Tuesday, August 15, 2017

American Heart Association Still Clings to Alternative Facts: Claims that Smoking is No Safer than Vaping

Scientists like myself are often frustrated by "denialists" who refuse to acknowledge global warming, disseminate false information about adverse effects of vaccines, or - historically - failed to acknowledge the severe health effects of cigarette smoking. But I never expected this denialism to be coming from within my own movement in public health.

Today, it appears that the American Heart Association is still taking a public denialist stance with regards to the health benefits of quitting smoking by switching to vaping. Despite overwhelming scientific evidence that vaping is much safer than smoking and that quitting smoking by switching to electronic cigarettes has dramatic and immediate health benefits, the American Heart Association is still clinging to the false message that smoking may be no safer than vaping.

According to an article appearing today in The Daily Mail:

"Dr Aruni Bhatnagar, director of the American Heart Association's Tobacco Research and Addiction Center, added: 'We just don't know if moving to e-cigarettes is good enough to reduce the harm.'"

As the Daily Mail is not necessarily a trustworthy source (note the headline that a single e-cigarette can potentially lead to a heart attack), I confirmed this quote with other sources. The same quote appeared in the San Diego Union-Tribune two weeks ago. It seems clear that the American Heart Association, through its Tobacco Research and Addiction Center, is still clinging to the belief that smoking may be no more hazardous than vaping. Furthermore, the American Heart Association is disseminating this false information to the public.

The Rest of the Story

The American Heart Association's claim that quitting smoking by switching to electronic cigarettes does not reduce the harm of cigarette smoking flies in the face of overwhelming scientific evidence that switching from smoking to vaping leads to an immediate improvement in respiratory symptoms and improves lung function. Improvement in spirometry measurements was observed even in dual users, but was most substantial in smokers who switched completely to e-cigarettes. Remarkably, respiratory symptoms improved in patients with chronic obstructive pulmonary disease (COPD) who switched to electronic cigarettes.

In addition to improving respiratory health, e-cigarettes also lower carcinogenic risk compared to smoking, as they deliver many fewer and much lower levels of carcinogens. 

The American Heart Association's claim is not only false, but it is potentially damaging. If smokers believe this false information, they may decide that there is no reason to quit smoking using e-cigarettes. Or, even worse, ex-smokers who quit using e-cigarettes may return to smoking. After all, if it is not clear that vaping reduces harm compared to smoking, then what's the point of vaping? You might as well enjoy the real thing.

I'm surprised that cigarette companies haven't jumped on the opportunity to use the American Heart Association's endorsement of smoking:

"We at Philip Morris believe the public should heed the advice of respected public health organizations. According to the American Heart Association, we just don't know if quitting smoking by switching to e-cigarettes reduces the harm. So if you're thinking of trying to quit smoking by switching to vaping, don't bother. There's no certainty that it will reduce your health risks. But it will certainly decrease your enjoyment of the tobacco smoking experience."

Thursday, August 10, 2017

It's Official: Anti-Tobacco Groups Willing to Throw Away the Lives of Smokers to Promote Radical Ideology

For months, I have been arguing that the major anti-tobacco groups in the United States have been waging a war against electronic cigarettes that is motivated not by a pure concern for the public's health, but by an ideological opposition to the idea that anyone could get pleasure from nicotine in whatever form -- even if they are improving their health and saving their life.

Today, the American Thoracic Society (ATS) made it official.

In a letter to the editor published in the Washington Post, the American Thoracic Society confirmed what I have been suggesting for months.

The vice chair of the American Thoracic Society’s Tobacco Action Committee essentially confirmed that the ATS is willing to throw away the lives of smokers in order to promote the radical ideology that no one should derive pleasure from nicotine in any form, even if it is a life-saving switch from deadly cigarettes to very low-risk e-cigarettes.

In the letter, Dr. Enid Neptune writes: "As a physician who treats patients devastated by tobacco-caused lung disease, I was concerned by the Aug. 5 editorial “Breaking nicotine’s grip,” which embraced Food and Drug Administration Commissioner Scott Gottlieb’s plan for regulating tobacco products. The commissioner seems unconcerned about switching one form of nicotine addiction with another. Nicotine in any form is bad for your health, adversely affecting neurological and cardiovascular systems and reproductive health. Evidence shows that nicotine can be a gateway drug. ... The FDA’s job is to protect youths from all types of tobacco and nicotine addiction, not to negotiate which types of nicotine addiction it will allow."

The title of the letter is: "The FDA’s new plans could just switch one form of nicotine addiction with another."

The Rest of the Story

The writer makes a great point. We should never promote the idea of people switching from one addiction to another. And it is not the concern of public health what health risks are associated with any form of addiction. All addiction is bad and our job in public health is to make sure that no one, anywhere, at any time, is addicted to any substance.

For example, when heroin addicts are treated with methadone or bupenorphine, the physician is just substituting one addiction for another. These physicians seem unconcerned about switching one form of nicotine addiction with another. Opiates in any form are bad for your health, adversely affecting neurological and cardiovascular systems and reproductive health. Evidence shows that opiates can be a gateway drug and there is a great risk of overdose with any opiate. The job of physicians is to protect people from all types of opiate addiction, not to negotiate which types of opiate addiction they will allow.

