Conflicting vapor studies are making global headlines and confusing consumers.
By Timothy S. Donahue
Statistics can be a tricky business. When three new studies on the vapor industry were released in late August and early September, they sent seemingly conflicting messages about whether e-cigarettes could help people quit smoking or would lead them to tobacco. Then, major media outlets ran separate stories on all the studies, which sent the vapor industry into a deeper state of confusion.
First, researchers from the University of Pittsburgh Center for Research on Media, Technology and Health and the Dartmouth-Hitchcock Norris Cotton Cancer Center published a study in the Journal of the American Medical Association (JAMA) Pediatrics that linked e-cigarette use to higher probabilities of teens turning to tobacco cigarettes. Then, just a few minutes later, Public Health England (PHE) released its report claiming that e-cigarettes were “95 percent” safer than traditional tobacco.
The JAMA study stated that teens who use e-cigarettes are significantly more likely to try combustibles later on, finding that teens who use e-cigarettes are much more likely to start using traditional cigarettes within a year, compared to peers who do not use e-cigarettes. Researchers looked at about 700 people from ages 16 to 26. None had tried cigarette smoking at the study’s start, and 16 had tried e-cigarettes. The study asked participants if they would try a cigarette if a friend offered them one, or whether they thought they would smoke a cigarette within the next year. Those who answered “definitely no” were found to be “non-susceptible” to cigarette smoking.
A year later, 10 percent of the never-triers of e-cigarettes had taken at least one puff on a traditional cigarette. But 38 percent (six of 16) of e-cigarette triers had taken at least one traditional cigarette puff. “What is extremely worrisome is that these findings further indicate that e-cigarette use by our nation’s youth, which is a major concern in itself, may also be a gateway to smoking,” American Heart Association CEO Nancy Brown said in a statement. “This new study truly underscores just how dangerous of a habit e-cigarette use can be, especially if it is leading to teens taking up additional tobacco products.”
Not everyone agreed. In fact, numerous researchers went on the record as saying the JAMA study was meaningless, citing specifically the criteria of calling someone who had taken “just one puff” a smoker. “This study focused on cigarettes and reports no information on prior hookah, cigar, marijuana, alcohol or smokeless tobacco use,” Lynn Kozlowski, a professor of health behavior at The University at Buffalo, wrote in The Conversation, an academic journal. “If even two of the 16 were discounted because of prior use of other products [and two were], these results would likely be statistically insignificant.” It should be mentioned that several researchers disagreed with Kozlowski’s assertions, stating that they “are not actually legitimate.”
Gregory Conley, president of the American Vaping Association, a vapor advocacy group, said it should come as no surprise that teens who are willing to try vaping are also going to likely try a cigarette. “These ‘gateway’ studies aren’t even assessing habitual use of cigarettes; they’re only asking about ever use,” says Conley. “The fact is youth smoking has declined by a record, dramatic 40 percent since experimentation with e-cigarettes began to increase in 2011. The evidence showing e-cigs to be a gateway out of smoking for both teens and adults is far more clear than any assertion that vaping is leading teens to take up cigarettes.”
In contrast to the JAMA study, the PHE report found that regular users of e-cigarettes are almost exclusively adults who are already smokers, that there is no evidence that e-cigarettes are “renormalizing smoking or increasing smoking uptake,” and that they are not acting as a “gateway” for young adults and adolescents. The PHE report nevertheless advised caution and underlined the importance of providing balanced information.
Overseen by Peter Hajek, a professor of clinical psychology at the Wolfson Institute of Preventive Medicine, and Ann McNeill, a professor of psychiatry, psychology and neuroscience at King’s College London, the PHE report stated, “While vaping may not be 100 percent safe, most of the chemicals causing smoking-related disease are absent and the chemicals which are present pose limited danger.”
“It is not known whether current [e-cigarette] products are more or less effective than licensed stop-smoking medications,” the report continues, “but they are much more popular, thereby providing an opportunity to expand the number of smokers stopping successfully.”
Shortly after the PHE study’s release, The Lancet, a weekly peer-reviewed general medical journal, claimed the PHE “95 percent safer” figure came from a 2014 study published in European Addiction Research, an academic journal. The Lancet said that PHE failed to disclose that the previous study used no “hard evidence” to reach its conclusion.
That 2014 study, led by Imperial College London researcher David Nutt, was based on the conclusions of a two-day workshop of “international experts,” during which the members scored a range of nicotine products for harm. They concluded that e-cigarettes had 4 percent of the harm of traditional cigarettes. Nutt and his co-authors conceded in the study that there was a “lack of hard evidence for the harms of most products on most of the criteria” and that “there was no formal criterion for the recruitment of the experts.”
