• What do studies say about electronic cigarettes?

    Editor’s Note: Just so you’re aware, comments conveying anecdotal stories or arguing that anecdotes matter here will not be approved.

    I got into a twitter discussion yesterday on electronic cigarettes. Evidently, Jenny McCarthy is now pitching them. Some of us were not amused. I don’t really trust Ms. McCarthy on almost any health-related issues. But people have asked me if there is any actual harm reduction with their use. That’s a question worth asking.

    I went to the medical literature. Unfortunately, there’s not much there. But here’s what I could find (with respect to clinical trials on humans):

    • A 2010 review found that lab studies show that carcinogen levels in e-cigs are much lower than traditional cigarettes. It also commented on some of the studies below.
    • A 2010 single blind randomized repeated measures cross-over trial of 40 smokers gave people (1) tobocco e-cigs, (2) placebo e-cigs, (3) nicotine inhalers, or (4) cigarettes on each of four days, three days apart, after a night of abstinence. They measured desire to smoke. The tobacco e-cigs reduced desire to smoke over the placebo, and were more well tolerated than the inhalers.
    • A 2011 prospective pilot study looked at 40 smokers who were unwilling to quit. They instead tried to get them to reduce consumption through the use of e-cigs. They found that more than half the participants reduced smoking by at least 50% at 34 weeks without significant side effects.
    • A 2012 study found that active or passive exposure to tobacco smoke increased white blood cell coulds, lymphocyte counts, and granulocyte counts for at least an hour. E-cigs did not, nor did a control situation. It’s not clear how this translates clinically, but it’s a laboratory finding in favor of e-cigs.
    • A 2012 study randomized 86 smokers to a nicotine e-cig, a placebo e-cig, or just holding the e-cig. They measured desire to smoke and withdrawal symptoms. Women had positive results with active use of either e-cig, but men did better with nicotine. There were no health outcomes.
    • An unblinded prospective 2013 study of e-cig use in 12 schizophrenic smokers for a year found that it decreased consumption without any significant side effects. Of course, this is not an RCT, and not definitive.
    • A 2013 study of 15 smokers and 15 non-smokers were exposed to nothing, tobacco smoking, and e-cig smoking (active for smokers and passive for non-smokers). Nicotine exposure, measured by cotinine levels, was similar in the two cigarette types. But lung function was impaired by traditional cigarettes, and not with e-cigs.
    • A 2013 randomized controlled trial gave 300 smokers full strength e-cigs, partial strength e-cigs, or placebo e-cigs for 12 weeks. At one year, they found that overall use and exhaled carbon monoxide declined in all three groups. But there were no differences between groups, and by a year, only 9% had quit and 10% more had a reduction. So it’s unclear if the tobacco was necessary, and how robust the results were. Here’s an article on that study.

    That’s about it. If I missed anything significant, let me know.

    My thoughts? If you’re looking for a means to help you quit, there’s a tiny bit of evidence that they might help, but that evidence favors placebo e-cigs about as much as tobacco e-cigs. There’s a bit of evidence that e-cigs are better than traditional cigarettes for lung function, although those studies are really small and transient. There’s also some tiny amount of evidence that e-cig smoke changes laboratory values less than the smoke of traditional cigarettes, although the clinical meaning of this is unclear. So it’s hard to get too excited about e-cigs.

    But tobacco smoking is terrible, full stop. If something is less terrible, I don’t see how we totally rule that out without some thought. As pediatricians, when parents or family members can’t quit smoking, we ask them not to smoke around children. Why? Because we don’t want the perfect to be the enemy of the good. We’d rather have some improvement than none.

    I don’t see enough evidence to be totally psyched about e-cigs. I wish they were better regulated. But I see enough promise to warrant some larger RCTs.

    @aaronecarroll

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    • One potential complication, hinted at by your wish for better regulation: in many places where smoking is banned (inside bars, &c.), e-cigs will get strange looks but are allowed. Even if they turn out to be far less harmful, there’s a huge potential downside if lack of regulation encourages people to e-smoke more – not to mention the risk to bystanders in formerly smoke-free areas if there are substantial negative effects from passive e-smoking.

    • Aaron, You missed a lot that is significant. As perhaps the only regular TIE reader who is an expert on this topic I will resist the temptation to publicize this post in the tobacco harm reduction / vaping enthusiast world and spare you the 100 (or 500) critical comments and stories of how vaping (e-cigarette use) was the only thing that saved people from smoking. I’ll try to cover it.

