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*SOURCE: David Mendez, PhD, Kenneth E Warner, PhD, A magic bullet? The potential impact of e-cigarettes on the toll of cigarette smoking, Nicotine & Tobacco Research | *SOURCE: David Mendez, PhD, Kenneth E Warner, PhD, A magic bullet? The potential impact of e-cigarettes on the toll of cigarette smoking, Nicotine & Tobacco Research | ||
=The Science of Vaping= | |||
*Are Electronic Nicotine Delivery Systems (ENDS) safer than smoking? | |||
To be effective as a tobacco harm reduction strategy, vaping must be proven to be safer than smoking. With more than a decade of extensive research and thousands of academic papers, it has been conclusively proven that vaping is safer. The most comprehensive meta-analysis of all available studies was conducted by Public Health England (an agency of the British Government) and the Royal College of Physicians, the world’s oldest medical body. According to the results, vaping is at least 95 percent safer than smoking. These figures have been consistently re-affirmed every year since the first analysis came out in 2015. | |||
*While some academics and policymakers may disagree with the exact 95% figure, there is no doubt that the lack of combustion in e-cigarettes makes them significantly safer than traditional cigarettes. | |||
*SOURCE: McNeill A, Brose LS, Calder R, Hitchman SC, Hajek P, McRobbie HJ. E-cigarettes: an evidence update. A report commissioned by Public Health England. 2015. | |||
*SOURCE: Beaglehole R, Bates C, Youdan B, Bonita R. Nicotine without smoke: fighting the tobacco epidemic with harm reduction. The Lancet. 2019; 394(10200), 718-720. | |||
*SOURCE: Tobacco Advisory Group of the Royal College of Physicians. Nicotine without smoke – tobacco harm reduction. London: RCP. 2016. | |||
=How accurate is the estimate that vaping is 95 percent safer than smoking?= | |||
*The estimate that vaping is 95 percent safer than smoking was first derived by Public Health England in 2015 and confirmed in a second review of the evidence in 2018. Independently of this, the identical estimate was arrived at by the Royal College of Physicians in 2016. | |||
*Public Health England is an executive agency of the Department of Health and Social Care in the United Kingdom. The Royal College of Physicians was founded in 1518, and is considered one of the world’s most prestigious professional medical bodies. Both these organizations conducted rigorous metanalysis on hundreds of available studies to reach this conclusion. | |||
*These remain the two most thorough and comprehensive analysis of all available scientific data. It is noted that while other medical bodies have made statements confirming that e-cigarettes are far less harmful than combustible tobacco, they have generally not provided estimates, and these remain the “gold standard” in research. | |||
*It is also important to note that while the 95 percent figure is an estimate and not the exact number by which risk is reduced, there is no dispute whatsoever in the scientific community that vaping is considerably less harmful than smoking. So, whether the exact number is 90 percent or 99 percent, vaping works and saves lives. | |||
*SOURCE: E-cigarettes: an evidence update. Public Health England. 2015 | |||
*SOURCE: E-cigarettes and heated tobacco products: evidence review Annual update of Public Health England’s e-cigarette evidence review by leading independent tobacco experts, 2018 | |||
*SOURCE: Nicotine without smoke: Tobacco harm reduction. Royal College of Physicians. 2016 | |||
=What is the effect of vaping on the body?= | |||
*While cigarette smoke is known to contain thousands of harmful chemicals, the vast majority of these chemicals are either completely absent in electronic cigarette aerosol or exist only at trace levels. Additionally, the emissions of toxicants were 82 to >99 percent lower on a per-puff basis for e-cigarettes compared to cigarettes. | |||
*There is “conclusive evidence that completely substituting e-cigarettes for combustible tobacco cigarettes reduces users’ exposure to numerous toxicants and carcinogens present in combustible tobacco” and “evidence supports the relative safety of e-cigarette emission aerosols for the respiratory tract compared to tobacco smoke.” | |||
