Tobacco harm reduction 101

From Tax Payers Alliance https://www.protectingtaxpayers.org/report/harmreduction101/

Tobacco harm reduction and vaping – why should you care?

• More than 34 million adults in the United States (U.S.) currently smoke cigarettes. Accounting for more than 480,000 deaths every year (or about 1 in 5), cigarette smoking is the leading cause of preventable disease and death in the US. In addition, more than 16 million Americans live with a smoking-related disease. For these reasons, it is a public health priority to reduce the number of smokers.

• Eliminating smoking of combustible cigarettes will not only benefit sufferers of smoking-related illnesses and their families, but will also benefit taxpayers due to the reduced cost of care for these individuals. As such, smoking cessation should be a priority for anyone who cares about public health and reducing suffering and death.

• In recent years, tobacco harm reduction (THR) through the use of reduced-risk products such as electronic cigarettes and “heat not burn” devices (collectively known as “Electronic Nicotine Delivery Systems or ENDS), as well as snus, and oral nicotine products such as lozanges, has been proven to help smokers quit and help save lives. Unfortunately, considerable misinformation has spread, leaving most Americans unaware of the overwhelming scientific evidence regarding these products and their incredible benefit to society.

• This short Q&A is designed to help answer some of the most common questions about THR and its benefits.

What is harm reduction?

• Harm reduction, sometimes known as harm minimization, is a proactive series of public health policies to reduce the negative effects associated with human behaviors such as recreational drug use and sexual activity. Harm reduction policies include measures like sex-education programs, needle exchange programs, and opioid replacement therapies such as prescribing methadone to heroin addicts. Unlike abstinence-only approaches, harm reduction is based on a basic pragmatism recognizing that some individuals will always engage in risky or dangerous behaviors and that is smarter to seek to minimize the damage that these activities can cause rather than putting forth the futile effort to eliminate the behavior or activity.

• Harm reduction in a myriad of activities has proven highly effective in saving millions of lives around the world.

How does harm reduction apply to smoking?

• THR specifically refers to policies designed to help smokers transition to less harmful products. Traditionally, these THR methods have included nicotine replacement therapies like patches and gums, which deliver nicotine to the user without the harmful effects associated with combustible cigarettes. More recently, newer and more innovative nicotine delivery systems such as electronic nicotine delivery systems have been introduced, while other delivery systems such as snus and nicotine lozanges have seen users continue to use nicotine without the deadly chemicals caused by the process of combustion. These options pose a fraction of the risk presented by traditional tobacco products.

• SOURCE: Cdc.gov, 2014 Surgeon General’s Report: The Health Consequences of Smoking-50 Years of Progress.

• SOURCE: Creamer MR, Wang TW, Babb S, et al. Tobacco Product Use and Cessation Indicators Among Adults – United States, 2018. Morbidity and Mortality Weekly Report 2019; 68: 1013-1019 (accessed 14 Nov 2019).

Is nicotine harmful?

• Nicotine is the key reason that people become addicted to smoking even though it is not the reason that people die from smoking. Nicotine is a mild stimulant similar to coffee, and while addictive, nicotine is not carcinogenic. It is a fundamental principle of tobacco tpolicy that people “smoke for the nicotine but die from the tar.” Additionally, nicotine is not classified as a carcinogen by the International Agency for Research on Cancer and is relatively safe for human consumption in low concentrations.

• Although potentially lethal at very high doses, the blood levels typically achieved by consuming nicotine via harm reduction products “does not result in clinically significant short- or long-term harms” which is why smokers have been using nicotine replacement therapies (NRT) for decades without incident. These products replace smoking with nicotine patches and gums, which provide users with controlled doses of nicotine. These patches and gums are widely sold as consumer goods, including to people under the age of 18. NRT products have been consistently approved for smokers as young as 12 years old for 30 years, with no noted adverse effects.

• It is also worth noting that, regardless of its benign health impacts, millions of vapers go on to completely quit nicotine and thus eliminate their exposure to even nicotine itself.

• SOURCE: World Health Organization International Agency for Research on Cancer. IARC monographs on the evaluation of carcinogenic risks to humans. Volume 83, tobacco smoke and involuntary smoking. Geneva: International Agency for Research on Cancer, 2004.

• SOURCE: Greenland S, Satterfield M, Lanes S. A meta-analysis to assess the incidence of adverse effects associated with the transdermal nicotine patch. Drug Saf. 1998; 18:297–308.

• SOURCE: Tobacco Advisory Group of the Royal College of Physicians. Nicotine without smoke – tobacco harm reduction. London: RCP, 2016.

• SOURCE: Lee PN, Fariss MW. A systematic review of possible serious adverse health effects of nicotine replacement therapy. Archives of toxicology, 2016.

What are Electronic Nicotine Delivery Systems (ENDS)?

• Electronic Nicotine Delivery Systems (ENDS), usually known as vapes or electronic cigarettes (e-cigarettes), were invented in 2003 as a way to simulate the experience of smoking without the associated health effects of inhaling smoke. Since 2012, ENDS have become particularly popular as a method for smokers to quit their deadly habit. In particular, these products benefit users who have tried and failed at other methods of quitting.

• Vaping products mimic the sensation of smoking and provide nicotine to addicted persons without the smoke from burning tobacco. Because ENDS mimic the sensation of smoking, they provide users a method of nicotine delivery similar to their habits. What is absent is the deadly cocktail of chemicals that make cigarettes dangerous to smokers themselves and those around them. As a result, public health bodies around the world have concluded that vaping is significantly safer than traditional products. Using ENDS products allows users to avoid the process of tobacco combustion entirely and thus the harmful health byproducts of smoking.

