Tobacco (90) Q5. What are the pros and cons of vaping? (14)

30 March, 2023

Dear Dr Pakenham-Walsh,

Thank you for bringing up the discussion on electronic cigarettes.

Let’s start with the first issue you raised, which is that of language. “Vaping” is a term that is generally avoided by some health professionals because it implies that the emissions of e-cigarettes are merely “vapor” and are thus safe. While most other ingredients of e-liquids (except for nicotine) are generally recognized as safe for ingestion (i.e. propylene glycol, vegetable glycerine), e-cigarette liquids still contain tobacco-specific nitrosamines which have no safe level for exposure and carry significant risk of genotoxicity. In addition, nicotine itself presents a hazard, and there is significant evidence of it contributing to cardiovascular disease including hypertension and vascular calcification. [1] It would do well to note that the Flavor Extract Manufacturers’ Association has emphasized that the use of the term “generally recognized as safe” when it comes to flavors only pertains to the typical use case of flavorings in food. [2] Certain flavors (cinnamon, chocolate, and vanilla, to name a few) also exert toxicological effects when suspended in aerosol and delivered to mammalian lungs. [3]

The presumption that ENDS are a substitute for cigarettes [4] no longer holds universally true in the context of current evidence. This assertion has been deconstructed and addressed by The Editorial Team at The Lancet [5], and at least one systematic review [6] and our appreciation of epidemiological evidence thus far leads us to disagree with quit-smoking claims from proponents of ENDS as quit-smoking aids.

If we were arguing from first principles, then a true cessation aid must neither 1) drive initiation, dual-use or poly-use of tobacco nor 2) render users more likely to smoke cigarettes. But what does the epidemiological

evidence say? As early as 2016, the US Surgeon General had already raised concerns of e-cigarette use being associated with concurrent use of conventional tobacco products. [7] Indeed, subsequent analysis of the Population Assessment on Tobacco and Health has shown that current smokers who initiated vaping, especially daily ENDS users, generally had worse (1:7.88) odds of quitting tobacco. [8] On the other hand, other longitudinal studies do show that children who have not used conventional tobacco at baseline, who have used e-cigarettes, are around three times more likely to use combustible cigarettes within just 1 year of follow-up (2:86:1). Further, transitions from never-use to dual use are also more likely to occur than transitions from dual-use to non-use (p<0.05). [9] The same pattern is seen with adults who are either trying to use ENDS to quit or who are using only ENDS; both of them just end up going back to cigarettes. [10]

Considering all this, it is very difficult to recommend ENDS as smoking cessation aids. If youth use of ENDS are a harbinger of subsequent tobacco use, then there is so much to be said about being strict with the regulation of ENDS. [11] Singapore has banned ENDS (and tobacco heating systems), and it enjoys near single-digit smoking prevalence figures without the “help” of ENDS. Australia, on the other hand, has implemented a very strict prescription-only model, but it is still grappling with a youth use epidemic with ENDS. [12,13] In the UK, where the policy direction embraces e-cigarettes, current use of e-cigarettes has roughly doubled among the youth in 2022 compared with the last two years. [14]

Now, the elephant in the room: if e-cigarettes were indeed a quit-smoking revolution, then why would the tobacco industry go to lengths in North America and elsewhere to promote these products to teens? [11, 15] Are they not being marketed to feed the tobacco industry’s profit margin, instead?

The WHO notes that over 30 countries have now either banned or strictly regulated the use of e-cigarettes. [16] Global experience validates the WHO’s 2016 recommendations, where e-cigarettes must be strictly regulated if not banned altogether. [17]

E-cigarettes are not there to help anyone quit smoking. If anything, independent research shows that they are more likely there to keep people smoking.

Regards,

Anton Oliver Javier*,* MD, DIH

References:

[1] Scientific Committee on Health, Environmental and Emerging Risks. Opinion on electronic cigarettes. Luxembourg: European Commission. https://health.ec.europa.eu/system/files/2022-08/scheer_o_017.pdf.

[2] FEMA. Updated FEMA Statement on the Use of Flavors in Vaping Products. Retrieved 29 March 2023 from URL:

https://www.femaflavor.org/safety-regulatory-authority-use-flavors-focus...

.

