This section will examine electronic cigarettes (e-cigarettes) to see if they are really a safe alternative to smoking tobacco and also a good way to quit smoking. We look at the history of tobacco and ask if the marketing of e-cigarettes is honest and factual. Are they a safe alternative or just the tobacco industry making up lost ground with a new way to hook new addicts?
This section will contain the following headings:
- The Rise of Tobacco
- Dangers of Tobacco Discovered
- Deception and Lies
- What are Electronic Cigarettes?
- E-cigarettes, an Aid to Quit or a Way to Trap New Addicts?
- The Marketing of Nicotine
- Is Vaping Safe?
- Interpreting the Evidence
- Further Resources
- Site Index
The Rise of Tobacco
Tobacco was introduced to Europe from the New World by Sir Walter Raleigh in the reign of Elizabeth I and became popular in the 1570s. James I (VI of Scotland) who succeeded her, did not like the habit and wrote 1A Counterblaste to Tobacco, in 1604, describing smoking as a “savage custom”, “hateful to the nose” and “making a kitchen of the inward parts of man, soiling and infecting them with an unctuous and oily kind of soot.”
Until the 20th century there was no real suggestion that tobacco was harmful. The tools used to detect such as problem did not exist and as life expectancy was so short, a toxin that tended to strike people down in their 50s or beyond would not have been noticed. However, the 20th century saw three major changes. One was the introduction of paper rolled cigarettes rather than just pipe smoking. Another was the much greater use of tobacco including its use by women. The third was a longer expectation of life as well as better registration of causes of death.
Smoking has been alleged to have beneficial properties and was widely advocated as a panacea from the 16th to the mid-19th century. Even tobacco smoke enemas had their advocates. This was a technique that was used to try to resuscitate those who had drowned.2(When the Earth Was Flat: All the Bits of Science We Got Wrong. Book) Presumably anyone who fails to respond to having tobacco smoke forced up their rear end must be dead. In the early part of the 20th century, athletics coaches used to advise their protégées to smoke in the belief that this increased lung capacity.3(Sex and Drugs and Sport and Cheating. Book. Paul Anthony Sex and Drugs and Sport and Cheating.) Obviously, no one has tested the hypothesis. They also recommended cocaine lozenges to ward off tiredness and gave injections of strychnine during marathon racing to keep the athletes going.
Smoking was very common during both world wars and possibly encouraged. It gave a sense of camaraderie and a feeling of familiarity and safety. Smoking has been portrayed in films as sophisticated and even comparatively recently, characters such as James Bond smoked cigarettes. He obviously liked to live dangerously. Tobacco companies would give free cigarettes to film stars to get them to promote their products by using them in public and on screen.
Doctors were seen as role models and they would have smoked as much as any other group. After the dangers were exposed, doctors led by example in giving up smoking
Film stars and even doctors, nurses and dentists were telling us that smoking was good for us. It may seem astounding today, but a look at a series of 15 advertisements is most revealing. 4The history of tobacco health claims
Dangers of Tobacco Discovered
In the 1940s, the Government asked the Department of Community Medicine at Oxford, headed by the great epidemiologist, Sir Austin Bradford Hill, to discover the reason for the increasing incidence of lung cancer since the turn of the century. They had no preconceived idea but researched about 25 different potential causes, none of which fitted, except for cigarette smoking where the association was very strong. This also a showed a dose dependent response. In other words, the more cigarettes that are smoked, the greater the risk of lung cancer. Then it was shown that tobacco smoke contains carcinogens (cancer-producing substances), and this gave plausibility to the link.
The first paper showing an association between lung cancer and smoking was produced in 19505Doll R, Hill AB. Smoking and carcinoma of the lung; preliminary report. Br Med J. 1950 Sep 30;2(4682):739-48. [full text] and there were several papers about the relationship to coronary heart disease in the late 1940s and early 1950s. However, this was not public knowledge until the first report called “Smoking and Health” by the Royal College of Physicians in 19626Smoking and Health. Royal College of Physicians 1962. Since then smoking has become associated with other types of cancer, peripheral vascular disease, type 2 diabetes, stroke, increased risk of miscarriage and small babies, increased risk of complications of diabetes and much more. The World Health Organisation says that it is the most important cause of cancer and premature death in the developed world.
Deception and Lies
The tobacco industry had evidence of the dangers of its product at an early stage but recent court cases in the USA have confirmed that this was suppressed. They also ran a campaign to try to discredit the scientific evidence against their product. “It’s just statistics”, was one line. It was more than just very significant statistics. The carcinogens in tobacco smoke made it plausible too. To see how to distinguish between a possible innocent association and causation, look at the chapter Cohort or Longitudinal and Epidemiological Studies. I remember smokers trying to tell me that it was really pollution from cars that caused lung cancer. They were desperate to find an excuse not to have to give up their addiction. I pointed out that the Channel Islands did not have a great many cars or much air pollution, but they had the cheapest cigarettes in the country and with it the highest consumption. They also had the highest rate of lung cancer in the country.
There were papers that purported to show that smoking has a protective effect against Parkinson’s disease and Alzheimer’s disease. Both were funded by the tobacco industry, but they failed to disclose it. The truth is that smokers are underrepresented among patients with these conditions because they are usually conditions of old age and smokers are less likely live into old age. They pretend that they do not promote their product to children. The age cohort with the highest rate of smoking is 25 to 34 with the levels of smoking falling away with increasing age.7ASH Fact Sheet July 2019 In the previous ASH report the age cohort with the highest rate of smoking was 15 to 25.
In short, this is an industry that produces a very dangerous and highly addictive product with no discernible benefit, and it has actively suppressed information about the dangers and tried hard to discredit those who told the truth. In the meantime, their profits were strong and millions of people worldwide died prematurely of preventable disease. It has taken a vast amount of effort to get effective legislation such as the banning of smoking advertisements, first on television then in other media and the banning of smoking in public places. It has taken a great deal of work for the incidence of smoking to have declined to its current level. Prevalence of smoking amongst those over 16 has fallen from 51% of men and 41% of women or 45% overall in 1974 to 22% of men, 19% of women or 20% overall in 2012.8Office of National Statistics 2013
In 1994, United States Congressman Harry Waxman held a famous series of Congressional hearings. The presidents and CEOs of the seven largest American tobacco companies were subpoenaed to testify before the committee. On April 14, 1994, after more than six hours of probing questions by members of the House Energy and Commerce Subcommittee on Health and the Environment, the seven CEOs resolutely refused to alter their stance that they did not know that cigarettes were addictive. Each stated, under oath, that they did not believe nicotine was addictive. Within months, a perjury investigation was initiated by the Department of Justice but it concluded that it did not have enough evidence to prosecute for perjury because the CEOs testified that they believed nicotine did not addict people. Because they had used the word “believe,” they could not be prosecuted for perjury. Have a look at the clip from YouTube.9YouTube. 1994 – Tobacco Company CEOs Testify Before Congress I almost expect each one to have a nose that grows progressively longer, like Pinocchio.
Picture from the New York Times. The CEOs of seven tobacco companies line up to take the oath and blatantly lie to the hearing of congress in 1994, pretending that nicotine is not addictive
The tobacco industry has used its influence to affect policy in many parts of the world. A systematic review of 2014 identified common tactics and arguments that the tobacco industry uses to prevent the implementation of regulation and has shown that they are repeatedly used across different all parts of the world.10How Does the Tobacco Industry Attempt to Influence Marketing Regulations? A Systematic Review. Policymakers need to be aware of these in order to understand how the industry may try to manipulate the regulatory environment in their own interests, and public health advocates can use this information to prepare effective counter strategies. They stated that the recent failure of the British government to pursue plain packaging legislation highlights the importance of such knowledge. This was back in 2014.
Much knowledge of their conniving has come from compulsory disclosure as a result of litigation in the USA. The American Food and Drug Administration-commissioned the Institute of Medicine to make a report called “clearing the smoke”. An analysis of documents released through litigation showed that they had tried to influence that too.11Tobacco company efforts to influence the Food and Drug Administration-commissioned Institute of Medicine report clearing the smoke.