What types of vaping products are available?

• Vaping products are broadly divided into two main categories. In one product category, nicotine is mixed with water and then heated and vaporized into steam. The aerosol is then inhaled. These liquid-based products are what most people consider e-cigarettes.

• A newer technology, known as heat not burn, produces aerosol by the heating or steaming (instead of burning) of a tobacco-based mixture. Similar to other reduced-risk products, this process closely approximates a traditional smoking experience. However, as with e-cigarettes, the deadly chemicals present in traditional cigarettes are almost completely absent in these devices.

What is the difference between closed system and open system e-cigarettes?

• Liquid-based e-cigarettes are divided into two additional categories: open system and closed system. The health benefits of both compared to traditional cigarettes are nearly identical in that neither produces smoke, a byproduct of combustion. However, the design of the e-cigarette is different. Open systems are filled manually by the user with e-liquid generally obtained from a specialty vape store either in person or online. Many users prefer this as a quit-smoking aid as it allows for greater customization of the experience for the smoker’s particular needs. Closed systems use pre-filled tanks that are directly inserted into the device and then disposed of when finished. Closed system users cite the convenience of pre-filled tanks compared to open, manual systems.

Are there any other tobacco harm reduction products besides ENDS?

• Yes. Other harm reduction products include smokeless tobacco products and oral nicotine products. Smokeless tobacco, sometimes known as moist loose tobacco or snus, can be found in a teabag-like pouch and allows users to ingest nicotine without smoking it. This usually involves placing the product between the gum and the cheek. Other oral nicotine products include lozenges and similar products and do not contain any actual tobacco. In addition, nicotine replacement therapies such as patches and gums are also considered harm reduction products and have been available for decades.

Do ENDS help smokers quit and how do they compare to other nicotine replacement therapies?

• Multiple studies have shown that smokers who make the switch to vaping either substantially reduce their cigarette intake or quit completely, and that 69.4 percent of people who use e-cigarettes intended to use e-cigarettes as a complete replacement for regular cigarettes.

• Two recent studies out of the United Kingdom (U.K.) found that ENDS products are at least twice as effective as conventional smoking cessation aids, including traditional Nicotine Replacement Therapy products and “behavioral support.” ENDS relative effectiveness is likely significantly higher in the U.S. as the U.K. places nicotine caps on vaping products, making them less appealing to smokers.

• There are four main reasons why ENDS products are more effective than other nicotine replacement therapies:

• •The action of vaping is similar to that of smoking, and therefore assists with the habit-forming part of smoking.

• •Nicotine is delivered faster through the lungs than through the mouth or the skin (hence why some pharmaceutical companies market nicotine inhalers).

• •Vapes are more customizable with a variety of flavors, strengths and sensations, allowing users to adapt the product to best suit their need.

• •Appealing flavors have been instrumental in many adults successfully making the switch.

• As a result, a majority of smokers now use vaping as their preferred smoking cessation method.

• SOURCE: Berg CJ, Barr DB, Stratton E, Escoffery C, Kegler M. Attitudes toward e-cigarettes, reasons for initiating e-cigarette use, and changes in smoking behavior after initiation: a pilot longitudinal study of regular cigarette smokers. Open Journal of Preventive Medicine. 2014; 4(10):789-800.

• SOURCE: Etter JF, Bullen C. Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy. Addiction. 2011; 106(11):2017-2028.

• SOURCE: Polosa R, Caponnetto P, Morjaria JB, Papale G, Campagna D, Russo C. Effect of an electronic nicotine delivery device (e-cigarette) on smoking reduction and cessation: a prospective 6-month pilot study. BMC Public Health. 2011; 11(1):786.

• SOURCE: Jackson SE, Kotz D, West R, Brown J. Moderators of real-world effectiveness of smoking cessation aids: a population study. Addiction (Abingdon, England). 2019; 114(9):1627–38.

• SOURCE: Hajek P, Phillips-Waller A, Przulj D, Pesola F, Myers Smith K, Bisal N, Ross L. A randomized trial of e-cigarettes versus nicotine-replacement therapy. New England Journal of Medicine. 2019; 380(7), 629-637.

• SOURCE: Brose et al. Mental Health and Smoking Cessation – a population survey in England. BMC Medicine. 2020; 18:161.

• SOURCE: Benmarhnia T, Pierce J, Leas E, White M, Strong D, Noble M, Trinidad D. Can E-Cigarettes and Pharmaceutical Aids Increase Smoking Cessation and Reduce Cigarette Consumption? Findings From a Nationally Representative Cohort of American Smokers. American Journal of Epidemiology. 2018; 187.

• SOURCE: CASAA e-cigarette survey results.

How many American lives could vaping save?

• According to the most comprehensive peer-reviewed research on the effects of switching coordinated by the George Washington University Medical Center, if a majority of smokers in the United States quit smoking through the use of e-cigarettes over the next ten years, there would be 6.6 million fewer premature deaths with 86.7 million fewer life-years lost.

• A further study was released in August 2020 which examined the proportion of U.S. smoking-produced mortality that e-cigarettes might eliminate and produced 360 possible scenarios. Of these 357 (99%) yielded positive estimates of life-years saved (LYS) due to vaping by 2100, from 143,000 to 65 million

• SOURCE: Levy DT, Borland R, Lindblom EN, et al. Potential deaths averted in USA by replacing cigarettes with e-cigarettes. Tobacco Control. 2018; 27:18-25.

• 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.