OK - I was being facetious. But this demonstrates the insanity of the argument that the e-cigarette industry should be decimated through burdensome regulations because vaping is just another form of nicotine addiction and all nicotine addiction is equally evil.

I, and fortunately the new FDA Commissioner, strongly reject this radical ideology. Risk does matter. Addiction is a public health problem not because the concept of someone being addicted to a substance is severely damaging, but because the addictive substance carries severe health risks. Switching from a high-risk addictive substance to a low-risk addictive substance is not a zero-sum game. It is a critical and life-saving intervention. Just as methadone maintenance programs have saved thousands of lives from heroin-associated morbidity and mortality, electronic cigarettes are saving thousands of lives from smoking-associated disease and death.

While this writer speaks only for the American Thoracic Society, it is clear to me that this is indeed the underlying philosophy of all the major anti-tobacco groups, and even of many health departments and agencies, including the Centers for Disease Control and Prevention and the state health departments in California, Vermont, and Washington (to name a few).

Fortunately, Commissioner Gottlieb has rejected this philosophy, strongly and definitively. Public health is about saving lives, not fighting for some ideological principle of no addiction to any substance, regardless of how low-risk the product might be or how the product might be saving a life by switching someone to a much safer form of drug delivery.

Of course we need to restrict the sale and marketing of vaping products to youth and educate them about the health risks of all types of nicotine products, including real cigarettes and fake ones. But discouraging youth from using e-cigarettes should not come at the expense of wiping out 99% of the e-cigarette market, depriving millions of former smokers of the product they are using successfully to stay off tobacco cigarettes, and risking tens of thousands of these former smokers returning to cigarette smoking because their vaping products are taken off the market.

Saturday, August 05, 2017

New Study Provides Strong Empirical Support for New FDA Approach to Tobacco Product Regulation

A new study published in the journal Tobacco Control reports that the modeled cancer risk associated with vaping is less than 1% of that associated with smoking and is only slightly higher than, if not comparable to the cancer risk associated with nicotine replacement therapy (NRT). In select circumstances, electronic cigarettes produced high levels of aldehydes but only when the voltage was cranked up to excessive levels. Thus, under conditions of normal use, this study finds that tobacco-free e-cigarettes present a drastically reduced carcinogenic risk compared to tobacco cigarettes.

The study methods were as follows: "The cancer potencies of various nicotine-delivering aerosols are modelled using published chemical analyses of emissions and their associated inhalation unit risks. Potencies are compared using a conversion procedure for expressing smoke and e-cigarette vapours in common units. Lifetime cancer risks are calculated from potencies using daily consumption estimates."

The results were as follows: "The aerosols form a spectrum of cancer potencies spanning five orders of magnitude from uncontaminated air to tobacco smoke. E-cigarette emissions span most of this range with the preponderance of products having potencies less than 1% of tobacco smoke and falling within two orders of magnitude of a medicinal nicotine inhaler; however, a small minority have much higher potencies. These high-risk results tend to be associated with high levels of carbonyls generated when excessive power is delivered to the atomiser coil. Samples of a prototype heat-not-burn device have lower cancer potencies than tobacco smoke by at least one order of magnitude, but higher potencies than most e-cigarettes. Mean lifetime risks decline in the sequence: combustible cigarettes much greater than heat-not-burn, which is much greater than e-cigarettes (normal power), which are greater than or equal to nicotine inhaler."

The study concludes that: "Optimal combinations of device settings, liquid formulation and vaping behaviour normally result in e-cigarette emissions with much less carcinogenic potency than tobacco smoke, notwithstanding there are circumstances in which the cancer risks of e-cigarette emissions can escalate, sometimes substantially. These circumstances are usually avoidable when the causes are known."

The Rest of the Story

This study should put to rest any doubt within the tobacco control movement about whether vaping greatly reduces health risk compared to smoking. Numerous anti-tobacco groups and health departments have repeatedly asserted that vaping is no less hazardous than smoking, but this claim is false, and the present study adds significantly to the already substantial evidence that vaping is orders of magnitude safer than smoking. The anti-tobacco groups and health agencies that have made such statements should immediately correct them and issue retractions to alert the public to these important findings.

These results add strong empirical support to the new FDA approach to tobacco products, announced one week ago by FDA commissioner Dr. Scott Gottlieb, which emphasizes the regulation of tobacco products and e-cigarettes based on the wide differential in their health risk. It makes no sense to lump e-cigarettes in the same basket as tobacco cigarettes, given their drastically different health risks. However, that is precisely what the FDA was doing prior to Dr. Gottlieb's appointment as the new commissioner. Now, the agency is taking a much more sensible and evidence-based approach.

While this study does find that there are conditions under which e-cigarettes can be made to produce rather high levels of certain hazardous chemicals -- most notably aldehydes -- these conditions involve jacking up the voltage to excessive levels that typically produce dry puff conditions, something that vapers would almost certainly detect immediately and not tolerate. Nevertheless, the results do suggest that FDA safety standards related to the maximum allowable voltage or coil temperature may be warranted.