By Elaine Keller, with input from CASAA Board
[Note: Carl will resume his series about useful truths next week. We have a few lies we want to cover first.]
Good health advice is any instruction or set of instructions that, when followed, results in health improvement or the avoidance of illness or injury. Bad health advice, when followed, results in illness or injury that would have been avoided by not following the advice. The public expects organizations that position themselves as leaders in fighting disease to provide good health advice that is based on accurate information.
“Don’t be fooled by e-cigarettes,” states a press release from the Canadian Lung Association (CLA). “These electronic devices could be potentially harmful to lung health” and that smokers should “avoid” them. Is it good health advice to discourage smokers from using an effective method for quitting? Clearly not, since there is overwhelming scientific evidence that smoking is harmful, not just to lung health, but in many ways. They are trying to discourage quitting by any smoker who is not willing and able to do it their way.
If they truly were concerned about lung health, they would have pointed out that there is no doubt that vaping is better for lung health than smoking. Then they would have discussed any actual concrete concerns about vaping and lung health. Instead, they just presented several irrelevant details intended to distract the reader from the truth. It might have been defensible advocacy for the lung association to say something like, “If you have quit smoking using e-cigarettes, that is some progress, but now you need to quit the e-cigarettes.”
But that is not what they did. For example, two paragraphs of the CLA press release are devoted to conjecture that the products might appeal to children. There is no evidence of this, but more important, how does this support what they are supposedly claiming, that there is a health risk? They clearly did not believe they could support their claim about health risk. And for good reason, when you consider the available evidence about e-cigarette effects on lung health.
First, consider what consumers who switched from smoking to an e-cigarette say about their lung health. For example, a University of Geneva researcher wrote, “Respondents reported more positive than negative effects with e-cigarettes: many reported positive effects on the respiratory system (breathing better, coughing less), which were probably associated with stopping smoking.”
Second, what do other sources say? In 2009, the U.S. Food and Drug Administration (FDA) invited consumers to use the agency’s Adverse Event Reporting System (AERS) to report problems experienced with using e-cigarettes. Results were reported in a letter to the editor of Nicotine and Tobacco Research. There had been 1 AE reported in 2008. There were 10 AE reports in 2009, 16 in 2010, 11 in 2011, and 9 in the first quarter of 2012. The types of problems reported are very similar to those reported with pharmaceutical products such as nicotine gum or lozenges, for example, headache, sore throat, abdominal pain, coughing, etc. The author commented, “Of note, there is not necessarily a causal relationship between AEs reported and e-cigarette use, as some AEs could be related to pre-existing conditions or due to other causes not reported.”
The author also mentioned that the number of people reporting ever an using e-cigarette more than quadrupled between 2009 and 2010. If there were any serious health risks posed by e-cigarettes, we would expect the number of AE reports to quadruple as well, but the number of reports dropped in 2011.
Third, the clinical trials that have been completed and that are in progress would be stopped if serious adverse events, such as lung health impairment, occurred. To date, no clinical trial of e-cigarettes has been stopped due to adverse events.
Under the heading, “E-cigarettes are not proven safe,” pediatrician Dr. Theo Moraes, a medical spokesperson for the CLA is quoted, “People who use e-cigarettes inhale unknown, unregulated and potentially harmful substances into their lungs.” Is this statement accurate? No, it’s a lie. It is a lie simply because we have a quite a good accounting of what is in e-cigarette vapor. Additionally, its implication is a lie. As Dr. Phillips pointed out in an earlier post, before the first study of e-cigarette chemistry was ever done, we were 99% sure that cigarette smoke was many times more hazardous than vapor. People who smoke inhale thousands of chemicals from combustion, many of which are quite hard on the lungs (to say nothing of other parts of the body). Those chemicals are basically absent from vapor.
The substances in e-cigarette liquid are well known, and all ingredients are government-approved for human use (though not specifically in the form of e-cigarettes, of course). They include USP grade propylene glycol and/or vegetable glycerin, water, approved food flavorings, and (optionally) pharmaceutical-grade nicotine. Numerous toxicology studies have been conducted on the liquids and on the vapor, and none have found quantities of any chemical that are believed to be substantially hazardous.