Before the report of the Royal College of Physicians in 1962, smoking was equally prevalent across all social classes. After the report, it fell and continued to fall, at first just among doctors. Since then it has fallen in all occupations but more among the educated classes, so that there is now a distinct social class trend, with the incidence of smoking rising as social class falls. Similarly, smoking has declined in developed countries and promotion of smoking has been more aggressive in developing countries to make up the shortfall. A study of cigarette consumption estimates for 71 countries from 1970 to 2015 was most revealing.12Cigarette consumption estimates for 71 countries from 1970 to 2015 Several of the same authors examined the Impact of the WHO Framework Convention on Tobacco Control on global cigarette consumption and found that it had had very little effect.13Impact of the WHO Framework Convention on Tobacco Control on global cigarette consumption
The tobacco industry now acknowledges that smoking is dangerous. This has not stopped them from promoting it heavily where they can, usually in developing countries. Uruguay has introduced legislation to make packs of cigarettes bear a health message covering 80% of the packet. The tobacco industry has contested this in court in an overt attempt to intimidate a small country.14(Interview on “Burning desire. The seduction of smoking”. BBC2 5th June 2014.) They claim loss of intellectual property and even if they fail, they may succeed in delaying implementation. This is an industry with no moral scruples, and they are not to be trusted in any way.15Philip Morris v Uruguay: A Story That Deserves Retelling Uruguay has a GDP of around $60 billion with a population of 3.4 million which is approximately 1% of the US population. Philip Morris International has an annual revenue of $78 billion and a current work force of 80,600.
In the UK, the introduction of plain packaging and a minimum price for cigarettes in June 2017 resulted in a reduction in sales.16Longitudinal evaluation of the impact of standardised packaging and minimum excise tax on tobacco sales and industry revenue in the UK. The investigators calculated that the volume of tobacco sales fell from 2.33 billion packets of cigarettes in May 2015 to 2.04 billion in April 2018. However, sales of roll-your-own increased.
It has taken a very long time to get smoking levels down and despite the vast amount of evidence that has been public knowledge for decades, young people still take it up. Now a new method of administering nicotine has arrived. We need to examine the evidence to see what role, if any, it may play. How should it be regulated and what limitations should be put on its promotion?
What are Electronic Cigarettes?
Now there is a novel product called electronic or e-cigarettes. They were first produced in China on 2003. A patent for electronic cigarettes was filed in 1963 but it has taken improvements in battery technology for it to become a commercial proposition. Initially it was produced by manufacturers who were not part of the tobacco industry but British American Tobacco (BAT) became the first company to take up the new development and others have followed.
There is no combustion with electronic cigarettes, but they turn nicotine and other chemicals into a vapour that is inhaled. The devices are powered by battery and a unit provides as many as 300 puffs, roughly equivalent to the number of drags from a pack of 20 cigarettes. Inhaling this vapour is called “vaping”. The working mechanism of the cigarette is based on the use of a piezoelectric ultrasound emitting element to vaporize a pressurized jet of electronic cigarette “e-liquid” that contains nicotine. This substance inhaled is a mixture of water vapour and nicotine as well as other chemicals including propylene glycol.17Physics Central. Physics Buzz Blog vegetable glycerine and flavourings. It is unclear exactly how much nicotine the e-cigarette smoker inhales. It may be less than conventional cigarettes, but it has been shown that when smokers switch to low tar, low nicotine brands they inhale more often and deeper.18New lower nicotine cigarettes can produce compensatory smoking and increased carbon monoxide exposure. They need to feed their craving for nicotine.
How should we see the product?
- Is it a way of helping to wean addicts off a nicotine addiction?
- Is it a safer form for those whose cravings prevent them from giving up completely?
- Is the evil industry back again, trying to bypass restrictions on smoking in public places, increasing their sales and profits?
- Is it another way of selling a highly addictive and dangerous product whose safety has not been proven?
- Does it really reduce tobacco consumption, or does it get people addicted to nicotine and they continue with e-cigarettes or even move back to conventional cigarettes?
We need to examine the nature of the product and the evidence about it. Then we shall examine the promotion and advertising.
E-cigarettes, an Aid to Quit or a Way to Trap New Addicts?
A search of PubMed in early 2014, showed around 150 results for e-cigarettes, going back only to around 2009. A similar search in 2019 produced 4,035 results. This is a product that it still in its infancy but being investigated. Bearing in mind who produces it and from what, there should be a demand for overwhelming evidence of its safety before it is let loose on the market.
Opinion seems to be that if e-cigarettes are to be permitted, it is as an aid to stopping smoking rather than a new fad to get young people addicted. Remember that the main product is nicotine which is highly addictive as well as having adverse effects on health. It has an adverse effect on the developing brain and so should be avoided in adolescence and in pregnancy. However, the effectiveness of e-cigarettes as an aid to quitting is not established. Some suggest that they may be acceptable as a less toxic habit for those already trapped who do not have the strength of character to give up.
A paper from California involving 1,549 participants concluded that “We found that e-cigarette use by smokers was not followed by greater rates of quitting or by reduction in cigarette consumption 1 year later.”19A Longitudinal Analysis of Electronic Cigarette Use and Smoking Cessation Another study found that e-cigarettes did not help people to quit but in teenagers may contribute to nicotine addiction.20Electronic Cigarettes and Conventional Cigarette Use Among US Adolescents A systematic review and meta-analysis concluded that e-cigarettes make smokers 28% less likely to quit and they should not be marketed as a smoking cessation aid.21. E-cigarettes and smoking cessation in real-world and clinical settings: Younger e-cigarette smokers in particular do not seem to be motivated to use them to stop.22Electronic cigarette use by college students E-cigarettes are available in a variety of flavours including many fruit flavours, vanilla and coffee. They are the tobacco industry’s equivalent of alcopops.
Big tobacco is not back.
It never went away
In view of how the trend in papers seems to suggest that e-cigarettes are of no value or unproven value in smoking cessation, I was surprised when a paper appeared that seemed to suggest the opposite.23Real-world effectiveness of e-cigarettes when used to aid smoking cessation The paper was accompanied by considerable media publicity.24E-cigarettes ‘help smokers to quit’ This suggested the hand of the tobacco industry at work. However, the funding for the research was from Cancer UK and it may be that when the industry at last saw a positive paper, they pushed it to journalists to get it to the public. The stories were rather more positive than the authors of the paper would accept. The three groups were those who used e-cigarettes bought over the counter, nicotine replacement therapy (NRT) such as patches bought over the counter or nothing. This was not a randomised controlled trial (RCT) as the participants selected what they wished to do. The discussion at the end of the paper shows that there were a number of confounding factors. It was noted that the choice of e-cigarettes was more common among those of higher social class and they may have a better chance of successfully quitting with any support.
A randomised controlled trial has found that smokers who use e-cigarettes to quit are almost twice as likely to stop smoking combustible tobacco at one year, compared with those who use nicotine replacement products such as patches or gum.25A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy. This was published in the New England Journal of Medicine but was based on research from a NHS stop-smoking clinic. At the end of a year, 18.0% of those in the e-cigarette group met the study’s primary endpoint of sustained abstinence, as validated with expired air carbon monoxide testing, compared with 9.9% of the participants who used nicotine replacement products. There were 886 subjects in the trial, which is a reasonable number, and all also received support and counselling. The relative risks and confidence levels were not very impressive and as they were still using a nicotine product, they are not truly abstinent. In fact, more e-cigarettes users were still using their nicotine delivery system after a year than those who used other methods.
The conclusions of CancerUK and Public Health England both seem to be at variance with American policy. An editorial in The Lancet asked26E-cigarettes—is the UK throwing caution to the wind? I found the advice from CancerUK to be quite astoundingly positive, almost like an advertisement for e-cigarettes.27E-cigarette safety I was most surprised in 2015 when Public Health England, in a report called 28E-cigarettes: an evidence update, was quite so positive, including saying that e-cigarettes were 95% safer than normal ones. I was obviously not alone in my incredulity as they found it necessary to issue an explanation called 29Underpinning evidence for the estimate that e-cigarette use is around 95% safer than smoking: authors’ note
Their estimates of safety, which should really read, as “possibly less deadly” seemed to be based on much lower levels or absence of known carcinogens as well as carbon monoxide. Reassurance, based on lack of carcinogens or much lower levels, may be false as rather more smoking-related deaths are due to heart attacks and stroke than cancer. Much of the evidence below, suggesting that they are still dangerous for heart disease and lung disease, came at a later date. Still, the recommendation in the UK seem to be at odds with both the rest of Europe and North America.
