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|August 26, 2015

Electronic (e)­cigarettes are about 95% less harmful to health than tobacco cigarettes, and they might be useful inhelping people kick the smoking habit, according to a report commissioned by Public Health England (PHE).

The authors of the report also found that regular users of e­cigarettes are almost exclusively adults who are alreadysmokers. In fact, the rate of youths and adults who smoke cigarettes has continued to decline in England, and there isno current evidence that e­cigarettes are "renormalizing smoking or increasing smoking uptake," they write.

In addition, there is no evidence that e­cigarettes are a "gateway" to tobacco products for teens and young adults.Despite some experimentation among never smokers, e­cigarettes are attracting very few people who have neversmoked, the authors, led by Ann McNeill, PhD, professor of tobacco addiction at the National Addiction Centre, King'sCollege, and Peter Hajek, PhD, CClinPsych, director of the tobacco dependence research unit at the Wolfson Instituteof Preventive Medicine in London, United Kingdom.

Report at Odds With Other Conclusions

At first glance, the PHE report appears to be at odds with research that has drawn different conclusions on variousissues related to e­cigarettes.

For example, in an updated draft recommendation on behavioral interventions and medications for tobacco smokingcessation in adults, the US Preventive Services Task Force issued an "I" statement for e­cigarettes, meaning it cannotat this time recommend for or against use as a cessation aid, as reported by Medscape Medical News. And a recentmeta­analysis suggested that e­cigarettes had potential as a smoking­cessation tool, but the conclusion was thatstronger evidence is needed and the devices need to be better regulated.

Given the growing popularity and increasing use of e­cigarettes, questions remain about their effects on teens andyoung adults. In fact, a study published at the same time as the PHE report arrived at a different conclusion about thegateway issue (JAMA. 2015;314:700­707).

In an editorial accompanying the JAMA study (2015;314:673­674), Nancy A. Rigotti, MD, from the MassachusettsGeneral Hospital and Harvard Medical School in Boston, explains that the study provides "the strongest evidence todate that e­cigarettes might pose a health hazard by encouraging adolescents to start smoking conventional tobaccoproducts."

But Dr McNeill takes issue with the conclusions reached in the JAMA study.

"One of the issues we raise in our report is that of measurement," she told Medscape Medical News. "It is not thesame to equate 'ever use' with use, as ever use can mean that someone had just tried an e­cigarette once."

In the JAMA study, that was the measure of e­cigarette use and smoking. "Adolescence is a time of experimentation,so what we are really concerned with is any regular use of e­cigarettes and uptake of smoking," Dr McNeill explained.

"I don't think we would conclude that their study contradicts our findings, and I believe the JAMA authors would agreewith this," she added. "We do, however, need more research in this area of this kind."

Dr Hajek said he agrees that the JAMA study does not show that vaping leads to smoking. "It just shows that peoplewho are attracted to e­cigarettes are the same people who are attracted to smoking," he pointed out. "People who

E­Cigs 95% Less Harmful Than Smoking and Helpful forCessationRoxanne Nelson

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drink white wine are more likely to try red wine than people who do not drink alcohol."

More Nuanced and Balanced

PHE issued two reports on e­cigarettes last year. Since then, two literature reviews were conducted to update theevidence base and to assess recent survey data from England, so this year's report expands on the implications forpublic health.

Aside from the gateway issue, the report highlights the overall safety of e­cigarettes and their possible use as smoking­cessation agents.

Some media headlines in the United Kingdom, and even a press release issued by the government, have made itsound like this report is giving a green light to vaping by asserting that these devices are perfectly safe, but the actualreport is far more nuanced, balanced, and cautious, said Stella Bialous, RN, DrPH, president of Tobacco PolicyInternational and associate professor of nursing at the University of California, San Francisco.

In fact, the report concludes that that there is emerging evidence that e­cigarettes might be effective for smokingcessation, but adds that more regulation is needed, Dr Bialous said in an interview. "All other cessation aids have gonethrough a series of clinical trials and testing for safety and efficacy; we don't have that kind of data yet for e­cigarettes,"she noted.

The authors advise caution and emphasize the importance of the public being provided balanced information on therisks of e­cigarettes, "so that smokers understand the potential benefits of switching and so that nonsmokersunderstand the risks that taking up e­cigarettes might entail."

Under the current regulatory system, individual e­cigarette products vary considerably in quality and specification, andthere are not yet any data available on long­term safety. But going by the best estimate of experts, e­cigarette userepresents only a fraction of the smoking risk, the PHE team explains.

However, Dr Bialous said she doesn't feel that the data being presented are convincing as far as e­cigarettes beingsafer than smoking. She pointed out, as do the authors of the report, that most people (roughly two­thirds) are usingboth e­cigarettes and combustible tobacco products, and data are needed on the natural trajectory of "dual use."

The report states that cigarette smoking, overall, has declined in England among adults and youth, and that overallnicotine use has declined among adults since e­cigarettes became available. These findings suggest that e­cigarettesdo not appear to be undermining, and may even be contributing to, the long­term decline in cigarette smoking.

"But most people are using both, and not as means of quitting," Dr Bialous pointed out. "We don't know theconsequences of using both, such as whether it actually makes it more difficult to quit smoking."

Emphasis on Cessation

In the United Kingdom, e­cigarettes are being positioned as a possible tool to help with smoking cessation, whereas inthe United States, e­cigarettes are more about lifestyle, according to the report.

"I agree with the United Kingdom, in that they are framing e­cigarettes in the context of smoking­cessation aids, asopposed to the United States, where they are advertised in every way except for cessation," said Michael P. Eriksen,ScD, dean of the School of Public Health at Georgia State University in Atlanta.

In the United States, "they are marketed like cigarettes with glamour, celebrities, and sex," he told Medscape MedicalNews. "They can't be marketed as cessation aids because the FDA won't allow it."

But even though they haven't been proven as aids, if they can help cessation, "then I'm all for it," he said.

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E­cigarettes seem to be at least as effective as existing licensed nicotine­containing smoking­cessation products. AndDr Eriksen pointed out that e­cigarettes have a behavioral component that is similar to smoking.

"Right now we are seeing a lot of dual smokers," he said. "From a research standpoint, it could be that there will be atransition period of dual use and then smoking will decline — but those data don't exist at this point. We are seeingpeople doing both, with a small decline in smoking cigarettes."

As far as their safety, he agrees that e­cigarettes are probably safer than combustible tobacco products. "But theestimate of 95% is probably too high," Dr Eriksen contended. "That estimate is based on expert opinion, not scientificstudies."

E­cigarettes contribute to the promise of novel cessation products, and these products are going to keep improving."Everyone wants to reduce the burden of tobacco use, and if e­cigarettes can help you quit, then we are all for it," hesaid. "But we need to be aware of unintended consequences. The best advice is not to start in the first place."

The US Food and Drug Administration (FDA) has issued a proposed rule that would extend the agency's authority tocover products that meet the legal definition of a tobacco product, such as e­cigarettes. While waiting for an FDAruling, many states have already implemented regulations about where people can vape, along with laws that preventthe sale of e­cigarettes to minors.

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Cite this article: E­Cigs 95% Less Harmful Than Smoking and Helpful for Cessation. Medscape. Aug 26, 2015.