      There is actually enormous evidence that e-cigarettes (a) help people quit and (b) are very low risk. Someone would not know that if they just read the mainstream media (dominated by anti-tobacco extremists who oppose e-cigarettes because they are not part of the tobacco-free world plan, and because they look like smoking). Nor is looking only at journal articles sufficient, especially if you believe the rhetoric in them rather than carefully looking at the numbers. Most of the collective knowledge in this fast moving field exists in blogs and such and the journals will not catch up for years. The medicalized view in health research, to favor RCTs even when they are not really the right methodology to assess a social and behavioral phenomenon creates further problems. I trust that these points are obvious to you as a blogger, economist, and social scientist once you think about them.

      We — The Consumer Advocates for Smoke-free Alternatives Association (CASAA), a consumer (not industry!) advocacy organization — have a collection of over 1000 tobacco harm reduction success stories (a small fraction of the total that have been published somewhere). Most of them are about e-cigarette use and the vast majority report a history of trying to quit smoking using other methods and failing. This is far more compelling evidence than appears in any journal.

      The uptake of e-cigarettes almost perfectly matches the decrease in smoking in the US for the last few years. Not proof of causation, obviously, but since approximately 100% of e-cigarette users are ex-smokers (or current smokers who are cutting down or transitioning off), it is a stretch to insist that it is not causal.

      As for the health effects, those studies that claim to find negative effects on lung function basically just show the same minor transient effects from e-cigarettes as from inhaling humid air, as I and others have documented. See e.g., http://antithrlies.com/tag/gratziou/ CASAA has funded a university study (which we hope will be released this week) that reviews the various chemistry studies of the exposure. It shows that the levels are well below that which would be problematic. The biological studies to date are not terribly useful, but when interpreted honestly (i.e., not by people who are intent on opposing tobacco harm reduction) they consistently show nothing problematic. There can be no precise quantification, but those of use who are familiar with the relevant science estimate that e-cigarettes are in the order of 99% less harmful than smoking.

      I would be happy to correspond about this more if you are interested.

      • You’re describing stories. Anecdotes. If there are well-conducted studies you’d like to share, I’m happy to look at them.

        • How do we know that most consumer products “work”? Not medical trials. It is “stories”, “Anecdote” — along with sales figures, of course. These are consumer products, they are used almost exclusively to quit smoking, and they are exploding in popularity. How do we know that Amazon is an effective substitute for indy bookstores? When asked about their use, most consumers report the same story of their motivations. What study are you proposing that would be more informative than those observations?

          • “How do we know that most consumer products “work”? Not medical trials. It is “stories”, “Anecdote” ”

            This is, of course, completely wrong. Some small number of people who attempt to quit succeed, through a variety of means (cold turkey, CBT, nicotine patches, cutsey products*). Proving that the product/technique they used had anything to do with their success up and beyond their attempt to quit, the placebo effect, and individual differences requires careful science.

            Without the careful science, you are in danger of coming across as a snake oil salesman of the worst type. You might want to consider whether or not you’ve crossed that line.

            *: One of the greatest ads in Japanese advertising history was for a cigarette-shaped pacifier for figety-handed attempting-to-be-ex smokers.
            http://www.youtube.com/watch?v=-Fj5CcYWPMI

            (Each bloke says “With this, I quit smoking”, but the last one says “With this, I lost my job”, where the this (raised little finger) is the Japanese symbol for extreme problems with a personal relationship.

            • Funny that you assert my observation (which is backed by a rather obvious concrete example) is “exactly wrong” without producing any kind of argument to support your assertion. It appears that you have heard about the concept of a placebo effect but do not really understand what it means. It might help if you understand if you actually consider the argument I made (albeit briefly):

              Millions of people have switched from buying books at a storefront to buying them from Amazon. Do we have evidence? Of course we do. We have the sales data and we can just ask basically anyone who is buying books at Amazon “did you used to buy books from a storefront” and learn that the answer is yes. Is there a carefully controlled study that shows that Amazon is not a placebo? What would that even mean. Perhaps book buyers are completely stupid and they are just tricked into believing Amazon has better prices. But so what? That does not change the point at hand, as to whether lots of people are making the substitution.

              As for the Japanese product in your link, I have no idea how that is supposed to relate to your claim. But it does invoke an observation that is pretty good support for mine. There was an imitation-cigarette product introduced in Japan called (the English name, obviously) Zero-Style Mint. I am not sure that is what appears in the video because I don’t speak any Japanese, but it does not matter. There was an explosion of interest, with huge sales — for about a month. And then it crashed and burned. It turns out it did not really deliver any nicotine etc., and so lots of smokers liked the idea but few liked the actual product. I think this might be what you would (incorrectly) call a placebo, but it was neither placebo nor not-placebo — it was simply a product that was not a satisfying substitute for cigarettes. This contrasts with e-cigarettes which become more and more popular by the week as smokers discover that they are a good substitute.