In 2020, Cochrane produced a review called 30Electronic cigarettes for smoking cessation. Even this Cochrane review was very short on evidence. They found 50 completed studies, involving 12,430 participants, but only 26 were randomised controlled trials (RCTs). They rated 4 studies as at low risk of bias overall, 37 at high risk overall and the remainder at unclear risk. They concluded that there was evidence that e-cigarettes with nicotine increase quit rates compared to those without nicotine and compared to nicotine replacement therapy (NRT). Evidence comparing them with usual care or no treatment also suggests benefit, but this is less certain. More studies are needed to confirm the degree of effect, particularly when using modern products. Confidence intervals were wide for data on adverse effects, serious adverse effects and other safety markers. They did not detect any clear evidence of harm from nicotine e-cigarettes, but the longest follow‐up was 2 years and the overall number of studies was small.
An important issue which never seems clear when discussing the effectiveness of e-cigarettes as an aid to quit, is the definition of success. Is it stopping smoking combustible tobacco, even if still addicted to e-cigarettes, or is it being off all forms of nicotine delivery? I think that the end-point is usually giving up smoking conventional cigarettes. They are still addicted to nicotine and still inhaling the products from e-cigarettes. An analogy is getting addicts to stop heroin. Is it a success when they stop taking heroin and rely on their daily methadone or is success when they are drug free? Both are important end-points.
Substances that give a quick “hit” such as crack cocaine and inhaled nicotine are more highly addictive than substances that give a slower response. Therefore, when trying to treat addiction, an early goal is often to switch the patient from a fast-acting substance such as heroin to a slow acting one such as methadone. For those addicted to the benzodiazepine drugs, the first step is usually to convert to a single, long acting drug, usually diazepam. On this basis, e-cigarettes have no place in the treatment of nicotine addiction as a switch to nicotine patches would be much better. With both conventional and e-cigarettes there is a certain amount of ritual that is absent from applying patches. The ritual and socialising that may accompany e-cigarettes adds to the attraction and the reluctance to quit. The ritual is also absent from plain nicotine inhalers. A paper looking at well-educated young American adults, concluded that e-cigarettes are even more addictive than the usual type.31E-Cigarettes are More Addictive than Traditional Cigarettes
A paper from Europe, although the lead researcher was from Harvard, looked at e-cigarette use throughout the European Union with an analysis of 26,566 youths and adults from 27 countries.32Determinants and prevalence of e-cigarette use throughout the European Union: They found that 20% of current smokers had tried e-cigarettes together with 4.4% of ex-smokers and 1.1% of non-smokers. The ex-smokers should beware as nicotine is highly addictive and they may be drawn back into old ways. Although it was claimed that vaping was not drawing in new nicotine addicts, the renormalisation of smoking or vaping may maintain nicotine addiction and hinder efforts to stop tobacco use. A second study reveals that ten new brands and 240 new flavours of e-cigarette are becoming available on-line every month.33Four hundred and sixty brands of e-cigarettes and counting: implications for product regulation The study also found that new brands are being sold on the basis of “choice and versatility” whereas previously they were sold as substitutes for cigarettes.
According to the American Centers for Disease Control and Prevention, from September 2010 to February 2014, the number of calls to poison centres about e-cigarettes rose from 1 per month to 215 per month. Children have been attracted to the bubble-gum and fruit flavours of e-cigarettes and are then poisoned by a toxic dose of nicotine. The fact that such flavours are available suggests an attempt to appeal to new young would-be vapers rather than an aid to help established smokers stop.
When the tobacco industry says that they are promoting e-cigarettes as an aid to help people quit, they are saying, in effect, that they are helping to reduce their market and, ultimately, to put themselves out of business. In view of their track record, do you believe this? It has taken more than 50 years, but legislation is closing in on them and this is a way to market their product without impediment. I am very cynical about their motives, and with good cause.
A paper from the USA found that in 2013, more than 250,000 young people who were non-smokers had used e-cigarettes and this was associated with increased intentions to smoke cigarettes. They concluded that enhanced prevention efforts for youth are important for all forms of tobacco, including e-cigarettes.34Intentions to smoke cigarettes among never-smoking U.S. middle and high school electronic cigarette user It may be that those who tried e-cigarettes would otherwise have tried tobacco but vaping is a new, “cool” innovation and may well be more attractive than traditional smoking.
E-cigarettes are marketed as “a healthier alternative to smoking” which is by no means the same as being safe. The term “healthier” implies even healthier which is totally inappropriate in this context. The term “safer” is similarly inappropriate. E-cigarettes contain substantially lower levels of known carcinogens and other toxins than normal cigarettes and they also expose bystanders to less pollution but still some is present. A better term than “safer” would be “probably less dangerous”.
In a statement in May 2019, the European Respiratory Society said that e-cigarettes and other heated tobacco delivery devices are harmful and do not help people quit smoking.35e-Cigs Don’t Help People Quit, May Be Harmful, Clinicians Say A professor from Hannover said, “Until we know more about the long-term effects of their use on human health, it is irresponsible to recommend that they be used in population-wide tobacco control strategies. Evidence-based tobacco dependence treatments already exist and are safe and cost-effective, and we must utilise this. Nothing should enter the lungs besides clean air — we must not give up on smokers.”
In France, a million smokers have quit in a year due to improved tobacco control, with higher prices, plain packaging, campaigns, national tobacco-free month and a dedicated national smoking-reduction programme, and there has been a decline in smoking among teenagers and those on low incomes. We know what works.
A paper from the UK suggests that e-cigarettes have not tempted more people to smoke.36Have e-cigarettes renormalised or displaced youth smoking? Another from Warwick, which surveyed 499 school pupils aged 11-16 years, found that more than half of e-cigarette users had never smoked tobacco. They were concerned as nicotine addiction may lead them into smoking later.37More than half of adolescent E-Cigarette users had never smoked a cigarette: findings from a study of school children in the UK A systematic review and meta-analysis showed that e-cigarette use predisposes to later tobacco smoking.38Association Between Initial Use of e-Cigarettes and Subsequent Cigarette Smoking Among Adolescents and Young Adults A problem is that those who chose to vape may well be the same ones who would, in earlier times, have chosen to smoke tobacco. Hence, there may be some damage limitation. However, I think that we should be concerned about young people taking up vaping.
The Marketing of Nicotine
An Internet search for images of advertisements for e-cigarettes was disturbing. They are back to the bad old days of promoting “flavour and taste” with an image of being sexy and à la mode. There is no suggestion of this being a way to stop smoking or even a damage limitation exercise for the hopelessly addicted. The image is of young, vibrant, sexy people. These seem to be American rather than British material. British advertising has included endorsement by a demagogue called Nigel Farage who is known to be a cigarette smoker and he has accepted £30,000 for his help .39Farage lobbies for ‘remarkable’ e-cigarettes in video after donation from maker
The US Surgeon General and the Commissioner of the Food and Drug Administration regard the uptake of vaping amongst young people as an unprecedented epidemic.40Vaping and e-Cigarettes in Kids: An Unprecedented Epidemic The Surgeon General, talking about his own children said, “Like many kids, when I ask them what they know about e-cigarettes, they reply that it is harmless water vapor. Absolutely not. We know that many of these substances contain nicotine. As a matter of fact, the most popular product that children are using is JUUL, which cannot be obtained without nicotine. But we also know that a third of young people who do report that they are vaping are vaping marijuana. That substance is in addition to all of the other chemical substances that are included in vaping mixtures. Many of these mixtures are made bootleg and can harm youth in so many ways.”
In 2011, less than 2% of U.S. high school students reported having used e-cigarettes in the previous month but by 2015, this had jumped to 16%. The following year, the U.S. Surgeon General issued a report concluding that e-cigarette use among young people was “a public health concern.” Ensuing public education campaigns and policies helped bring the prevalence of e-cigarette use in the past month, among U.S. high school students down to 11% in 2016. (National Academies of Sciences, Engineering, and Medicine. Public health consequences of e-cigarettes. Washington, DC: National Academies Press, 2018. There is no online reference for this.)
A paper from the USA which shows how much advertising of e-cigarettes has been directed at young people starts by noting, “Currently, the US Food and Drug Administration does not regulate electronic cigarette (e-cigarette) marketing unless it is advertised as a smoking cessation aid.”41Exposure to Electronic Cigarette Television Advertisements Among Youth and Young Adults Logic would suggest that it should be the other way round. This is the only way that marketing should be allowed.
The CDC confirms that advertising pays and attracts new, young vapers
There is evidence from studies to suggest that e-cigarettes may increase the likelihood of future cigarette use in young people.42Effects of Shared Risk Factors on E-cigarette and Cigarette Use Trajectories From Late Adolescence to Young Adulthood An article in the New England Journal of Medicine in 2019 was called, 43The Dangerous Flavors of E-Cigarettes.
