child-resistant packaging — a response to drastic increases in the number of poisonings over the last few years, which went from 1,543 in 2013 to nearly 4,000 in 2014, according to reports.

Leno’s bill passed the Senate last week and is now in the Assembly where it will likely first be heard in the committee on public health.

The center hired an independent lab to test 97 products purchased from Rite-Aid, 7-Eleven, online and Bay Area vapor stores between February and July 2015. The results showed 21 products produced one of the chemicals at a level more than 10 times the state’s safety standard and seven products produced one of the chemicals at more than 100 times the safety level, according to the center.

Although e-cigarettes are frequently touted as a safer alternative to traditional tobacco, the tests found one nicotine-free product produced acetaldehyde at more than 13 times the state’s legal safety threshold and formaldehyde at more than 74 times the threshold, according to the center.

Others contend e-cigarettes are a better alternative to traditional tobacco products and the industry is not completely opposed to certain regulations, according to the SFATA.

“It also is essential to note that vapor products are considered 95 percent less harmful than combustible cigarettes and are a contributing factor to the recent decline in cigarette smoking,” according to the SFATA, which cited a recent report conducted by Public Health England. “Vapor products are intended only for adult smokers and adult vapers and the industry does not market to underage consumers and fully supports age restrictions on their use,” according to the SFATA.

But lawmakers are only beginning to catch up to the e-cigarette industry’s growing market. Various efforts have been made to classify the smokeless e-cigarettes as tobacco products and deter them from being marketed to youth.

Locally, cities across the county have enacted or begun to consider their own policies to tighten tobacco regulations that include e-cigarettes while state efforts have stalled.

Now, Leno is hopeful this study continues to highlight the need for a statewide policy.

“This study reconfirms what other major public health agencies have found, which is that most e-cigarette products contain chemicals known to cause cancer. This is especially concerning given that the fastest growing segment of e-cigarette smokers is middle and high school students,” Leno wrote in an email. “It is unacceptable for the state of California to continue to let this unregulated industry sell its tobacco and nicotine products to both young people and adults with such little oversight. We must act now in order to protect public health.”


By Madhuparna Bhattacharjee

In the coming weeks, Oman may take a decision to completely ban electronic cigarettes, which are increasingly becoming popular around the world as a substitute for tobacco smoking and claimed to be risk-free by manufacturers.

Talking to Muscat Daily, Dr Jawad al Lawati, senior consultant and rapporteur of the National Tobacco Control Committee in the Ministry of Health, said, “Sale of e-cigarettes is at present not allowed in the country and a permanent comprehensive ban is being considered by concerned authorities.”

As of now, the sultanate has no formal ban in place on such cigarettes.

Oman, however, is on the list of nations that restrict their promotion and sale.

The Ministry of Commerce and Industry (MoCI) is considering a ban on e-cigarettes in view of several international recommendations based on case reports and medical studies illustrating their addictive nature, Dr Lawati said.

“They have not been approved by international health agencies such as the US Food and Drug Administration (FDA) or the World Health Organization (WHO) and the safety of these cigarettes is yet to be proven,” he added.

The electronic nicotine delivery systems report (by The WHO Framework Convention on Tobacco Control (FCTC) for 2014 states that 47 countries either have bans or restrictions in place on e-cigarettes.

Among the 47 are Argentina, Bahrain, Brazil, Brunei Darussalam, Cambodia, Colombia, Greece, Jordan, Kuwait, Lebanon, Lithuania, Mauritius, Mexico, Nicaragua, Oman, Panama, Qatar, Saudi Arabia, Seychelles, Singapore, Suriname, Thailand, Turkey, UAE, Uruguay, Venezuela.

Of these, 33 countries including Oman prohibits or restricts advertising, promotion or sponsorship of e-cigarettes in their policies. The other GCC countries doing the same are Bahrain, Kuwait, Qatar, Saudi Arabia and UAE.

A regulation to implement a decision by health ministers of Gulf countries is under way. It will impose a complete ban on sale and marketing of e-cigarettes, says a recent report titled ‘Country Laws Regulating E-cigarettes: A Policy Scan’, published by John Hopkins, Bloomberg School of Public Health, an institute for global tobacco control.

Health officials fear that e-cigarettes are a point-of-entry, which introduce conventional cigarettes and other tobacco products to children, youth and non-smoking adults, Dr Lawati said. Some smokers in Oman smuggle the devices into the country.

CSU researcher studies e-cigarettes being gateway to tobacco

A Colorado State University faculty member was involved in a new study showing that teens who use e-cigarettes are more likely to start smoking combustible types of tobacco products, like cigarettes, cigars and hookah.