[3] Effah F, Taiwo B, Baines D, Bailey A, Marczylo T. Pulmonary effects of e-liquid flavors: a systematic review. J Toxicol Environ Health B Crit Rev. 2022 Oct 3;25(7):343-371. https://doi.org/10.1080/10937404.2022.2124563.

[4] Nutt DJ, Phillips LD, Balfour D, Curran HV, Dockrell M, Foulds J, Fagerstrom K, Letlape K, Milton A, Polosa R, Ramsey J, Sweanor D. Estimating the Harms of Nicotine-Containing Products Using the MCDA Approach. Eur Addict Res 2014;20:218-225. https://doi.org/10.1159/000360220.

[5] The Lancet. E-cigarettes: Public Health England's evidence-based confusion. The Lancet 2015;386(9996):829.

https://doi.org/10.1016/S0140-6736(15)00042-2.

[6] Hedman L, Galanti MR, Ryk L, Gilljam H, Adermark L. Electronic cigarette use and smoking cessation in cohort studies and randomized trials: A systematic review and meta-analysis. Tobacco Prevention &

Cessation. 2021;7:62. https://doi.org/10.18332/tpc/142320.

[7] Office of the Surgeon General. E-cigarette use among youth and young adults: A report of the surgeon general. Bethesda, Maryland: US Department of Health and Human Services.

https://e-cigarettes.surgeongeneral.gov/documents/2016_SGR_Full_Report_5...

.

[8] Berry KM, Reynolds LM, Collins JM, Siegel MB, Fetterman JL, Hamburg NM, Bhatnagar A, Benjamin EJ, Stokes A. E-cigarette initiation and associated changes in smoking cessation and reduction: the Population Assessment of

Tobacco and Health Study, 2013-2015. Tob Control. 2019 Jan;28(1):42-49. https://doi.org/10.1136/tobaccocontrol-2017-054108.

[9] Wills TA, Knight R, Sargent JD, Gibbons FX, Pagano I, Williams RJ. Longitudinal study of e-cigarette use and onset of cigarette smoking among high school students in Hawaii. Tob Control. 2017 Jan;26(1):34-39.

https://doi.org/10.1136/tobaccocontrol-2015-052705.

[10] Baenziger ON, et al. BMJ Open 2021;11:e045603. doi:10.1136/bmjopen-2020-045603

[11] Jirathanapiwat W and Reyes J. Today’s Teens, Tomorrow’s Customers: Baiting youths with new products to create a new generation of addicts. Bangkok: Southeast Asia Tobacco Control Alliance.

https://seatca.org/dmdocuments/WNTD%202020%20report-SEATCA-Final.pdf.

[12] Southeast Asia Tobacco Control Alliance. (9 November 2022) Countries urged: Follow Singapore’s successful enforcement of ban on electronic smoking devices. Bangkok: SEATCA.

https://seatca.org/countries-urged-follow-singapores-successful-enforcem...

[13] Chrysanthos N. (18 Jan 2023) GPs warn big tobacco is ‘trading one public health disaster for another’ with vapes. Sydney: The Sydney Morning Herald.

https://www.smh.com.au/politics/federal/gps-warn-big-tobacco-is-trading-...

[14] Action on Smoking and Health GB. (July 2022) Use of e-cigarettes (vapes) among young people in Great Britain. London: ASH UK. https://ash.org.uk/about.

[15] Struik LL, Dow-Fleisner S, Belliveau M, Thompson D, Janke R. Tactics for Drawing Youth to Vaping: Content Analysis of Electronic Cigarette Advertisements. J Med Internet Res. 2020 Aug 14;22(8):e18943. doi:

10.2196/18943. PMID: 32663163; PMCID: PMC7455879.

[16] World Health Organization. (25 May 2022) Tobacco: E-cigarettes. Geneva: WHO.

https://www.who.int/news-room/questions-and-answers/item/tobacco-e-cigar...

[17] World Health Organization. (August 2016). Electronic Nicotine Delivery Systems and Electronic Non-Nicotine Delivery Systems (ENDS/ENNDS): Report by WHO. Geneva: WHO FCTC Convention Secretariat.

https://fctc.who.int/publications/m/item/fctc-cop-7-11-electronic-nicoti...(ends-ennds)

*Anton Javier*

FCTC Program Officer

Email: anton@seatca.org | Mobile: (+63)939 536 1355

Southeast Asia Tobacco Control Alliance

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