        • I will give you my own study! I started smoking Marboro cigarettes when I was 11, I am about to turn 39. I smoked two packs a day for 27 years. I have tried nicotine gum, the patch and smokeless cigarettes. I can’t smoke at work so I was also using smokeless tobacco. Are you aware that the smokeless cigarette (nicotine inhaler) contains lead? When I learned that I never touched another smokeless cigarette. Did you know the patch contains mercury? Upon learning that I never tpuched another patch. I am frightened to take Chantix, I already know two people who attempted suicide and one person who was committed to a mental institution because Chantix causes an insanely long list of nasty side effects that begin with: Warning: May cause clinical depression, psychosis, paranoia, hallucinations, suicidal and homicidal thoughts and behaviors in some individuals. The list of side effects goes on with the standard liver damage, kidney failure, vision problems, ulcers and other nasty effects.

          I started puffing on an electronic cigarette 6 months ago and haven’t even wanted a real cigarette or chewing tobacco since. The electronic cigarettes at the gas station don’t work. They are made by the cigarette companies and designed to fail. Blu, the brand you see on TV, will kill the urge long enough to attend that meeting or watch that movie at the theater but as soon as you can get to the nearest designated smoking area you will light a real cigarette. Blu is owned by phillip Morris (Marlboro) and is heavily regulated, doesn’t have enough nicotine to satisfy an ultralight smoker and will not disclose the ingredients contained within. My unregulated EGO-T CE4 battery with Kangertech Evod clearamizer allows me to adjust battery voltage, and ohm rating (resistance) in the heating element, amount of nicotine in milligrams, propylene glycol/vegetable glycerine ratio and flavorings for a smoother more satisfying cleaner vape. Yes I do know what’s in my electronic cigarette. 4 ingredients, food grade propylene glycol(used in fog machines), food grade vegetable glycerine(can also be used in fog machines), food flavoring, and nicotine to make a water soluble vapor that doesn’t clog your lungs with tar and other non soluble things. Ypu eat three of those ingredients every day. I haven’t had or wanted a real cigarette in 6 months. I can breathe much better now. I can taste much better now. I can smell things a lot better now. None of the non smokers around me complain when I puff on my electronic cigarette. I get compliments on my flavors instead. Whoever wants to ban the electronic cigarette is a complete nutcase and if they succeed I will start smoking cigars and spitting tobacco juice in public places out of protest.

    • Is it not possible that nicotine (devoid of the tars of cigarettes) might have uses that are positive, much like caffeine or even amphetamine?

    • You cite 8 studies on the positive effects of e-cigarette usage, and say that these studies are not nearly enough.

      But what about the ONE study done by the EPA which condemned 2nd hand smoke as the horrible, terrible, soul-sucking spawn on Satan that it’s been the rallying cry of the anti-smoker leagues? That study which, when challenged in court, brought the EPA’s director at the time a sound reprimand by the judge on record as being grossly misinterpreted to further a political and personal agenda?

      fyi – there have been many studies after the EPA one, and NONE of them have been able to ‘prove’ the dangers of 2nd hand smoke to the extent of the EPA ‘findings…’ telling, I’d say, of the agenda.

      So…if ONE study, which cannot be duplicated, is enough for the various ‘charity’ groups to shout from the rooftops and get legislation passed which demonizes smokers…why is it that EIGHT studies showing the positive effects of e-cigarettes are only a ‘TINY bit of evidence’, and NOT enough to warrant further personal review.

      You, sir, need to remove the rose-colored glasses, and come meet the real world…

      • You’re kidding right? There are many, many studies of the effects of second hand smoke. The literature focusing just on the health of children exposed to tobacco smoke could stun a team of oxen.

        While I cite eight studies here, they are all small (few participants) and they’re almost all for different outcomes. So they don’t show the same things. They aren’t even in the same league.

        • No, actually, I’m not kidding. Of the hundreds of studies done to show the damaging effects of SHS to bystanders, nearly all of them show very little risk profiles – if you look at the actual DATA and not the write-up.

          But don’t take my word for it…LOOK AT THE DATA. Not the write up, not the conclusion, not what was splattered around the world by the media or the anti-smoking groups….look at the NUMBERS.

        • Aaron, I know I am not going to win you over with this comment, but I thought I would plant the idea. I have spent most of my career working to reduce smoking — I am not dabbling here. I personally hate being exposed to second-hand smoke (for aesthetic reasons) and so from purely selfish motives, like the fact that there is so much worry about it, and thus so many place bans for smoking. Oh, and I know a thing or two about epidemiology methods (you can ask your blog colleague Harold to confirm my bona fides if you doubt them). With that background, I will tell you that the evidence about the health effects of ETS is actually much weaker than you think.