The tobacco industry is back, if it ever went away, promoting a highly addictive product that has not been proved safe but there are unsubstantiated claims and innuendo. A survey in London concluded “This audit revealed widespread availability of e-cigarettes and in-store marketing in London, UK. Even if e-cigarettes prove to be an effective cessation aid, their sale and use are resulting in an increasing public presence of cigarette-like images and smoking behaviour. After decades of work to denormalise smoking, these findings raise the question of whether e-cigarettes are renormalising smoking.”44An observational study of retail availability and in-store marketing of e-cigarettes in London This view was supported in an American editorial.45The Renormalization of Smoking? E-Cigarettes and the Tobacco “Endgame” There is a place for nicotine without the products of combustion as a way of weaning people off smoking. It can be found with nicotine patches or chewing gum. However, this gimmick of vaping has nothing to do with weaning off nicotine. It is an opportunity for the tobacco industry to regain the market that it has lost. Since 1998, tobacco companies have been banned from paying for product placement of cigarettes in Hollywood movies. Now e-cigarettes are taking their place with six figure deals for e-cigarettes to be shown in a positive light on the cinema screen and then on the television in our homes.46E-cig makers rush for the silver screen
On the left, the old Camel advertisements for smoking doctors. On the right, the new “more doctors vape than use traditional cigarettes”. It may be true, but the numbers are very small.
The tobacco industry would like its adversaries to have to produce evidence of harm before it is banned. With their record this is the wrong way around. There should be unbiased evidence, not contaminated by them, to show that it is safe. Its use as an aid to quitting does not seem justified. We need evidence that it will not recruit new addicts, it does not cause cancer and it does not cause heart disease. Until this is available it should be strictly controlled, and advertising must be curtailed. They even tried to buy the website of ASH (Action on Smoking and Health) for Alternative Solutions for Health to promote e-cigarettes. It is an evil, lying industry that must be stopped.
A paper in the BMJ in 2019, examined the use of vaping among young people in Canada, USA and the England.47Prevalence of vaping and smoking among adolescents in Canada, England, and the United States The prevalence of vaping in the past 30 days, in the past week, and on 15 days or more in the past month increased in Canada and the US between 2017 and 2018, including among non-smokers and experimental smokers but there were no changes in England. Smoking prevalence increased in Canada, with modest increases in England, and no changes in the US. The percentage of ever vapers who reported more frequent vaping increased in Canada and the US, but not in England. This suggests that the marketing of vaping may be stronger in North America than in England but the general level of smoking among 16 to 19 years olds is going the wrong way.
Juul Laboratories, which dominates the US e-cigarette market with a turnover in excess of $1 billion a year, is promoting a study claiming that one of its products “dramatically” cuts adult smokers’ cigarette consumption but experts are casting doubt on the quality of the study.48E-Cig Giant Juul Touts Positive Study in a Questionable Journal It is published in what is known as a “predatory journal.” Such publications actively solicit authors with offers of low fees and an easy and rapid route to publication, which often results in the publication and promotion of less-than-rigorous research. Basically, it is way of getting rubbish into the mainstream with peer review that is lacking in vigour.
The online marketing of vaping products for children is quite horrific. An article in The Sunday Times in October 2018 stated, “The £1bn vaping industry in Britain is today exposed for using cartoon characters and images of sweets, popcorn and ice cream to market nicotine products that can hook children into addiction. A Sunday Times investigation reveals that vaping manufacturers exploit lax regulations, describe liquid nicotine mixtures for electronic cigarettes as “sweet treats” and sell them online for £1.”49Vaping brands ‘target children’ Children can buy online without age verification and the prices are within their range. From a parents’ perspective, some devices such as JUULs can look like normal school equipment and it does not leave a smell in the room or on the breath and clothes as tobacco does. This makes it much more difficult to know if children are indulging.
Schools are particularly worried about Juul, described as the “iPhone of e-cigarettes”. It has a slick design that can be easily passed off as a USB stick and carried in a pencil case. They say its flavours, such as apple orchard and alpine berry, appeal to teenagers.50Heads warn parents to look out for signs of vaping among 11-year-olds Hence, the device can look like a legitimate part of school equipment and there is no smell to give away that children have been using it, as there is with cigarettes. The article in The Times said, “A spokesperson for Juul Labs said that it “categorically” did not want “anyone underage or any non-smoker using our product” and that its mission was to help adults quit smoking.” So why do they produce flavours that are designed to appeal to young people. These are not aimed and the established smoker who wishes to stop.
The few papers that suggest that e-cigarettes may be useful in helping smokers to quit seem to come from the UK. Is our environment somehow different? Positive papers about e-cigarettes are fed to the media. Journalists are eager to take a story which is given to them. They often lack the skills to research it further and usually lack the time to do so. I have already mentioned why I think that inhaled nicotine is a poor technique for ending addiction but if it is to be used then there are much simpler nicotine inhalation devices that lack the glamour, ritual and camaraderie of vaping.
Just a few of the “refreshing” flavours produced by JUUL to hook the young into nicotine addiction
As the use of e-cigarettes among adolescents soars, the US Food and Drug Administration (FDA) said it has not ruled out taking the products off the market.51FDA Threatens to Remove e-Cigarettes From Market as Teen Use Surges The FDA commissioner said that he found himself debating with tobacco makers and retailers the merits of selling fruity flavours which are attractive to children. Unlike the nicotine replacement therapies, these products have been permitted to escape regulation. Flavours such as mint, menthol, and fruit mask the strong taste of tobacco in the vaping pods and appeal to young people. There is a call to ban all flavours from e-cigarettes. The focus should be on preventing adolescents from ever using e-cigarettes. Adolescents can order e-cigarettes easily online, and no age verification system is effective at preventing underage youth from obtaining them. Donald Trump has announced that he wants to ban flavoured e-cigarettes.52Trump set to ban flavoured e-cigarettes I never expected to say this, but Donald Trump has got it right.
Several countries including Australia, Brazil and Japan have banned or have limited aspects of the e-cigarette market. The United States has announced plans to remove flavoured e-cigarettes from stores. Even China’s state media has announced plans to curb e-cigarettes.
Is Vaping Safe?
Normal tobacco smoke contains thousands of chemicals, many of which are known toxins and carcinogens. The new version seems to contain rather fewer known toxins and carcinogens and at lower levels. However, there are new products that may cause damage. The material associated with vaping may contain new substances that are harmful to the lungs.53Case Report of Electronic Cigarettes Possibly Associated with Eosinophilic Pneumonitis in a Previously Healthy Active-duty Sailor The data to date are totally inadequate for making any firm conclusion.54 Electronic cigarettes in the USA: a summary of available toxicology data and suggestions for the future. The reference given is just one of several with similar conclusions.55Electronic Cigarettes and Vaping: A New Challenge in Clinical Medicine and Public Health The long term effect on cancer and lung function is unknown. There is reason to expect that it is toxic to the heart and circulation. They may not be as dangerous as conventional cigarettes, but they do have an adverse effect on air quality for others.56Use of electronic cigarettes (e-cigarettes) impairs indoor air quality and increases FeNO levels of e-cigarette consumers Hence, vaping in public places must be suppressed as is smoking.
The primary purpose of this device is to deliver nicotine. This is a highly addictive drug and the evidence of addiction is overwhelming.57Neural bases of pharmacological treatment of nicotine dependence The relationship between smoking and cancer is unequivocal but this tends to be attributed to the tar and various other carcinogens. However, there is remarkably little evidence about the effects of nicotine without the rest of tobacco smoke on cancer and arterial disease. Vaping may be less likely to cause cancer but nicotine does seem to play a role in carcinogenesis with damage to DNA.58Lung carcinogenesis by tobacco smoke There is no carbon monoxide in the electronic product but nicotine has many adverse effects on the heart and circulation.59Cardiovascular toxicity of nicotine: implications for nicotine replacement therapy It increases heart rate and blood pressure and the adhesiveness of platelets, increasing the risk of thrombosis. Much of the research has focussed on tobacco smoke with its many toxins but the danger of nicotine per se is documented.60The role of nicotine in the pathogenesis of atherosclerosis The idea that nicotine without all the other products of tobacco combustion is innocuous is wishful thinking. The CEO of British American Tobacco says that nicotine is safe.61(Interview on “Burning desire. The seduction of smoking”. BBC2 5th June 2014) He did not mention the issue of addiction. Remember that in 1994 the top executives of America’s largest tobacco companies all lined up at a Congressional hearing to say that they did not believe that nicotine is addictive.62Tobacco Chiefs Say Cigarettes Aren’t Addictive It can still be seen on You-tube.63The Seven Dwarves: I believe that nicotine is not addictive. You-tube Studies of nicotine without smoke tend to be limited to cell biology and animal studies. The evidence is limited but far from reassuring. Beware of websites that promote the concept of safe e-cigarettes as they are funded by the industry.
