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.

 

Vaping (Marijuana) and Lung Disease: Tale of Two State Health Departments

A few days ago, vaping-related deaths in two states were publicized by their respective state health agencies.  The announcements reflect a stark difference in tone and accuracy.

MICHIGAN

“The Michigan Department of Health and Human Services (MDHHS) [announced] the third death associated with the outbreak of vaping-related lung injuries in the state” on January 10.  Dr. Joneigh Khaldun, MDHHS Chief Medical Executive and Chief Deputy for Health, said “We extend our deepest condolences to the family. I urge people not to use THC-containing e-cigarettes or vaping products until the specific cause of these vaping-related severe lung injuries being reported nationwide has been identified.”  (emphasis added)

MDHHS recommendations start with the following: “People should not use THC-containing e-cigarette or vaping products, particularly from informal sources such as friends, family or in-person or online sellers.” (emphasis added)  The agency says people should avoid vitamin E acetate and “should not add any other substances not intended by the manufacturer to products… Adults using e-cigarettes or vaping products as an alternative to cigarettes should not go back to smoking.”

This is an example of a public health agency providing useful information to marijuana and tobacco users: Don’t vape THC products that are not from legitimate retailers.  Don’t stop vaping legitimate nicotine products and return to smoking.

 

KENTUCKY

On the same day, the Kentucky Department for Public Health “announced the state’s first probable fatality related to vaping.”  Eric Friedlander, acting Secretary of the Cabinet of Health and Family Services, said, “To protect public health, we urge Kentuckians – especially young people -- to stop using all vaping products.” (emphasis added)  Public Health Commissioner Dr. Angela Dearinger added, “health experts can’t guarantee the safety of any e-cigarette or vaping product.”

In its three-page press release, Kentucky never identified THC liquids as the probable cause of the lung injuries, and failed to inform marijuana users about the dangers of unregulated THC products. Officials urged the public “to stop using all vaping products,” which is likely to send those former smokers who had successfully switched to e-cigarettes back to smoking.   

The Kentucky Health Cabinet boasts that it “is one of the largest agencies in state government, with nearly 8,000 full- and part-time employees located across the Commonwealth focused on improving the lives and health of Kentuckians.”  It is regrettable that with all these resources, public health officials are distributing misleading information that may contribute to higher smoking rates.

Australian tobacco researchers, led by Coral Gartner at the University of Queensland, have published a scathing analysis of how THC-related lung injuries and deaths in the U.S. were – and still are – exploited by American health officials and media to fuel a crusade against e-cigarettes and nicotine vaping products.  The Australians itemize the key flaws in this misguided campaign:

“[M]ost [lung injury] cases developed suddenly within a short period, mostly in young males, in only one country. Over 40 million people have vaped nicotine in the UK, USA and Europe, and vaping has been around for nearly a decade without any similar clusters of serious acute cases of lung injury.  If vaping nicotine were the cause of these lung injuries, many more cases should have been reported in these countries…”

“[C]annabis oils, like nicotine‐based vaporisers, have also been used since around 2014 with almost no reports of lung injury. What recently changed is the proliferation of black market cannabis vaping products, some of which are sold in the same packaging as legal cannabis vaping products.”

“In October, the CDC concluded that vaping contaminated THC products was the likely cause of the lung damage.” 

While the CDC was slow to blame unregulated THC products, it is inexcusable that state health departments continue to release inaccurate information about dangerous products.