          An large fraction of what is out there is pure junk science. I suspect it is obvious to you that, for example, banning smoking in bars cannot conceivably reduce total heart attacks in the population by 50% or 20% or even 10%. Yet that is what you are asked to believe if you take the “peer reviewed journal articles” at face value. If it is obvious that these are (intentionally) biased via cherry-picking the data, ignoring confounding, model fishing, etc., then it is not too difficult to realize that many of the results in the plausible range are similarly biased.

          If we try to distill it down to the better studies, we find that only for people with the most extreme exposure to ETS (particular nonsmoking spouses of smokers) is there any barely detectable effect on disease endpoints, and often such an effect is not detected. It is reasonable to conclude their is some effect — though that conclusions comes as much from reasoning by analogy, that high-level exposure to ETS is, in effect, a low-level exposure to smoking (score another one for scientific reasoning rather than blindly relying on study data!) — but it is far smaller than people have been led to believe.

    • As a smoker of 41 years who only got an e-cig to cut down on the amount I was smoking because of wheezing and coughing issues, I can attest to the fact that it changed my life. I had no desire to quit….I planned to die a smoker….and as I told everyone, I don’t care if they go to $100 a pack because I plan to keep smoking.

      To make a long story short, I never so much as took a drag off a real cigarette after the first day and that was over 4 yrs ago. Within about 3 weeks of switching over to an e-cig I stopped wheezing and coughing. do I feel healthier….hell, yes!

    • Oh…and as an aside for the snake oil salesman commenter above…we still have snake oils salesmen today…they are still among us.

      But instead of traveling around in a brightly painted, rickety old wagon and selling their miracle cures to one village at a time…they’ve upscaled.

      Now they wear 3 piece suits. They travel the globe in luxury, private jets. They employ millions of people a year, and rake in billions (if not trillions) in profits. And they sit on the advisory councils of the very regulatory body that was created to protect us from them in the first place.

      • regarding comment :

        by Peg Stueber on August 6th, 2013 at 23:59

        “Oh…and as an aside for the snake oil salesman commenter above…we still have snake oils salesmen today…they are still among us.”

        In response to someone commenting regarding their success of quitting real cigarettes by using e-cigarettes.

        It’s called a ‘testimony’….

        E-cigarette changed that person’s life and health… As it has thousands of others who have provided their testimony in various forms (if you cared to look around with open eyes).

        I personally wish to know why you dismiss someone’s personal experience as snake oil?

        This is not an actor on a advertisement paid to “sell you something” with a false or misleading claim.

        This is a person who felt strongly enough about a product that improved her health, that she wanted to provide, what at the time, runs contrary to what you and others are saying.
        It is incredibly disrespectful to dismiss her experience and comment in such a way because it goes against your point of view.

        Does her single testimony prove e-cigarettes are a healthy, successful alternative to quitting real smoking? Of course not. If a million people could line up in front of you and tell you a similar story, would that be evidence enough for you that it at least proves successful at assisting people in quitting smoking?
        Well, you can be the judge of that.

        But to argue a point successfully, it depends on being able to actually consider both sides.

        How many people have you actually talked to who have successfully transitioned off real cigarettes, and are experiencing health benefits?

        And how many would you be prepared to outright dismiss as you did that comment, as having ‘fallen for some snake oil sales pitch’? Our as giving a snake oil pitch themselves?

        “Testimony” alone, can sink a company or have it thrive. If a new product comes out that a bulk of users report as rubbish, it will struggle to be in business long… Testimony of real world people’s experience is very important but you just dismiss it outright as what?

        Having a personal “testimony” as to the success and benefits to my personal health that e-cigarettes have brought me, and having heard hundreds of similar testimonies, I believe, through critical thinking and observation, that e-cigarettes are positive…
        I have not been brainwashed or tricked…. I have used real world experience an open mind, and a desire to seek a healthier life for myself.

        I believe I have found it.

        I may be wrong and may be a fool… And I’m prepared to accept others may think I am both…

        But so be it..

    • Dear Aaron,

      As with all these things I suggest you talk to a few “vapers” in your area and ask them to recommend a store. Sit in that store and ask the multitudes of people coming in if they work or not. I think this will answer this for you.

      I don’t mean the “cigalikes” I mean the ego kits with liquid.