Safer than cigarettes is not safe.
Look at what is inhaled
Vaping in children and adolescents is a cause for concern as the developing brain reacts to nicotine differently from the mature brain. There is even a suggestion that nicotine may induce epigenetic changes that sensitize the brain to other drugs and prime it for future substance abuse.64Nicotine and the adolescent brain There is also evidence that females may be more susceptible than males.65Sex-dependent effects of nicotine on the developing brain
In 2018, the Science and Technology Select Committee of the House of Commons said that misconceptions about the risks of e-cigarettes meant that the government was missing a chance to improve public health and urged it to consider relaxing regulations on the advertisement, sale, taxation and use of the devices to encourage more smokers to switch.66Relax ban and let people vape on buses and trains, MPs urge The report said, “Many businesses, public transport providers and other public places do not allow e-cigarettes in the same way that they prohibit conventional smoking, but there is no public health rationale for treating the use of the two products the same.” Even if these substances are less deadly than conventional smoking, they should not be seen as normal behaviour. It said, forcing vapers in with smokers in shelters, for instance, “could undermine their efforts to quit”. I disagree. This shunning of smokers should include vapers and give them the incentive to quit too. Have the House of Commons Science and Technology Select Committee looked at the evidence of the dangers of these products? I am often dismayed by their lack of knowledge and insight, but very few scientists chose to enter politics.
We used to have to tolerate being smoked over wherever we went, in pubs, cinemas and restaurants. It has taken a great deal of effort to allow non-smokers clean air. Allowing people the freedom to vape wherever they like, would be a very retrogressive step both for freedom and health.
Just how safe is vaping? It is still a fairly recent innovation and so much is still to be learned and long-term studies such as those for smokers are not yet feasible. However, evidence is mounting that e-cigarettes are not as safe as claimed. Even without nicotine, there is evidence that the inhaled substance affects the lining of the arteries and this is known to be a precursor of atheroma.67Acute Effects of Electronic Cigarette Aerosol Inhalation on Vascular Function Detected at Quantitative MRI An in vitro study has reached the same conclusion.68Modeling Cardiovascular Risks of E-Cigarettes With Human-Induced Pluripotent Stem Cell-Derived Endothelial Cells The response of the respiratory system to e-cigarettes is also similar to the response to tobacco.69Acute respiratory responses to the use of e-cigarette A review concludes that e-cigarettes are potentially linked to asthma.70Electronic Cigarettes: Their Constituents and Potential Links to Asthma The authors add that they have not considered the potential hazard of extra chemicals inhaled in flavoured products.
Do e-cigarettes reduce the risk of heart attacks compared with conventional tobacco? A recent longitudinal study concluded “Some-day and every-day e-cigarette use are associated with increased risk of having had a myocardial infarction (heart attack), adjusted for combustible cigarette smoking. Effect of e-cigarettes are similar as conventional cigarette and dual use of e-cigarettes and conventional cigarettes at the same time is risker than using either product alone.”71Electronic Cigarette Use and Myocardial Infarction Among Adults in the US Population Assessment of Tobacco and Health
72A narrative review evaluating the safety and efficacy of e-cigarettes as a newly marketed smoking cessation tool from 2019 was interesting. The article starts by stating, “E-cigarettes are an alternative to traditional tobacco-based cigarettes. While having considerable societal awareness, conflicting evidence exists to support their claims that they are an effective smoking cessation tool and are safe. Currently there are more than 7,000 flavours with evidence that they exhibit detrimental cellular and tissue effects.
A literature review was conducted utilising PubMed and Google Scholar Databases identifying papers between 2014 and 2019. The aims of this study were to accurately gauge the safety and efficacy of e-cigarettes as a smoking cessation tool.” This does not examine their use among young people who see them as “cool” rather than a smoking cessation aid. It states, “Evidence shows that e-cigarettes can have detrimental effects on several cell lines and animal models with their flavourings and nicotine content implicated; this has, however, not translated into major health outcomes after 3.5 years follow-up but has been linked to chronic lung disease and cardiovascular disease. While advertised as an effective smoking cessation tool, no consensus can be made regarding their effectiveness although the first robust randomised controlled trial reports some success. This, however, is offset by the fact that the most common e-cigarette use is as a dual user and that there is evidence of threefold increased risk of future tobacco smoking.”
Two reports show the very different approaches towards e-cigarettes. One called 73Protecting Youth From e-Cigarettes: 5 Things to Know, is very clear about the dangers of vaping for young people. The other called 74PHE Addresses ‘False Fears’ About e-Cigarette Safety says that Public Health England (PHE) finds a growing number of adults wrongly believe vaping is more harmful than smoking. There may be some common ground here in that both are concerned about young people taking up a habit of nicotine addiction, but for the older person who is unable to get drug-free, e-cigarettes may offer a less dangerous alternative to tobacco.
The risk of lung disease among those who vape seems to be more than just theoretical. In 2019 there have been cases of severe lung disease and several deaths. In August 2019, the American CDC and FDA were investigating 193 potential cases of severe lung illness associated with e-cigarette product use had been reported by 22 states. These were reported between 28th June and 20th August 2019.75CDC, FDA, States Continue to Investigate Severe Pulmonary Disease Among People Who Use E-cigarettes On 24th August 2019, the BBC reported the first vaping-related death from Illinois.76First death linked to vaping reported in Illinois By the end of August, there were calls to stop vaping as the number of cases soared.77Calls Mount to Stop Vaping as Lung Injury Cases Skyrocket No specific product seems to be implicated but some people had used illicit sources for their materials, including some which contained THC, the active ingredient of cannabis.
A report of the effect of vapour from e-cigarettes on both laboratory mice and smokers was far from reassuring.78Short-term e-cigarette vapour exposure causes vascular oxidative stress and dysfunction The vapour caused increases in oxidative stress in the circulation, in the brain and in the lungs, where it had the potential to induce marked adverse consequences. They concluded, “Since e-cigarette use is increasing, particularly amongst youth, our data suggest that aggressive steps are warranted to limit their health risks.”
An article in the European Heart Journal was called 79Effects of tobacco cigarettes, e-cigarettes and waterpipe smoking on endothelial function and clinical outcome Until now I have ignored waterpipes (shisha, hookah, narghile) which is an emerging trend, especially among younger generations. The article says that there is growing body of evidence that e-cigarettes are not a harm-free alternative to tobacco cigarettes and there is considerable debate as to whether e-cigarettes are saving smokers or generating new addicts. They provided an updated overview of the impact of tobacco/waterpipe (shisha) smoking and e-cigarette vaping on endothelial function (meaning the function of the cells lining the lungs), a biomarker for early atherosclerosis from human and animal studies.
They briefly discuss heat-not-burn tobacco products and their cardiovascular health effects. They also discuss the impact of the toxic constituents of these products on endothelial function and subsequent heart and arterial disease. They also provide an update on current recommendations, regulation and advertising with focus on the USA and Europe. As outlined by the WHO, tobacco cigarette, waterpipe, and e-cigarette smoking/vaping may contribute to an increased burden of symptoms due to coronavirus disease 2019 (COVID-19) and to severe health consequences.
The UK Committee on Toxicity report on e-cigarettes from Public Health England came out in September 2020 and again, it was rather more positive towards them than the rest of the world. This appears to be standard for Public Health England. I have not given the reference for this report as it is accessible only for registered medical practitioners. However, a response to the report from many experts around the country was much more wary and this is freely available and of interest.80expert reaction to Committee on Toxicity report on ecigs
There is far too much in the article to summarise properly here, but it is far from reassuring. It also lists the many poisons found in these products. None should be regarded as safe. It is so important, that I have added it to “Further Resources”.
According to a survey for the American Society of Clinical Oncology, 20% of those aged 20-22 and 24% of those aged 22-38 believes e-cigarettes are “harmless”. They are so wrong.
Interpreting the Evidence
A problem with researchers, that has been previously mentioned, is called “confirmation bias”. This is when researchers expect a result and so are more likely to get it, as with the early reports of a reduced risk of coronary heart disease with hormone replacement therapy (HRT). I wonder if many of the researchers into e-cigarettes may suffer from the problem. I wonder if I am so inherently opposed to smoking that I take a prejudiced view and would never accept anything contrary to my view. I am very biased against the tobacco industry and in this I am not alone, but with their history we need to be very wary about allowing a new foothold to promote their addictive drugs.
