Nicotine & Tobacco Research, ntx166

Source DOI: https://doi.org/10.1093/ntr/ntx166

Abstract

Objectives

While cessation from cigarettes is a top priority for public health, controversy surrounds the role of e-cigarettes for quitting cigarettes. This study examines the role of e-cigarettes in quit attempts and 3-month cigarette abstinence using a large, recent nationally representative US sample.

Methods

Data from the 2014/15 Tobacco Use Supplement-Current Population Survey (TUS-CPS) on cigarette and e-cigarette use and individual characteristics were supplemented with information on state tobacco control policies. We estimated frequencies and multivariate logistic equations for making a quit attempt among those who smoked 1 year earlier and for remaining abstinent at least 3 months among those making a quit attempt. These two outcomes were related to demographic characteristics, tobacco control policies and different frequency measures of e-cigarette use (ever, at least 1, 5, 20 of the last 30 days, a continuous measure of days use).

Results

Having made a quit attempt was more likely among smokers using e-cigarettes than non-users. Among those making at least one quit attempt, quit success was lower among ever users, but higher among those with at least 5 days use of e-cigarettes in the last month. Both quit attempts and quit success were linearly related to the frequency of e-cigarette use.

Conclusions

Consistent with randomized trials and those observational studies that measure frequency of e-cigarette use, both quit attempts and quit success were positively associated with increased frequency of e-cigarette use. Frequency of e-cigarette use was important in gauging the nature of these relationships.

Implications

Previous studies have obtained mixed results regarding the relationship of e-cigarette use to cigarette smoking cessation. This study provides a more precise methodology for considering the relationship of e-cigarette use to quit attempts and to quit success, and finds that quit attempts and quit success increase with the number of days use in the past month.

Received 18 July 2017, Revised 18 August 2017, Accepted 28 August 2017, Available online 31 August 2017

Source DOI: https://doi.org/10.1016/j.fct.2017.08.044

Abstract

Purpose

In 2015, a study identified 5–15-fold higher levels of formaldehyde emissions from an old-generation e-cigarette working at 5.0 V compared to tobacco cigarettes. We set to replicate this study using the same e-cigarette equipment and e-liquid, while checking for the generation of dry puffs.

Design

Experienced e-cigarette users (n = 26) took 4 s puffs at different voltage settings and were asked to report the generation of dry puffs. Formaldehyde emissions were measured at both realistic and dry puff conditions.

Results

Dry puffs were detected at ≤4.2 V by 88% of participants; thus, 4.0 V was defined as the upper limit of realistic use. Levels ranged from 3.4 (SE = 2.2) μg/10 puffs at 3.3 V to 718.2 (SE = 58.2) μg/10 puffs at 5.0 V. The levels detected at 4.0 V were 19.8 (SE = 5.6) μg/10 puffs. At 4.0 V, the daily exposure to formaldehyde from consuming 3 g of liquid with the device tested would be 32% lower compared to smoking 20 tobacco cigarettes.

Conclusions

The high levels of formaldehyde emissions that were reported in a previous study were caused by unrealistic use conditions that create the unpleasant taste of dry puffs to e-cigarette users and are thus avoided.

Received: 2 August 2017 / Accepted: 23 August 2017 / Published: 29 August 2017

Int. J. Environ. Res. Public Health 2017, 14(9), 973;