*Numerous studies have shown that switching to vaping drastically lowers the build-up of carcinogens and tar in the bodies of smokers. A 2016 study published in Nicotine and Tobacco Research found that after switching from tobacco to e-cigarettes, nicotine exposure remains unchanged, while “exposure to selected carcinogens and toxicants is substantially reduced.” A long-term cross-sectional study also found that transitioning to ENDS from smoking drastically lowered the levels of tar, toxins, and carcinogenic chemicals found in the bodies of both former smokers and current dual users of both cigarettes and e-cigarettes. | |||
*The two most dangerous carcinogens in tobacco smoke, acrylonitrile and 1,2-butadiene, account for more than three-quarters of the cancer risk from smoking and are not found in vapor at all. Another class of carcinogens called tobacco-specific nitrosamines (TSNAs) is found in vapers at levels of only 2 percent of those found in smokers. It is of little surprise then that, of persons suffering from chronic obstructive pulmonary disease, 75.7 percent of persons switching from cigarettes to e-cigarettes had improved respiratory symptoms, compared to only 0.8 percent where symptoms continued to worsen. In the same way, respiratory exacerbations were halved in patients who quit or reduced substantially their tobacco consumption after switching to electronic cigarettes. Similar benefits were found in asthma patients. | |||
*A European study similarly concluded that, where cigarettes were assigned a 100 percent rating for “maximum relative harm” (MRH), e-cigarettes were only given a 4 percent rating of MRH. | |||
*Among e-cigarette users who had never smoked combustible tobacco, there is no evidence that current or former e-cigarette use is associated with any respiratory disease. This finding contradicts incorrect claims that the demonstrated relationship between e-cigarette use and respiratory disease is completely explained by e-cigarette users who are also current or former smokers of combustible tobacco. | |||
*SOURCE: National Academies of Sciences, Engineering, and Medicine. 2018. Public Health Consequences of E-Cigarettes. Washington, DC: The National Academies Press. | |||
*SOURCE: Chemical Research in Toxicology. 2016; 29, 10, 1662–1678. Publication date: 18 September 2016. | |||
*SOURCE: Polosa R, O’Leary R, Tashkin D, Emma R, Caruso M. The effect of e-cigarette aerosol emissions on respiratory health: a narrative review. Expert Review of Respiratory Medicine. 2019; 13(9):899-915. | |||
*SOURCE: Kenkel DS, Mathios AD, Wang H. E-Cigarettes and Respiratory Disease: A Replication, Extension, and Future Directions. NBER Working Paper No. 27507 July 2020 JEL No. I12. | |||
*SOURCE: Shahab L, Goniewicz ML, Blount BC, Brown J, McNeill A, Alwis KU, et al. Nicotine, Carcinogen, and Toxin Exposure in Long-Term E-Cigarette and Nicotine Replacement Therapy Users: A Cross-sectional Study. Annals of Internal Medicine. Epub ahead of print, 7 February 2017. | |||
*SOURCE: Farsalinos KE, Polosa R. Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review. 2014. | |||
*SOURCE: Polosa R, Morjaria JB, Prosperini U, et al. Health effects in COPD smokers who switch to electronic cigarettes: a retrospective-prospective 3-year follow-up. International Journal of Chronic Obstructive Pulmonary Disease. 22 Aug 2018; 13:2533–2542. | |||
*SOURCE: Goniewicz ML, et al. Exposure to Nicotine and Selected Toxicants in Cigarette Smokers Who Switched to Electronic Cigarettes: A Longitudinal Within-Subjects Observational Study, Nicotine and Tobacco Research. 2016. | |||
*SOURCE: Nutt DJ, et al. Estimating the Harms of Nicotine-Containing Products Using the MCDA Approach. European Addiction Research. 20 April 2014; 218–25. | |||
*SOURCE: Shahab L, Goniewicz ML, Blount BC, Brown J, McNeill A, Alwis KU, et al. Nicotine, Carcinogen, and Toxin Exposure in Long-Term E-Cigarette and Nicotine Replacement Therapy Users: A Cross-sectional Study. Annals of Internal Medicine. 2017. | |||
*SOURCE: Stephens WE. Comparing the cancer potencies of emissions from vapourised nicotine products with those of tobacco smoke. Tobacco Control. 2017. | |||
*SOURCE: Xia B, Blount BC, Guillot T, et al. Tobacco-Specific Nitrosamines (NNAL, NNN, NAT, and NAB) Exposures in the US Population Assessment of Tobacco and Health (PATH) Study Wave 1 (2013-2014) [published online ahead of print, 27 July 2020]. Nicotine and Tobacco Research. | |||
*SOURCE: Polosa R, Caponnetto P, Sands MF. Caring for the smoking asthmatic patient. Journal of Allergy and Clinical Immunology. 2012; 130(5):1221–1224. | |||
*SOURCE: Margham J, McAdam K, Forster M, et al. Chemical composition of aerosol from an e-cigarette: a quantitative comparison with cigarette smoke. Chemical Research in Toxicology. 2016 Oct 17; 29(10):1662–1678. | |||