    • Current EU proposals to ban all eCigs except those able to meet medicinal licensing will leave several million existing users with little choice. As a user of electronic cigarettes I am not impressed with NRT products so far made by pharmaceutical companies and I see medicinalisation of electronic cigarettes as a huge and harmful step backwards for tobacco harm reduction. It also infringes on my choice to consumer nicotine in a much safer way.

      A lot of useful links here:

      http://www.clivebates.com/?p=853

      Also worth following the link here http://www.qmul.ac.uk/media/news/items/smd/104506.html to a recent article in the Lancet arguing against medicinal regulation.

    • Aaron,

      Many surveys have been published (including in peer reviewed journals) finding that many smokers have quit smoking and/or sharply reduced their cigarette consumption by switching to e-cigarettes.

      A Gallup Poll just found that 48% of former smokers in US reported quitting “cold turkey”, 5% with nicotine patch, 3% with e-cigarettes, 2% with prescription drugs, 1% with nicotine gum.
      http://www.gallup.com/poll/163763/smokers-quit-tried-multiple-times.aspx?
      http://www.huffingtonpost.com/2013/08/04/quit-smoking-cigarettes_n_3684381.html

      Please note that most former smokers quit smoking >25 years ago, that FDA approved “tobacco dependence” treatments have been marketed by drug companies, promoted by health agencies and industry funded anti-tobacco/medical/health groups, and subsidized by taxpayers and insurance policy holders for decades (Nicorette gum – 1984, Wellbutrin – 1986, Nicoderm/Habitrol patches – 1992, Chantix – 2006).

      In sharp contrast, newer e-cigarettes (2006) have been lied about and demonized by many health agencies (i.e. FDA, CDC, WHO, state/local health departments) and many drug industry funded anti-tobacco, medical and health groups (i.e. CTFK, ACS, AHA, ALA, AAP, AMA, ATTUD, Legacy, ASH, Mayo) and researchers.

      In 2009, the FDA unlawfully banned e-cigarette imports, and US Customs agents seized nearly 1,000 shipments at US Ports before all 13 federal judges adjudicating litigation filed by two e-cig companies struck down FDA’s ban.

      Furthermore, the use of e-cigarettes has been banned in public places and workplaces by extremist state/local governments and employers.

      I noticed that you are a pediatrician, and wanted to inform you that during the past decade the American Academy of Pediatrics has made many misleading fear mongering claims about e-cigarettes, dissolvables, snus and other exponentially less hazardous smokefree alternatives for smokers, and that AAP has refused to ethically disclose that it has received millions of dollars from competitor drug companies that market less than effective NRT products (that have a 5% success rate for smoking cessation) and less than safe Wellbutrin and Chantix.

      More than 99% of all tobacco attributable disease, disability and death in the US is caused by daily inhalation of tobacco smoke. In contrast, the daily consumption of smokefree tobacco/nicotine products pose negligible if any increased disease risks.

      The growing mountain of scientific and empirical evidence indicate that e-cigarettes:
      – are 99% (+/-1%) less hazardous than cigarettes,
      – pose no risks to nonusers,
      – are virtually all consumed by smokers (or by smokers who became vapers),
      – have helped several million smokers quit or significantly reduce cigarette consumption, and
      – have never been known to addict a nonsmoker to nicotine.

      For nearly three decades I’ve successfully campaigned to ban smoking in workplaces, sharply reduce tobacco marketing to youth, hold cigarette companies accountable in civil courts, increase cigarette taxes, and help smokers quit smoking.

      E-cigarettes are the most effective products ever invented/marketed to help smokers quit smoking and/or to sharply reduce their cigarette consumption.

      I’m confident that history will judge e-cigarettes to be as beneficial for public health as childhood vaccines, antibiotics, condoms, pasteurization, and sewage/water treatment.

      Bill Godshall
      Executive Director
      Smokefree Pennsylvania
      1926 Monongahela Avenue
      Pittsburgh, PA 15218
      412-351-5880
      smokefree@compuserve.com

    • Dear Mr. Godshall!

      Please, can you tell this the EU politicians who want to ban the e-cigarette in the pharmacy? ;-)

      Thanks for your words!

    • For information and a lot of links to the evidence you are looking for from an impeccable source ( a former director of ASH UK ) check out http://www.clivebates.com who has become a strong advocate for ecigs to be used in tobacco harm reduction.

    • Is there data available about how many e-cig users are former or current smokers and how many are new users of nicotine?

    • …. it’s just a more healthy and efficient delivery source. enough said.

    • if it looks like a cigarette, feels like a cigarette, tastes like s cigarette, sounds kinda like a cigarette, and doesn’t smell like a cigarette, and isn’t as harmful to your health as a cigarette; it may be better than a cigarette.