That study, “Association of Electronic Cigarette Use With Initiation of Combustible Tobacco Product Smoking in Early Adolescence,” focused on 2,530 14-year-old students at 10 public high schools in Los Angeles who had never tried combustible tobacco. The researchers separated the students into two groups: 222 who acknowledged using e-cigarettes in the past and 2,308 who said they’d never tried them. Six months later, about 31 percent of the group that had reported using e-cigarettes said they had used a combustible tobacco product, while only 8 percent of the non-users had tried combustible tobacco.

“Sure enough, the kids who had used e-cigarettes were more likely to start using combustible tobacco,” said Riggs, a co-investigator who collaborated on the research design and data analysis for the project. “Results provide support for the hypothesis that e-cigarettes can be a stepping stone to combustible tobacco use.”

Growing health concern

Riggs said that while the use of e-cigarettes in Colorado is sometimes overshadowed by the legalization of marijuana, they represent an emerging public health concern.

“The perception is that e-cigarettes are less harmful because they contain fewer known carcinogens,” he said. “But they still contain nicotine, the addictive chemical which contributes to dependence. We are particularly concerned with adolescent nicotine use because the adolescent brain appears to be more susceptible to addiction than the adult brain.”

Exacerbating the problems with the growing popularity of e-cigarettes is that they can be flavored, making them even more appealing to youth.

Riggs, whose research expertise is in understanding adolescent brain development and its role in risk-taking behavior, said the study does not definitively mean that e-cigarettes caused the kids to start smoking, because other factors could be involved. But it’s a strong indication that e-cigarettes can act as a gateway.

He said one logical next step for the researchers is to examine the causal pathways linking e-cigarette use to combustible tobacco use.

“What is it about these youth, or their environments, that makes them more likely to transition to combustible use?” he asked.

The study was part of a larger project called the Health and Happiness Study, a five-year $3.5 million research grant funded by the National Institute of Drug Abuse. The principal investigator on the study was Adam Leventhal of the Department of Preventive Medicine at the University of Southern California.

The Department of Human Development and Family Studies is in CSU’s College of Health and Human Sciences.

India may be grilled at WHO meet on failure to implement larger pictorial warnings on tobacco packs

NEW DELHI: India may have to face tough questions on tobacco control at the upcoming south-east Asia regional committee meeting of the World Health Organization next week.

Assessment of tobacco control measures taken by various countries in the region is among the top agendas to be taken up for detailed discussion during the meeting, sources said.

The meeting, which will take place in Dili in Timor Leste, will be attended by health ministers from 11 countries of the south-east Asia region including Indian health minister J P Nadda.

“Accelerating efforts to protect people against tobacco is one of the key topics for discussion at the meet. It is most likely that India will have to explain its position in the context of delay in implementation of the larger pictorial warnings on packs of tobacco products,” said an official, who is going to attend the WHO meeting.

The health ministry had earlier set a deadline of April 1 to increase the size of pictorial warnings on packs of tobacco products. A notification to this effect was also issued allowing time to manufacturers to prepare for the implementation. However, following interim recommendations by a Parliamentary Committee on Subordinate Legislation examining the proposed amendments to the Cigarettes and Other Tobacco Products Act, 2008, the ministry had put the final notification for the implementation on hold. The committee had sought more time to do stakeholder consultation and submit its final report to the health ministry.

Though, the ministry has maintained all through that it is determined to take stringent measures in order to control consumption of tobacco products, the delay in implementing larger pictorial warnings triggered criticism against the government.

Despite pressure from the civil society as well as the international community, the government has also failed to indicate a deadline for the committee to submit its recommendation or to say how long the ministry will wait before issuing its final order.

Though, the committee recently held consultations with civil society as well as industry players, no resolution has been arrived at so far. Meanwhile, the agriculture ministry has also given its consent to the proposal for larger pictorial warnings.

Sources said now India may again have to explain its move to satisfy queries and concerns from the international community at Dili.

Apart from tobacco, the meeting will also witness discussions on post-2015 Global Sustainable Development Goals, and expanding effective services with stronger health workforce.

The Regional Committee, the highest policy making body of WHO in the region, will also deliberate on anti-microbial resistance, an issue which needs urgent attention and action.

Eliminating neglected tropical diseases like kala-azar, leprosy and yaws; adapting and implementing the End Tuberculosis strategy; the way forward for preventing and controlling cancer; and sustainable universal health coverage will be other areas of focus at the meeting.

The Lancet attacks UK health agency’s claim that e-cigarettes are 95% safer than tobacco

Health agency’s report on e-cigarettes used shaky evidence, ignored conflicts of interest.

An editorial in the current issue of The Lancet criticises Public Health England (PHE) for using weak evidence in its recent review of evidence on e-cigarettes, and a press release that followed.