*SOURCE: Callahan-Lyon P. Electronic cigarettes: human health effects. Tobacco Control. 2014; 23(suppl 2):ii36–ii40. | |||
*SOURCE: Cotta KI, Stephen CD, Mohammad NU. A review on the safety of inhalation of propylene glycol in E-cigarettes. Global Journal of Pharmaceutical Science. 2017; 2(2):555584. | |||
=What do the world’s major medical bodies have to say about vaping?= | |||
*Almost every major public health organization has endorsed nicotine vaping as safer than smoking and an effective way to help smokers quit. This list includes Cancer Research UK; the British Medical Association; the British Lung Foundation; the New Zealand Minister of Health; the US National Academies of Sciences, Engineering, and Medicine; the American Association of Public Health Physicians; the Royal Australian College of Physicians; the French National Academy of Pharmacy; and the German Federal Institute for Risk Assessment. | |||
*SOURCE: The statements of 27 respected scientific and public health organizations that have concluded that nicotine vaping is safer than smoking (and helps smokers quit). | |||
=Does vaping pose a risk to bystanders like passive smoking?= | |||
*Vaping produce no smoke so there are no carcinogenic particles are present in the air and inhaled by other people. Multiple studies have found that vaping products do not pose any material risk to passive smokers. Because of the non-existence of these risks, Public Health England recommends that smoke-free workplace laws and laws which prohibit indoor smoking do not apply to alternative nicotine delivery products. | |||
*SOURCE: Hall W, Gartner C, Forlini C. Ethical issues raised by a ban on the sale of electronic nicotine devices. Addiction. 2015; 110:1061–7. | |||
*SOURCE: Burstyn I. Peering Through the Mist: Systematic Review of What the Chemistry of Contaminants in Electronic Cigarettes Tells Us About Health Risks. BMC Public Health. 2014. | |||
*SOURCE: Tobacco Advisory Group of the Royal College of Physicians. Nicotine without smoke – tobacco harm reduction. London: RCP, 2016. | |||
*SOURCE: Public Health England. Use of e-cigarettes in public places and work places. 2016. | |||
=What about chemicals or flavoring agents in e-cigarettes?= | |||
*While electronic cigarettes do contain some flavoring agents, these chemicals occur at far lower concentrations than they do in tobacco smoke. Other chemicals, such as propylene glycol (a main component in the aerosol product) have been found to pose no threat when inhaled. | |||
*E-cigarette use (5g per day) represents a 79.0–96.8 percent reduction in formaldehyde, a 99.5–99.8 percent reduction in acetaldehyde, and a 96.0–99.5 percent reduction in acrolein exposure compared to smoking 20 tobacco cigarettes. | |||
=Does e-cigarette liquid contain formaldehyde?= | |||
*A number of media reports have claimed that e-cigarettes contain high levels of formaldehyde. It is important to note that formaldehyde is normally present at low levels in both indoor and outdoor air and is commonly used in building materials and even household products. | |||
*However, high levels of formaldehyde are not present in electronic cigarettes. This claim was based on one—since discredited—study where researchers produced formaldehyde by deliberately overheating e-cigarettes to the point where the product was unusable. A standard nicotine vaper would not be inhaling high levels of formaldehyde. | |||
*SOURCE: Farsalinos K. E-cigarettes emit very high formaldehyde levels only in conditions that are aversive to users. Food and Chemical Toxicology. 2017. | |||
=Does vaping cause “popcorn lung?”= | |||
*A common myth surrounding vaping is that it causes bronchiolitis, commonly called “popcorn lung” (after diacetyl, a buttery flavor, used in the manufacture of microwave popcorn was found to be associated with the illness). | |||
*In reality, not a single vaper has been found to have developed this condition, and multiple studies found no indications that e-liquids cause it. Even more importantly, diacetyl is contained in a combustible cigarette at 750 times the amount found in e-cigarette aerosol. Even at this relatively high level, there has not been a single case linking cigarette smoking to bronchiolitis. | |||
*SOURCE: Fujioka K, Shibamoto T. Determination of toxic carbonyl compounds in cigarette smoke. Environ Toxicol. 2006; 21:47–54. | |||
*SOURCE: Flavorings-related lung disease: diacetyl [Internet]. Washington, DC: Occupational Safety and Health Administration, U.S. Department of Labor. | |||