An interesting review was called 81The E-Cigarette Debate:What Counts as Evidence? It started, “Two major public health evaluations of e-cigarettes—one from the National Academies of Science, Engineering, and Medicine (NASEM), the other from Public Health England (PHE)—were issued back to back in the winter of 2018. While some have read these analyses as broadly consistent, providing support for the view that e-cigarettes could play a role in smoking harm reduction, in every major respect, they come to very different conclusions about what the evidence suggests in terms of public health policy. How is that possible?”
Different people, with a different perspective, can interpret the same evidence in different ways.
I have formed the following conclusions:
- The balance of papers shows that the bulk of opinion is that e-cigarettes are not an effective way to renounce nicotine addiction. The social aspect and ritual are more likely to increase use especially among the young.
- In the UK in particular, the industry has managed to project its product to governments and regulatory agencies, as an aid to quit smoking despite there being evidence of better methods. It has managed to get them to ignore its blatant attempts to woo young, new addicts.
- There may be a place for their use in mature smokers who cannot quit just as methadone is used to treat heroin addicts. It should be controlled and licensed accordingly.
- They represent a small but growing proportion of the market at present whilst in much of the world the full toxic and carcinogenic product is heavily promoted.
- They are probably less carcinogenic than conventional tobacco as they contain fewer known carcinogens. However, they still induce changes that may precede cancer and other lung disease. Although they do not produce carbon monoxide, they may well predispose to atheroma and with it, coronary thrombosis and strokes. As rather more deaths from smoking are due to heart disease than cancer, this still represents a great concern. Public Health England’s assessment as 95% safer, or only 5% as deadly, seems difficult to accept. I suspect that like CancerUK, they have been examining the carcinogens without paying much attention to the potential for heart disease and non-malignant lung disease.
- E-cigarettes should only be allowed to be marketed as a smoking cessation tool, although it does not seem to be the best. Marketing that is blatantly aimed at attracting new users, despite what the industry says, must be banned.
- Flavoured products for vaping must be banned.
- E-cigarettes are a retrogressive way of getting around bans on smoking and this evil industry will stop at nothing.
In the UK e-cigarettes have been regulated as a medicine delivery system from 2016.82NHS Choices. E-cigarettes to be regulated as medicines We need much more rigorous controls.
Even if e-cigarettes have a place for those trying to stop smoking or for those unable to stop, the director of the American CDC states, “E-cigarettes are not safe for youth, young adults, pregnant women, or adults who do not currently use tobacco products.”83CDC Director’s Statement on the first death related to the outbreak of severe lung disease in people who use e-cigarette or “vaping” devices
An editorial in The Lancet was called 84E-cigarettes: time to realign our approach?. It noted that by 1st October 2019 there were at least 1,080 cases of lung disease attributable to vaping with 18 deaths in the USA, scattered over many states. No specific cause was identified but some had been vaping THC, the psychoactive ingredient of cannabis. Of those affected, 80% were under 35.
Manufacturers of e-cigarettes, and some bodies such as Public Health England, have advocated their use for smoking cessation and as a safer (less deadly) alternative to cigarettes. However, the The Lancet says that evidence for both these claims is weak. No one has launched or marketed e-cigarettes as smoking cessation products. They are all are sold as tobacco, not medicinal, products. Perhaps if they were, they would require evidence of safety and efficacy, which is lacking. They noted that three randomised trials of third-generation products show low rates of abstinence at 6 months. Smokers switch to e-cigarettes and then remain dependent long term. Is this really abstention? The very high nicotine levels delivered by some e-cigarettes could make them more difficult to quit than cigarettes. Data on long-term health effects are not available to support the claims of safety. Unlike e-cigarettes, the current first line treatment of nicotine replacement therapy under medical supervision, has a strong evidence base demonstrating safety and efficacy.
The Lancet editorial states, “Claims that e-cigarettes are useful harm-reduction tools are further undermined by their high uptake among young people. Cigarette smoking among US adolescents had declined substantially in the past 20 years, but there has been a huge rise in adolescents using e-cigarettes, with rates of use at around 25% among 18-year-olds and 20% among 16-year-olds. The availability of flavoured e-liquids is cited by nearly a third of users as a major reason to start vaping, especially among younger adults. Concerns have been raised around the marketing of e-cigarettes to young adults and new users. Advertising featuring young, attractive models, sponsorship of sports events and parties, product placement, and direct payments to social media influencers are strikingly similar techniques to those used previously by the cigarette industry. In many cases, e-cigarette marketers have commandeered the public health message around smoking to promote a healthy and glamorous alternative. In response, the US Food and Drug Administration wrote to Juul Labs, criticising illegal marketing that claimed that their e-cigarettes were less harmful than cigarettes.”
According to a South Africa website from October 2019, a number of countries have banned e-cigarettes. They include Argentina, Brazil, Brunei, Cambodia, Colombia, Egypt, India, Indonesia, Jordan, Lebanon, Malaysia, Mexico, Panama, Philippines, Qatar, Singapore, Taiwan, Thailand, Uruguay, Venezuela and Vietnam. I think they should have added Israel. E-cigarettes are not entirely banned, but they are restricted in Australia, Canada, Hong Kong, Norway and Japan. They are also regulated heavily as medical products in Denmark, but none have been licensed so far. More counties will probably follow suit. The Chinese and Indian governments have taken steps to restrict access to electronic cigarettes. The motivation has been to protect young people from e-cigarette use and possible lifelong addiction and, less altruistically, lobbying by domestic cigarette industries.85E-cigarette regulation must prioritise smoking cessation among adults Public Health England, however, continues to endorse e-cigarettes as safer than cigarettes and suitable for cessation of smoking.
The editorial also says, “No solid evidence base underpins the marketing claims that e-cigarettes are healthier than cigarettes or that they can support quitting, but lax regulation has allowed e-cigarette manufacturers to pervert the success of antismoking public health messages and position e-cigarettes as healthy. The renormalisation of smoking in the form of e-cigarettes, not only among smokers, but also among young people and never smokers, risks population-wide nicotine use and dependence on a massive scale. Surely it is time to align the public health approach to e-cigarettes with that of cigarettes.”
An article in The Times asked, 86Is vaping safe? Is it the best way to quit smoking or a health time bomb? It argues a good case. There is still a great deal to learn about this new product and steps must be taken to protect the young from it. The evidence suggests that it is nothing like as free of adverse effects as some would have us believe. Statements from the industry show that they have not changed their ways and are as likely to lie as blatantly as ever. All they care about is profit, regardless of the death and destruction of health that they produce.
Delegates at the European Respiratory Society International Congress in 2019 were concerned enough about the tobacco industry’s influence on research to pass a bylaw to state that investigators who receive funding from e-cigarette companies will be denied the right to present their research there. There was a similar vote in 2000 that restricted researchers who received funding from tobacco companies. Professor Vestbo from Manchester University said that there was concern that colleagues will be used. He said that researchers may get laboratory support to do research that is obviously beneficial to the vaping industry, and it makes it look more credible. In the 1960s and 70s, big tobacco companies funded scientific research that suggested smoking was not as harmful to human health as it is now known to be. He was worried that marketing and industry-funded science will prevail, as it did with big tobacco, especially because e-cigarettes are seen as a harm-reduction tool.
A task-force report on electronic nicotine delivery, issued by the ERS tobacco control committee does not recommend population-based harm-reduction strategies for tobacco cessation. In fact, it states that there is “no evidence that e-cigarettes are safer than tobacco in the long term.”87Electronic cigarettes: a task force report from the European Respiratory Society The science on the harm e-cigarettes can cause to humans is still not clear.
Dr Filippidis of Imperial College said that a long-time smoker might switch to e-cigarettes because it’s “better” for him, but a teenager may not understand that this is a bad choice for a 16-year-old who does not smoke.
In September 2020, the UK Committee on Toxicity produced a report on e-cigarettes for Public Health England. Some of the recommendations are freely available to view but the full report is not.88UK Committee on Toxicity report on e-cigarettes However, expert reaction to the report is freely available.89expert reaction to Committee on Toxicity report on ecigs Rather like Public Health England, the opinion of the committee is that e-cigarettes are less dangerous than ordinary tobacco but by no means free of toxicity. The expert opinion is rather more circumspect, especially with regard to their use as an agent to quit.