However, the PHE authors responded to The Lancet critique, which was based on the one perceived flaw. The “error” was centered on just one of 185 references PHE used, essentially ignoring the rest of the 111-page document. “The Lancet believes that the message [that] smokers can benefit from switching to vaping is an undesirable one,” the authors wrote in their response. “The estimate that e-cigarette use is around 95 percent less harmful than smoking is based on the facts that, first, cigarette smoke constituents that harm health are either absent in e-cigarette vapor or, if present, are mostly at levels much below 5 percent of smoking doses; and second, the main chemicals present in e-cigarettes only have not been associated with any serious risk. Our review highlighted how smokers are currently misinformed about these relative risks.”
Carl V. Phillips, chief scientific director for the Consumer Advocates for Smoke-Free Alternatives Association (CASAA), a consumer advocacy NGO that supports tobacco harm reduction, agreed with some of The Lancet’s criticisms, adding that the “95 percent” claim came from a made-up number (referring to Nutt’s study) and the study is a “case of working that magic that turns vague junk science claims” into concrete facts. “The ‘95 percent’ claim has led to criticisms and attempts at clarification, every single one of which, as far as I can tell, is wrong,” said Phillips. “Everyone in sight is trafficking in non-science at a minimum, and nonsense quite often.”
Then it happened again. Just a few days after the PHE study, the Center for Environmental Health (CEH), a California, USA-based health advocacy group, reported that 97 e-cigarette products purchased from major retailers and online sellers were shown to produce two potentially cancer-causing chemicals, acetaldehyde and formaldehyde, after testing by an independent laboratory. This was in complete contradiction to PHE’s second “fact” that it had used to base its conclusions.
Vapor industry experts and anti-smoking advocates alike cried foul of the CEH study almost immediately after its release. Not only did the study not list any methods, they argued, but it also didn’t state what products were tested. It did, however, name a few of the companies whose products it had tested. Oddly, the CEH study also included an apparently staged photo of a seemingly pregnant woman vaping, an issue the study didn’t confront.
“[The CEH report] made junk science claims that would tend to scare smokers away from switching to e-cigarettes,” said Phillips. “In particular, their headline claim in their press release was ‘High Levels of Cancer-Causing Chemicals in the Majority of Nearly 100 E-cigarettes Tested.’ How high? They offer absolutely no context for that word in the press release and nothing clear in the report. We know that the real answer is ‘not high enough to worry about.’ The two chemicals they are talking about are formaldehyde and acetaldehyde, which have been measured in pretty much every study of e-cigarette emissions and found not to be present at levels that pose a concern.”
Numerous vapor industry experts complained that all the mentioned studies had serious flaws. According to Francisco Garcia, a researcher at the University of Arizona, the truth is that “there is not enough evidence to evaluate the effectiveness, safety, or benefits and harms of using e-cigarettes to help people quit smoking.” Anecdotally, however, there are possibly millions of stories and blog posts that can be found online of ex-smokers extolling the virtues of vapor. Just the CASAA website has a testimonials section with more than 5,300 stories of smokers using vapor to quit.
Several studies show that vaping more likely helps smokers quit, rather than push people towards traditional tobacco. In fact, a new online poll out of Scotland by psychologist Christopher Russell and colleagues at the Centre for Drug Misuse in Glasgow (an independent research entity), found that of the 7,300 people surveyed who said they had vaped at least once, 5,000 had been regular smokers when they first started vaping. More than 80 percent of smokers had quit completely since beginning to vape regularly, which, at the time of the survey, was an average of 14 months before they took the survey.
More than 56 percent of respondents who were still smoking at the time of the survey had at least halved their daily smoking since beginning to regularly vape (defined as at least every other day). The average reduction was from 23 cigarettes per day pre-vaping to four per day. In full disclosure, The Centre has received research funding from public bodies, such as the UK Government Department of Health and the United Nations, and from tobacco companies, such as British American Tobacco and Philip Morris International.
Conley quit smoking using watermelon-flavored e-liquid in 2010. He says one of the major issues with vapor studies is that the major medical journals that have the best public relations firms generally publish only research by those ideologically opposed to harm reduction for smokers. “Meanwhile, quality studies often get ignored by the media, in part because good news isn’t sexy,” says Conley. “With each passing year the number of negative and slanted studies just keep piling up. This has undoubtedly impacted smokers’ perceptions of the relative risk of vaping versus smoking, which is why one of the major conclusions of the recent Public Health England report was that health authorities need to combat this rampant misinformation.”
The one thing that can be garnered from most vapor industry studies to date is that e-cigarettes are most likely a reduced risk over smoking cigarettes. “E-cigarettes are not completely risk-free, but when compared to smoking, evidence shows they carry just a fraction of the harm,” said professor Kevin Fenton with PHE, who was not involved in this particular PHE study.
Exactly how much risk is reduced remains an open question—but we can expect the researchers to continue confusing us all.