In particular, The Lancet takes aim at the claim that e-cigarettes are around 95 percent less harmful than tobacco. It argues that the evidence for this statistic is weak, and that it originates with researchers who have relevant conflicts of interest.

Weighing up the potential benefits and harms of e-cigarettes has become an important public health question. The PHE report, authored by addiction researchers at King’s College London and Queen Mary University of London, makes the case that e-cigarettes are substantially less harmful than cigarettes, and seem to help smokers to quit more successfully.

This means, the report argues, that e-cigarettes could be very helpful in reducing smoking in the UK, lowering smoking-related death and disease while bringing down public health costs. However, according to the report, public perception of e-cigarettes is an obstacle. Surveys suggest that people are increasingly nervous about potential harm from e-cigarettes, with many people reporting that they think of them as “just as harmful” as cigarettes.

“There is a need to publicise the current best estimate that using EC is around 95 percent safer than smoking,” the report suggests. And publicising is what PHE did: a press release went out entitled “E-cigarettes around 95 percent less harmful than tobacco.” It was picked up widely in the media, with some reports suggesting that the figure was established directly by the PHE review.

The horse’s mouth

It wasn’t. The report cites two references for the figure: a paper in the journal European Addiction Research, and a review (PDF) of e-cigarette evidence presented to the UK’s All Party Parliamentary Group on Smoking and Health. The review in turn cites the European Addiction Research paper as its source for the statistic, so it’s safe to assume that this paper is where it originated.

The paper, authored by a group of scientists led by addiction researcher David Nutt, was the result of a collaboration exploring the harms of nicotine products. To estimate how harmful tobacco and other nicotine products are, the group took into account harm to the user (such as disease and addiction) and harms to non-users (like disease and environmental degradation).

The scores of various products were calculated, with cigarettes notching up a score of 99.6 out of a possible hundred, and e-cigarettes scoring only 4. However, Nutt and his co-authors note a number of caveats that encourage caution with these results. Most importantly, they note that there just isn’t much evidence available.

The estimated harms of nicotine products.

The estimated harms of nicotine products.

They go so far as to say that there is a “lack of hard evidence for the harms of most of the products on most of the criteria.” In other words, they were estimating. Estimating is a useful starting point, but it’s shaky ground for a litany of headlines. It’s even shakier ground when you consider that the paper declared relevant conflicts of interest for three of its 11 authors.

Of course, conflicts of interest don’t necessarily mean that the research is shady: that’s why they’re often declared right out in the open, on the paper itself. But the conflicts of interest combined with the weaknesses in the estimates of harm should invite caution about the conclusions, The Lancet argues: “the reliance by PHE on work that the authors themselves accept as methodologically weak raises serious questions not only about the conclusions of the PHE report, but also about the quality of the agency’s peer review process.”

Evidence and public perception

The authors of the PHE report responded to the editorial, arguing that its criticisms were based on “perceived flaws in one of the 185 references we used, ignoring the rest of our 111 page document.” There was a great deal more in the report, they write, which delved into evidence on how good e-cigarettes are at helping people quit, whether they’re likely to encourage people to start smoking, and other relevant questions.

The report’s authors also offer different grounds for the contested statistic: that the compounds we know to be harmful in cigarettes are either absent in e-cigarettes, or present at levels below 5 percent of their cigarette doses. Meanwhile, nothing that’s in e-cigarettes (but not cigarettes) has been shown to be harmful (yet). There’s no source cited for these calculations, and it’s not clear why the authors are claiming a different source for the statistic from the one they cited in their original report.

The public misinformation about the harms of e-cigarettes, combined with the potential benefit they hold for helping people to quit, justifies the publicity surrounding the “95 percent” statistic, the authors argue. They’re backed up by PHE directors in a further response to the editorial, arguing that other important findings, like the growing perception of harm from e-cigarettes, have been neglected in the critique.

The debate here really separates into two separate issues. The first is about the actual evidence for harms and benefits of e-cigarettes, which is still a very hazy picture. It’s still too early to know what the long-term effects might be, and the evidence for how helpful they are for quitters is mixed—even according to the review cited by the PHE report. Moreover, a recent Journal of the American Medical Association paper reported that we might be optimistic in thinking that e-cigarettes don’t get people started on smoking: they found that teenagers who had smoked e-cigarettes were more likely to start smoking tobacco.

The second multifaceted issue, which is less easily resolved by lots of long-term research, is about public information, over-hyped and uncritical reporting in the media, and the over-hyped press releases underlying that naive media coverage. Minds can be slow to change on matters of public health, and the ethics of reporting shaky statistics that could shape health perceptions for years to come are worthy of The Lancet’s scrutiny.