There are three different scenarios with regard to e-cigarette use and regulatory agencies need to be much more specific to each in their approaches. My interpretation of the evidence for each is:
- E-cigarettes as an aid to quit tobacco smoking are probably less effective than other methods and may even be counterproductive. Abstention is not achieved until the person has quit the e-cigarettes too.
- If a person is totally unable to stop using tobacco, then a switch to long-term e-cigarettes instead is a justified damage-limitation exercise.
- The promotion of e-cigarettes to gain new addicts must be stopped and flavoured products must be banned.
- E-cigarettes and vaping: policy, regulation and guidance.
From the UK Government website, April 2018, updated March 2020. It includes: England’s policy on e-cigarettes, UK e-cigarettes regulation, E-cigarettes evidence reviews, E-cigarettes public health consensus statement. Advice for organisations on vaping policies. There are also links to other relevant sites.
- E-cigarettes: Smoking Cessation Aid or Dangerous Addiction? Medscape 12 September 2019.
A recent review of the evidene and differences of opinions, especially across the Atlantic
- Using e-cigarettes to stop smoking. NHS 29 March 2019
NHS advice but I would say unduly reassuring about the safety of e-cigarettes in view of recent evidence.
- The Seven Dwarves: I believe that nicotine is not addictive. You-tube.
If you have not seen it have a look at seven CEOS of tobacco companies telling a congressional hearing that they do not believe that nicotine is addictive.
- The history of tobacco health claims by Sandee LaMotte, CNN 24 May 2017
An amazing collection of cigarette advertisements, well worth a look.
- Münzel T, Hahad O, Kuntic M et al. Effects of tobacco cigarettes, e-cigarettes and waterpipe smoking on endothelial function and clinical outcome. European Heart Journal 26 June 2020 [full text]
An important article that shows the severe consequences of smoking, vaping and water-piping. It also lists the many poisons found in the prodcuts. None should be considered safe.
- ‘A Counterblaste to Tobacco’: James I and his Aversion to Smoking. Worcester Cathedral Library and Archive.
- When the Earth Was Flat: All the Bits of Science We Got Wrong by Graeme Donald. 2012. Michael O’Mara Books
- Sex and drugs and sport and cheating by Paul Anthony. DB Publishers. 2014.
- The history of tobacco health claims by Sandee LaMotte, CNN 24 May 2017
- Doll R, Hill AB. Smoking and carcinoma of the lung; preliminary report. Br Med J. 1950 Sep 30;2(4682):739-48
- Smoking and Health. Royal College of Physicians 1962.
- ASH Fact Sheet 2013
- Office of National Statistics 2013
- YouTube. 1994 – Tobacco Company CEOs Testify Before Congress
- Savell E, Gilmore AB, Fooks G (2014) How Does the Tobacco Industry Attempt to Influence Marketing Regulations? A Systematic Review. PLoS ONE 9(2): e87389. [full text]
- Tan CE, Kyriss T, Glantz SA. Tobacco company efforts to influence the Food and Drug Administration-commissioned Institute of Medicine report clearing the smoke: an analysis of documents released through litigation. PLoS Med. 2013;10(5):e1001450 [full text]
- Hoffman SJ, Mammone J, Rogers Van Katwyk S, Sritharan L, Tran M, Al-Khateeb S, Grjibovski A, et al. Cigarette consumption estimates for 71 countries from 1970 to 2015: systematic collection of comparable data to facilitate quasi-experimental evaluations of national and global tobacco control interventions. BMJ. 2019
- Hoffman SJ, Poirier MJP, Rogers Van Katwyk S, Baral P, Sritharan L. Impact of the WHO Framework Convention on Tobacco Control on global cigarette consumption: quasi-experimental evaluations using interrupted time series analysis and in-sample forecast event modelling. BMJ. 2019 Jun 19;365:l2287 [full text]
- Interview on “Burning desire. The seduction of smoking”. BBC2 5th June 2014. (not available online)
- Philip Morris v Uruguay: A Story That Deserves Retelling. Medscape 18 April 2019
- Hiscock R, Augustin NH, Gilmore AB, Branston R. Longitudinal evaluation of the impact of standardised packaging and minimum excise tax on tobacco sales and industry revenue in the UK. Tobacco Control Published Online First: 12 July 2020. doi: 10.1136/tobaccocontrol-2019-055387. [full text]
- Benjamin Plackett. Physics Central. Physics Buzz Blog. 22nd August 2013
- Strasser AA, Lerman C, Sanborn PM, Pickworth WB, Feldman EA. New lower nicotine cigarettes can produce compensatory smoking and increased carbon monoxide exposure. Drug Alcohol Depend. 2007 Jan 12;86(2-3):294-300
- Grana RA, Popova L, Ling PM. A Longitudinal Analysis of Electronic Cigarette Use and Smoking Cessation. JAMA Intern Med. March 24, 2014
- Dutra LM, Glanz SA. Electronic Cigarettes and Conventional Cigarette Use Among US Adolescents. JAMA Pediatr. Published online March 06, 2014
- Kalkhoran S, Glantz SA. E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis. Lancet Respir Med. 2016 Feb;4(2):116-28. [full text]
- Sutfin EL, McCoy TP, Morrell HE, Hoeppner BB, Wolfson M. Electronic cigarette use by college students. Drug Alcohol Depend 2013 Aug 1;131(3):214-21
- Brown J, Beard E, Kotz D, Michie S, West R. Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study. Addiction. 2014 May 20. [full text]
- Nick Triggle. E-cigarettes ‘help smokers to quit’. BBC News
- Hajek P, Phillips-Waller A, Przulj D, Pesola F, Myers Smith K, Bisal N, er al. A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy. N Engl J Med. 2019 Feb 14;380(7):629-637. [full text]
- E-cigarettes—is the UK throwing caution to the wind? Lancet Editorial 25August 2018 Vol392 issue 10148EdDOI
- E-cigarette safety. CancerUk
- E-cigarettes: an evidence update. A report commissioned by Public Health. England 2015.
- Underpinning evidence for the estimate that e-cigarette use is around 95% safer than smoking: authors’ note. Public Health England
- Hartmann-Boyce J, McRobbie H, Lindson N, Bullen C, Begh R, Theodoulou A. et al. Electronic cigarettes for smoking cessation. Cochrane Systematic Review. – Intervention. Version published: 14 October 2020. CD0102162020
- Jankowski M, Krzystanek M, Zejda JE, Majek P, Lubanski J, Lawson JA, Brozek G. E-Cigarettes are More Addictive than Traditional Cigarettes-A Study in Highly Educated Young People. Int J Environ Res Public Health. 2019 Jul; 16(13): 2279. [full text]
- Vardavas C, Fillippidis FT, Agaku IT. Determinants and prevalence of e-cigarette use throughout the European Union: a secondary analysis of 26 566 youth and adults from 27 Countries. Tob Control doi:10.1136/tobaccocontrol-2013-051394.
- Zhu SH, Sun JY, Bonnevie E, Cummins SE, Gamst A, Yin L, Lee M. Four hundred and sixty brands of e-cigarettes and counting: implications for product regulation. Tob Control. 2014 Jul;23 Suppl 3:iii3-9. doi: 10.1136/tobaccocontrol-2014-051670. [full text]
- Bunnell RE, Agaku IT, Arrazola R, Apelberg BJ, Caraballo RS, Corey CG, et al. Intentions to smoke cigarettes among never-smoking U.S. middle and high school electronic cigarette users, National Youth Tobacco Survey, 2011-2013. Nicotine Tob Res. 2014 Aug 20
- e-Cigs Don’t Help People Quit, May Be Harmful, Clinicians Say. Medscape 31 May 2019
- Hallingberg B, Maynard OM, Bauld L, Brown R, Gray L, Lowthian E Have e-cigarettes renormalised or displaced youth smoking? Results of a segmented regression analysis of repeated cross sectional survey data in England, Scotland and Wales. Tob Control. 2019 Apr 1. [full text]
- Fulton E, Gokal K, Griffiths S, Wild S. More than half of adolescent E-Cigarette users had never smoked a cigarette: findings from a study of school children in the UK. Public Health. 2018 Aug;161:33-35.
- Soneji S, Barrington-Trimis JL, Wills TA, Leventhal AM, Unger JB, Gibson LA et al. Association Between Initial Use of e-Cigarettes and Subsequent Cigarette Smoking Among Adolescents and Young Adults: A Systematic Review and Meta-analysis. JAMA Pediatr. 2017 Aug 1;171(8):788-797. [full text]
- Farage lobbies for ‘remarkable’ e-cigarettes in video after donation from maker. Daily Telegraph 5th March 2014.
