The Scientific Evidence for E-Cigarettes

I am honored to join Drs. Riccardo Polosa and Pasquale Caponnetto and their colleagues at the University of Catania in Italy as a coauthor of a new scientific article on e-cigarettes published in Harm Reduction Journal (available here).  We scientifically disprove the stated premise of a recent NPR broadcast (here), “…little is known about the potential health effects [of e-cigarettes].”  NPR “expert” Stanton Glantz stated that “e-cigarettes today are the triumph of wishful thinking over data.”  Our publication shows that e-cigarettes are the triumph of scientific evidence over feigned ignorance.

For the benefit of members of the Flat Earth Society, I reproduce our summary here:

“The dream of a tobacco-free, nicotine-free world is just that—a dream. Nicotine’s beneficial effects include correcting problems with concentration, attention and memory, as well as improving symptoms of mood impairments. Keeping such disabilities at bay right now can be much stronger motivation to continue using nicotine than any threats of diseases that may strike years and years in the future.

“Nicotine’s beneficial effects can be controlled, and the detrimental effects of the smoky delivery system can be attenuated, by providing the drug via less hazardous delivery systems. Although more research is needed, e-cigs appear to be effective cigarette substitutes for inveterate smokers, and the health improvements enjoyed by switchers do not differ from those enjoyed by tobacco/nicotine abstainers.

“It is of paramount importance that government and trusted health authorities provide accurate and truthful information about the relative risks of smoking and alternatives to smoking. If the public continues to be misled about the risks of THR products, millions of smokers will be dissuaded from switching to these much less hazardous alternatives. One of us recently wrote that, “It’s time to be honest with the 50 million Americans, and hundreds of millions around the world, who use tobacco. The benefits they get from tobacco are very real. It’s time to abandon the myth that tobacco is devoid of benefits, and to focus on how we can help smokers continue to derive those benefits with a safer delivery system” [reference here].

“In the absence of regulatory standards, it is important that currently marketed products are of high quality. For example, the hardware should be reliable and should produce vapour consistently. The liquids should be manufactured under sanitary conditions and use pharmaceutical grade ingredients, and labels should contain a list of all ingredients and an accurate and standardized description of the nicotine content.

“According to a recent article by CDC researchers, the proportion of U.S. adults who have ever used electronic cigarettes more than quadrupled from 0.6% in 2009 to 2.7% in 2010 with an estimated number of current electronic cigarette users of about 2.5 million [reference here]. Although rigorous studies are required to establish THR potential and long term safety of electronic cigarettes, these figures clearly suggest that smokers are finding these products helpful. If they were ineffective one would not expect the market to take off as it is. Most importantly, even if this THR product proves to be effective for only 25% of the smoking population, it could save millions of lives world-wide over the next ten years.”  

A Directory of Tobacco Harm Reduction Experts for Inquiring Media

Mass media are in complete denial of the voluminous scientific literature supporting e-cigarettes as harm-reduction products.  A recent report on National Public Radio (here) is representative.  The host set up the story in classic fashion, pitting “expert” harm reduction naysayers against lay e-cigarette users, store owners and marketers.  The argument was settled before it began.

Are the media unable to find tobacco research and policy experts who support e-cigarettes and tobacco harm reduction?  Although we are relatively few, we are widely published and highly visible – testifying, editorializing, providing interviews when invited.  Independent and articulate authorities on tobacco harm reduction in the U.S. include:

Carl Phillips from Consumer Advocates for Smoke Free Alternatives (here)

Michael Siegel at Boston University (here)

Joel Nitzkin at R Street (here)

Gil Ross at the American Council on Science and Health (here)

Jeff Stier at the National Center for Public Policy Research (here)

Lynn Kozlowski, Dean of the School of Public Health and Health Professions, the University at Buffalo (here)

Bill Godshall at Smokefree Pennsylvania 

International experts include:

David Sweanor (here) in Canada

Clive Bates (here) and Christopher Snowdon (here) in the United Kingdom

Karl Fagerström (here) and Lars Ramstöm (here) in Sweden

Karl Erik Lund (here) in Norway

Riccardo Polosa (interviewed here) and Pasquale Caponnetto in Italy

Tobacco harm reduction is a worldwide phenomenon, and it deserves balanced and judicious media coverage.  Journalists, start with this list.  