*SOURCE: Polosa R, Cibella F, Caponnetto P, et al. Health impact of E-cigarettes: a prospective 3.5-year study of regular daily users who have never smoked. Scientific Reports. Vol. 7, 13825 (2017). https://doi.org/10.1038/s41598-017-14043-2. | |||
=What about recent severe lung injuries in the United States (EVALI)?= | |||
*In late 2019 a number of, predominantly, young Americans were hospitalized, with some tragically perishing, due to a previously unknown respiratory illness. It was speculated that this illness was caused by vaping, and it was referred to as E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI). | |||
*However, despite initial speculations, it has now been conclusively proven that all recent lung-injuries were caused not by nicotine e-cigarettes, but rather that every case of illness and tragic death has been as a result of illicit, black-market tetrahydrocannabinol (THC) vaping devices bought on the streets and laced with substances such as vitamin E acetate. No cases have been linked to legal nicotine e-cigarettes and restricting access to legal and regulated e-cigarettes will do nothing to address this problem. On the contrary, the effects will simply be to drive more people to purchase dangerous illegal bootleg vapes which will put even more lives in danger. | |||
*SOURCE: Center for Disease Control, Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products. | |||
*SOURCE: Butt YM, Smith ML, Tazelaar HD, Vaszar LT, Swanson KL, Cecchini MJ, Boland JM, Bois MC, Boyum JH, Froemming AT, et al. Pathology of Vaping–Associated Lung Injury. New England Journal of Medicine. 2019; 381:1780–1. | |||
*SOURCE: Blount B. C., Karwowski M. P., Shields P. G., Morel-Espinosa M., Valentin-Blasini L., Gardner M., et al. Vitamin E acetate in bronchoalveolar-lavage fluid associated with EVALI. N Engl J Med 2020; 382: 697– 705 | |||
*Can’t vitamin E acetate still be added to nicotine e-cigarettes? | |||
It is impossible for vitamin E acetate to be added to nicotine-based e-cigarettes. While THC is oil-soluble and therefore can be mixed with oils such vitamin E, nicotine itself is only water soluble. Oils cannot be successfully mixed into any nicotine vaping liquid. While it is theoretically possible for some open-container vaping devices to be altered to accept illicit THC oils, evidence has shown that “governments should protect consumers by regulating rather than banning vaping products. Bans preclude regulation and encourage an illicit market in these products”. | |||
*SOURCE: Hall W., Gartner C., Bonevski B. Lessons from the public health responses to the US outbreak of vaping-related lung injury. Addiction 2020. | |||
*SOURCE: A ban targeting only open-system e-cigarettes is unlikely to prevent a future EVALI-like outbreak among e-cigarette users. | |||
=Are heated tobacco products safer than cigarettes?= | |||
*Despite containing tobacco, heated tobacco products (sometimes called heat not burn devices) do not burn the product or create smoke. Therefore, most carcinogens created by traditional cigarettes are not present, completely absent, or at hundreds of levels lower than traditional cigarettes. One of the more popular heat not burn products is IQOS, which has been on the market in Japan and Italy since 2014 and has gradually been rolled out to other countries. Dozens of scientific studies have shown that switching completely from conventional cigarettes to the IQOS device significantly reduces the body’s exposure to 15 harmful or potentially harmful chemicals. Furthermore, IQOS emits “much lower amounts of carbonyl and PAH compounds than tobacco cigarettes.” | |||
*SOURCE: Dusautoir R, Zarcone G, et al. Comparison of the chemical composition of aerosols from heated tobacco products, electronic cigarettes and tobacco cigarettes and their toxic impacts on the human bronchial epithelial BEAS-2B cells. Journal of Hazardous Materials Volume 401. 5 January 2021, 123417. | |||
*SOURCE: Food and Drug Administration, FDA Authorizes Marketing of IQOS Tobacco Heating System with ‘Reduced Exposure’ Information. 2020. | |||
*What does the U.S. Food & Drug Administration say about heated tobacco? | |||
In July 2020, the FDA authorized the marketing of the first “heat not burn” device on the US market [known as IQOS] as a as “modified risk tobacco products”. This means that the FDA, after a comprehensive multi-year investigation, has confirmed that it significantly reduces the production of deadly chemicals compared to combustible cigarettes. | |||