The infamous FDA initial lab test is mentioned in the CLA press release, without pointing out that the “detectable levels of carcinogens” match the levels in FDA-approved nicotine patches. The “carcinogens”, tobacco-specific nitrosamines (TSNAs), are present at similar trace levels in any product that contains nicotine because nicotine is extracted from tobacco. The “toxic chemicals” turned out to be a non-harmful quantity of one chemical in one sample. Also not mentioned is the fact that the only two brands tested were the two companies that were in the process of suing the FDA, which is a red flag for bias.
Bottom line: Dr. Moraes is either deliberately misleading the public or is woefully uninformed about the contents and nature of e-cigarettes. He certainly does not understand the purpose of the products. “There are many nicotine replacement therapies approved by Health Canada to help someone quit smoking; the e-cigarette is not one of them,” he stated.
The nicotine replacement therapies (NRTs) approved by Health Canada are not aimed at helping people to quit smoking. They are aimed at treating “nicotine addiction”. They provide a reduced quantity of nicotine on a temporary basis, which is then further reduced and ultimately discontinued. E-cigarettes are not intended to treat nicotine addiction. They are used as a replacement for smoking that doesn’t require nicotine cessation.
Which works better? The vast majority of smokers who try to quit by cold turkey or using recommended medical interventions resume smoking. The published research probably overstates how often these “approved” therapies work, and even it agrees that they are nearly useless. As one example: “Approximately 75% to 80% of smokers who attempt to quit relapse before achieving 6 months of abstinence. Of the remainder, relapses may occur years after a smoker initially quits.” Consider what passes for “success” for NRT, such as a study comparing 6-month abstinence rates of those using NRTs versus those not using NRTs. In the first phase of the study, rates were 9.4% in the NRT group versus 3.5%. In the second phase, the rates were 6.9% in the NRT group compared with 4.3% in the non-NRT group. The authors stated, “NRT use was associated with improved chances of long‐term abstinence when controlling for nicotine dependence.” Both of these studies, as well as numerous others and simple common knowledge, also tell us that there are some smokers who are much less inclined to become abstinent from nicotine.
The critical difference between the “approved” approaches and typical e-cigarette use is that e-cigarettes do not involve becoming abstinent from nicotine. Once e-cigarette users have replaced all of their smoked cigarettes with e-cigarette use, they have stopped smoking. Because they are not required to become abstinent from nicotine, those who are more dependent or who simply are less inclined to give up the beneficial effects of nicotine, can continue to experience those benefits without destroying their health by smoking. We do not know what portion of all smokers who seriously try to switch to e-cigarettes succeed at it, but we do have good evidence that the rate is pretty good — certainly better than quit rates using “approved” methods — and that lots of people who would not have quit smoking using those other methods have quit by using e-cigarettes.
To summarize the evidence, e-cigarettes: (i) have not been shown to harm users, based on either actual outcomes or what we can predict from the chemistry; (ii) appear to be much more effective at smoking cessation than “approved” methods, even for those who would consider quitting nicotine entirely, and (iii) are clearly more effective for those who want to quit smoking but do not want to quit nicotine.
In the final analysis, the CLA, like the American Lung Association, is a liar. The CLA says “don’t be fooled,” but the evidence says that the CLA is the one trying to fool the public. If the CLA were truly concerned about lung health, it would be doing everything possible to help smokers stop smoking as quickly as possible. If they genuinely believed that e-cigarettes left some tiny fraction of the lung risk for those who quit smoking, then they would try to address that. Instead, the CLA is actively discouraging smoking cessation by misinforming Canadian citizens about the speculative risks of using e-cigarettes and overstated claims about everyone can easily just quit nicotine entirely.
If you smoke, or care about someone who does, don’t be fooled by the CLA or ALA. (And definitely make sure that you and people you know avoid supporting them financially.)