Monday, February 1, 2021

U.S. Preventive Services Task Force on E-Cigarettes: We Just Don’t Know!


The U.S. Preventive Services Task Force (USPSTF) released its updated recommendations for smoking cessation (here), and the outcome is utterly unsurprising and unacceptable: “the current evidence is insufficient to assess the balance of benefits and harms of e-cigarettes for tobacco cessation in adults.”

The task force claims that “Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.”

In fact, the recommendations are in lock-step with the policies of all other federal agencies.

The only “evidence” the task force deemed acceptable consisted of five randomized clinical trials (RCTs), and it briefly acknowledged that two showed success.  However, the report prominently notes that all trials were conducted outside the U.S., used e-cigarettes that were not available here, and “continued e-cigarette use rang[ed] from 38% to 80%. One study reported that 26.9% of all study participants were using e-cigarettes at 1 year.”

U.S. authorities are obsessed with the idea that only clinical trials can provide valid evidence that smokers can switch (here).  They are also excessively worried about continued use of e-cigarettes after smokers step away from the fire, which plays into their insistence that smoking cessation requires tobacco and nicotine abstinence.

The task force exposes its bias when discussing the “harms” of e-cigarettes, introducing four additional RCTs.  The worst symptoms reported were not serious: “coughing, nausea, throat irritation, and sleep disruption.”

In keeping with federal agency practice, this report cites e-cigarette or vaping product use-associated lung injury (EVALI), even though this pseudo-epidemic was linked conclusively to illicit marijuana products.  The task force does mention the real culprit – vitamin E acetate – but asserts disingenuously that we don’t know if nicotine e-cigarettes were involved.  They were not.

It is striking that the task force describes with conviction minor adverse effects of safer tobacco products, but feigns uncertainty about any positive effects, such as helping smokers quit or having no association with EVALI.  At least they put one honest statement at the top of their report: “480,000 deaths annually are attributed to cigarette smoking.”

The report closes with lists of “research needs.”  For e-cigarettes, this involves finding more evidence for anything negative.  For cessation, “[s]tudies must be well-designed RCTs.”  No matter how much evidence is found in government surveys (here and here), it won’t count.  Unsurprisingly, we need to know about “smoking relapse rates in adults who have used e-cigarettes for smoking cessation.”  Did the task force ever call for similar research for “FDA-approved methods”? 

Finally and most importantly, “More research is needed on understanding how to help adults quit e-cigarettes.”  For the task force, no other outcome, even for products that are vastly safer than cigarettes, is valid.


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