*As such, they can be marketed with the FDA approved information that as they heat not burn a product, “this significantly reduces the production of harmful and potentially harmful chemicals” and that “scientific studies have shown that switching completely from conventional cigarettes to the IQOS system significantly reduces your body’s exposure to harmful or potentially harmful chemicals.” | |||
*This is similar to a finding by the UK Government similarly investigated all evidence relating to Heat Not Burn products, determining that “there would be a likely reduction in risk for smokers deciding to use heat-not-burn tobacco products compared with continuing to smoke cigarettes as the exposure to HPHCs is reduced.” And that “A reduction in risk would be expected to be experienced by bystanders where smokers switch to heat-not-burn tobacco products.” | |||
*SOURCE: Statement on the toxicological evaluation of novel heat-not-burn tobacco products, Committees On Toxicity, Carcinogenicity And Mutagenicity Of Chemicals In Food, Consumer Products And The Environment, Food Standards Agency, United Kingdom | |||
*SOURCE: FDA Authorizes Marketing of IQOS Tobacco Heating System with ‘Reduced Exposure’ Information, U.S. Food & Drug Administration, July 7, 2020 | |||
=What about snus or moist loose tobacco?= | |||
*Snus or smokeless tobacco is a moist, powdered tobacco product that is placed under the consumer’s lip and absorbed into the bloodstream without the need for smoking. It delivers nicotine and tobacco satisfaction, like cigarettes, but without the deadly smoke. | |||
*As a result, it has far lower levels of carcinogens than those released when smoking tobacco is consumed. With decades of data on use and effects, “literature reviews have estimated that users of snus have at least 90–95 percent less smoking-related mortality, with minimal reduction in life expectancy, if any at all. The health benefits of smokers who completely transition to snus use are similar to those reported for smoking cessation.” Researchers have concluded that, “snus as an alternative to cigarettes has the potential to deliver enormous harm reduction benefits as demonstrated in Sweden, particularly in reducing the incidence of lung cancer and cardiovascular disease of which smoking is a known cause, where the product can be marketed and sold to adult smokers widely.” | |||
*In the U.S., according to the National Health Interview Survey (NHIS) mortality linkage and the National Longitudinal Mortality Study (NLMS), moist smokeless tobacco is far lower in health risks compared to conventional cigarettes, particularly for risk of lung cancer. The data demonstrates that smokers are more than 10 times as likely to die from lung cancer compared to smokeless tobacco users, three times as likely to die from any cancer compared to smokeless tobacco users, and twice as likely to die from any cause compared to smokeless tobacco users. | |||
*As a result, the FDA has authorized manufacturers to market their product with the following statement: “Using General Snus instead of cigarettes puts you at a lower risk of mouth cancer, heart disease, lung cancer, stroke, emphysema, and chronic bronchitis.” | |||
*SOURCE: Lee PN, Hamling J. The relation between smokeless tobacco and cancer in Northern Europe and North America. A commentary on differences between the conclusions reached by two recent reviews. BMC Cancer. 2009; 9:256. | |||
*SOURCE: Ramström L, Borland R, Wikmans T. Patterns of smoking and snus use in sweden: implications for public health. International Journal of Environmental Research and Public Health. 2016; 13:E1110. | |||
*SOURCE: Gartner CE, Hall WD, Vos T, Bertram MY, Wallace AL, Lim SS. Assessment of Swedish snus for tobacco harm reduction: an epidemiological modelling study. The Lancet. 2007; 369:2010–4. | |||
*SOURCE: Levy DT, Mumford EA, Cummins KM, Gilpin EA, Giovino EA, Hyland A, Sweanor D, Warner KE. The relative risks of a low-nitrosamine smokeless tobacco product compared with smoking cigarettes: Estimates of a panel of experts. Cancer Epidemiology, Biomarkers and Prevention. 2004; 13:2035–42. | |||
*SOURCE: Broadstock M. Systematic review of the health effects of modified smokeless tobacco products. New Zealand Health Technology Assessment Report. Feb 2007. | |||
*SOURCE: FDA grants first-ever modified risk orders to eight smokeless tobacco products. 22 October 2019. | |||
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