Note: Updated October 28, 2013.

More Exaggeration and Fear-Mongering From the CDC

Recently I discussed the irresponsible theatrics from federal officials about slight increases in e-cigarette use by teenagers (here).  That report appeared in the CDC’s September 6 issue of Morbidity and Mortality Weekly Report (here).  It turns out that this issue contained another grossly exaggerated CDC study that was tailor-made for major media treatment, and it succeeded.

The study, which examined death statistics from 2001 to 2010, claimed that 200,000 out of the 800,000 deaths each year among Americans from heart disease, stroke and hypertension are avoidable. 

As usual, CDC Director Dr. Tom Frieden was the scaremonger-in-chief: “These findings are really striking.  We're talking about hundreds of thousands of deaths that don't have to happen.  It's possible for us to make rapid and substantial progress in reducing these deaths.” (here).

Here is what the CDC didn’t tell Americans about these scary statistics. 

First, the CDC used a completely unrealistic definition to define these deaths as avoidable: anyone dying from heart disease, stroke or hypertension before the age of 75.  Hoping for a world where no one dies prematurely from any disease is admirable, but badgering Americans about “improving health-care systems and supporting healthy behaviors” as a way to eliminate ALL deaths from heart disease, strokes and high blood pressure up to age 75 is preposterous.

The biggest problem with the CDC report is that it cherry-picked a relatively flat period (2001-2010) of decline in these deaths.  Never mind that the decline over the period was 28% in men and 31% in women!  It completely ignored what has happened over the entire 45-year period for which data is available (here).  Look at the chart to see the astounding decline in these deaths since 1968, 78% in both men and women! 

The decline in cardiovascular deaths among Americans is nothing short of astonishing and breathtaking.  Of course, there’s always room for improvement.  But the CDC should be ashamed to create health care crises using isolated and exaggerated statistics.

The Hazards of Waterpipe Smoking

One of the hot trends in tobacco use is waterpipe smoking (the terms hookah, narghile or shisha are also used)(description here). Hookah bars are located throughout the U.S., especially near college campuses. 

While waterpipes vary in design, they all allow for charcoal-heated air to pass through a tobacco mixture and then through a water-filled chamber before being inhaled through a flexible hose. Owing to the use of charcoal, the resulting smoke contains toxic by-products of combustion. 

A study published last year in Food and Chemical Toxicology (abstract here) by researchers at the American University of Beirut and the Virginia Commonwealth University compared the smoke from a waterpipe with that from a conventional tobacco cigarette.  The lead author was Alan Shihadeh and the senior author was Thomas Eissenberg, a member of the FDA Tobacco Products Advisory Committee.

Dr. Shihadeh and colleagues first observed the smoking behavior of 31 waterpipe smokers during a 45- minute period.  They then programmed a smoking machine to puff on a waterpipe to produce a representative session; the mainstream smoke was analyzed for various by-products of combustion.  The results for a 45-minute waterpipe session are seen in the table below, compared with the emissions from a single cigarette.

Mainstream Smoke Emissions From a 45-minute Waterpipe Session Compared with a Single Cigarette
Agent (amount)	Waterpipe	Cigarette
Nicotine (mg)	1.04	0.73
Carbon Monoxide (mg)	155	12
Nitric Oxide (ug)	437	218
Tar (mg)	464	9.4
Benzo(a)pyrene (ng)	52	6.6
Volatile Aldehydes (ug)
Formaldehyde	59	21
Acetaldehyde	383	587
Acetone	118	270
Methacrolein	122	--

mg = milligrams

ug = micrograms

ng = nanograms

The waterpipe smoke contained considerable quantities of toxic by-products of combustion, in addition to nicotine.  Although there are clear differences between a 45-minute waterpipe session and smoking 10 to 30 individual cigarettes daily, the “results were unambiguous,” as the researchers commented. 

Waterpipe smoking produces unacceptable levels of toxic contaminants.  Don’t be snookered by hookah.