- Vaping and e-Cigarettes in Kids: An Unprecedented Epidemic. An Interview With US Surgeon General Jerome Adams and FDA Commissioner Scott Gottlieb. Medscape 28 January 2019.
- Duke JC , Lee YO, Kim AE, Watson K A, Arnold KT, Nonnemaker JM, Porter L. Exposure to Electronic Cigarette Television Advertisements Among Youth and Young Adults. Pediatrics. 15th April 2014. [full text]
- Dunbar MS, Davis JP, Rodriguez, Tucker JS, Seelam R, D’Amico EJ. Disentangling Within- and Between-Person Effects of Shared Risk Factors on E-cigarette and Cigarette Use Trajectories From Late Adolescence to Young Adulthood. Nicotine & Tobacco Research, nty179, 2nd October 2018.
- Drazen JM, Morrissey S, Campion EW, The Dangerous Flavors of E-Cigarettes. DOI: 10.1056/NEJMe1900484 30th January 2019
- Hsu R, Myers AE, Ribisl KM, Marteau TM. An observational study of retail availability and in-store marketing of e-cigarettes in London: potential to undermine recent tobacco control gains? BMJ Open. 2013 Dec 23;3(12):e004085. [full text]
- Fairchild AL, Bayer R, Colgrove J. The Renormalization of Smoking? E-Cigarettes and the Tobacco “Endgame”. N Engl J Med. 2014 Jan 23;370(4):293-5. [full text]
- E-cig makers rush for the silver screen. CBS News 14th September 2014
- Hammond D, Reid JL, Rynard VL, Fong GT, Cummings KM, McNeill A, et al. Prevalence of vaping and smoking among adolescents in Canada, England, and the United States: repeat national cross sectional surveys BMJ. 2019 Jun 20;365:l2219[full text]
- E-Cig Giant Juul Touts Positive Study in a Questionable Journal. Medscape News 20 March 2019
- Vaping brands ‘target children’. The Sunday Times 14 October 2018.
- Heads warn parents to look out for signs of vaping among 11-year-olds. The Times 9 September 2019.
- FDA Threatens to Remove e-Cigarettes From Market as Teen Use Surges. Medscape News 23 January 2019
- Vaping fears: Trump set to ban flavoured e-cigarettes. The Times 12 September 2019
- Thota D, Latham E. Case Report of Electronic Cigarettes Possibly Associated with Eosinophilic Pneumonitis in a Previously Healthy Active-duty Sailor. J Emerg Med. 2014 Jan 21.
- Orr MS. Electronic cigarettes in the USA: a summary of available toxicology data and suggestions for the future. Tob Control. 2014 May;23 Suppl 2:ii18-ii22. [full text]
- Palazzolo DL. Electronic Cigarettes and Vaping: A New Challenge in Clinical Medicine and Public Health. A Literature Review Front Public Health. 2013; 1: 56. [full text]
- Schober W, Szendrei K, Matzen W, Osiander-Fuchs H, Heitmann D, Schettgen T, et al. Use of electronic cigarettes (e-cigarettes) impairs indoor air quality and increases FeNO levels of e-cigarette consumers. Int J Hyg Environ Health. 2013 Dec 6
- Menossi HS, Goudriaan AE, de Azevedo-Marques Périco C, Nicastri S, de Andrade AG, D’Elia G, Li CS, Castaldelli-Maia JM. Neural bases of pharmacological treatment of nicotine dependence – insights from functional brain imaging: a systematic review. CNS Drugs. 2013 Nov;27(11):921-41
- Hecht SS. Lung carcinogenesis by tobacco smoke. Int J Cancer. 2012 Dec 15;131(12):2724-32. [full text]
- Benowitz NL, Gourlay SG. Cardiovascular toxicity of nicotine: implications for nicotine replacement therapy. J Am Coll Cardiol. 1997 Jun;29(7):1422-31
- Lee J, Cooke JP. The role of nicotine in the pathogenesis of atherosclerosis. Atherosclerosis. 2011 Apr;215(2):281-3. [full text
- Interview on “Burning desire. The seduction of smoking”. BBC2 5th June 2014. (not available online)
- Philip Hilts. Tobacco Chiefs Say Cigarettes Aren’t Addictive. New York Times. 15th April 1994
- The Seven Dwarves: I believe that nicotine is not addictive. You-tube
- Yuan M, Cross SJ, Loughlin SE, Leslie FM Nicotine and the adolescent brain. J Physiol. 2015 Aug 15;593(16):3397-412. [full text]
- Cross SJ, Linker KE, Leslie FM Sex-dependent effects of nicotine on the developing brain. J Neurosci Res. 2017 Jan 2;95(1-2):422-436 [full text]
- Relax ban and let people vape on buses and trains, MPs urge. The Times 17 August 2018.
- Caporale A, Langham MC, Guo W, Johncola A, Chatterjee S, Wehrli FW. Acute Effects of Electronic Cigarette Aerosol Inhalation on Vascular Function Detected at Quantitative MRI. Radiology. 2019 Aug 20:190562 [full text]
- Lee WH, Ong SG, Zhou Y, Tian L, Bae HR, Baker N, et al. Modeling Cardiovascular Risks of E-Cigarettes With Human-Induced Pluripotent Stem Cell-Derived Endothelial Cells. J Am Coll Cardiol. 2019 Jun 4;73(21):2722-2737.
- Brożek GM, Jankowski M, Zejda JE. Acute respiratory responses to the use of e-cigarette: an intervention study. Sci Rep. 2019 May 2;9(1):6844. [full text]
- Clapp PW, Jaspers I Electronic Cigarettes: Their Constituents and Potential Links to Asthma. Curr Allergy Asthma Rep. 2017 Oct 5;17(11):79. [full text]
- Bhatta DN, Glantz SA. Electronic Cigarette Use and Myocardial Infarction Among Adults in the US Population Assessment of Tobacco and Health. J Am Heart Assoc. 2019 Jun 18;8(12):e012317 [full text]
- Worku D, Worku E. A narrative review evaluating the safety and efficacy of e-cigarettes as a newly marketed smoking cessation tool. SAGE Open Med. 2019 Aug 18;7:2050312119871405. [full text
- Protecting Youth From e-Cigs: 5 Things to Know. Medscape March 2020.
- PHE Addresses ‘False Fears’ About e-Cigarette. Medscape March 2020.
- CDC statement, 21 August 2019. CDC, FDA, States Continue to Investigate Severe Pulmonary Disease Among People Who Use E-cigarettes
- First death linked to vaping reported in Illinois. BBC News 24 August 2019.
- Calls Mount to Stop Vaping as Lung Injury Cases Skyrocket. Medscape News 30 August 2019
- Kuntic M, Oelze M, Steven S, Kröller-Schön S, Stamm P, Kalinovic S, et al. Short-term e-cigarette vapour exposure causes vascular oxidative stress and dysfunction: evidence for a close connection to brain damage and a key role of the phagocytic NADPH oxidase (NOX-2). Eur Heart J. 2019 Nov 13
- Münzel T, Hahad O, Kuntic M et al. Effects of tobacco cigarettes, e-cigarettes and waterpipe smoking on endothelial function and clinical outcome. European Heart Journal 26 June 2020 [full text]
- expert reaction to Committee on Toxicity report on ecigs
- Fairchild AL, Bayer R, Lee JS. The E-Cigarette Debate: What Counts as Evidence? Am J Public Health. 2019 July; 109(7): 1000–1006.[full text]
- NHS Choices. E-cigarettes to be regulated as medicines. 12th June 2013.
- E-cigarettes: time to realign our approach? VOLUME 394, ISSUE 10206, P1297, 12 October 2019 [full text]
- CDC Director’s Statement on the first death related to the outbreak of severe lung disease in people who use e-cigarette or “vaping” devices. 23 August 2019.
- E-cigarette regulation must prioritise smoking cessation among adults. BMJ 2019;367:l6016
- Is vaping safe? Is it the best way to quit smoking or a health time bomb? The Times 2 April 2019.
- Bals R, Boyd J, Esposito S, et al. Electronic cigarettes: a task force report from the European Respiratory Society. Eur Respir J 2019; 53: 1801151 [https://doi.org/10.1183/13993003.01151-
- UK Committee on Toxicity report on e-cigarettes. Public Health England. 9 Sep 2020
- Expert reaction to Committee on Toxicity report on ecigs
This website is now completed, although I shall continue to do updates. The following list shows the sections or chapters. Just click on the topic in blue to go to that part of the site.