Source DOI: 10.3390/ijerph14090973

Abstract: Concern has been expressed about the use of e-cigarettes among young people. Our study reported e-cigarette and tobacco cigarette ever and regular use among 11–16 year olds across the UK. Data came from five large scale surveys with different designs and sampling strategies conducted between 2015 and 2017: The Youth Tobacco Policy Survey; the Schools Health Research Network Wales survey; two Action on Smoking and Health (ASH) Smokefree Great Britain-Youth Surveys; and the Scottish Schools Adolescent Lifestyle and Substance Use Survey. Cumulatively these surveys collected data from over 60,000 young people. For 2015/16 data for 11–16 year olds: ever smoking ranged from 11% to 20%; regular (at least weekly) smoking between 1% and 4%; ever use of e-cigarettes 7% to 18%; regular (at least weekly) use 1% to 3%; among never smokers, ever e-cigarette use ranged from 4% to 10% with regular use between 0.1% and 0.5%; among regular smokers, ever e-cigarette use ranged from 67% to 92% and regular use 7% to 38%. ASH surveys showed a rise in the prevalence of ever use of e-cigarettes from 7% (2016) to 11% (2017) but prevalence of regular use did not change remaining at 1%. In summary, surveys across the UK show a consistent pattern: most e-cigarette experimentation does not turn into regular use, and levels of regular use in young people who have never smoked remain very low.

5. Conclusions

This paper highlights the current rates of e-cigarette use among youth in the UK, where e-cigarettes form a part of a tobacco harm reduction policy landscape. Whilst it is estimated that there are 2.9 million e-cigarette current users among adults in Great Britain, regular use among 11–16 year olds remains very low, at 3% or less, and remains largely confined to regular smokers. Regular e-cigarette use among never smokers is very rare. These low rates of regular use suggest that youth experimentation is not currently leading to greater frequency of use, however, comparing youth e-cigarette data and trends across surveys and countries is crucial to better understand youth trends. Survey measures must be designed to assess frequency of use, rather than just ever or past 30 day use.

Centers for Disease Control and Prevention

Source DOI: mmwr/volumes/66/wr/mm6623a1.htm

Commentary by Dr. Michael Siegel: New CDC Data Should Put to Rest the Contention that E-Cigarettes are a Gateway to Youth Smoking

Summary

What is already known about this topic?

Tobacco use is the leading cause of preventable disease and death in the United States, and nearly all tobacco use begins during youth and young adulthood. Among youths, use of tobacco products in any form is unsafe.

What is added by this report?

In 2016, one in five high school students and one in 14 middle school students reported current use of a tobacco product on ≥1 of the past 30 days (3.9 million tobacco users). Moreover, 47.2% of high school students and 42.4% of middle school students who used a tobacco product in the past 30 days used ≥2 tobacco products. During 2015–2016, current use of electronic cigarettes (e-cigarettes) decreased among middle school students, and decreases in current use of any tobacco product, any combustible tobacco product, ≥2 tobacco products, e-cigarettes, and hookahs occurred among high school students. However, decreases in cigarette and cigar use during 2011–2016 were offset by increases in hookah and e-cigarette use, resulting in no significant change in any tobacco use. In 2016, e-cigarettes remained the most commonly used tobacco product among high (11.3%) and middle (4.3%) school students.

What are the implications for public health practice?

Sustained efforts to implement proven tobacco control strategies focusing on all types of tobacco products are critical to reduce tobacco product use among U.S. youths.
[pdf-embedder url=”http://ectaofcanada.com/wp-content/uploads/securepdfs/2017/06/mm6623a1.pdf” title=”Tobacco Use Among Middle and High School Students — United States, 2011–2016″]

Published in University of Waterloo

Source uwaterloo.ca/tobacco-use-canada

Published in BMJ Journals Tobacco Control

Source DOI: 10.1136/tobaccocontrol-2016-053041

ABSTRACT

Introduction Electronic cigarettes’ (e-cigarettes) viability as a public health strategy to end smoking will likely be determined by their ability to mimic the pharmacokinetic profile of a cigarette while also exposing users to significantly lower levels of harmful/ potentially harmful constituents (HPHCs). The present study examined the nicotine delivery profile of third- (G3) versus second-generation (G2) e-cigarette devices and their users’ exposure to nicotine and select HPHCs compared with cigarette smokers.

Methods 30 participants (10 smokers, 9 G2 and 11 G3 users) completed baseline questionnaires and provided exhaled carbon monoxide (eCO), saliva and urine samples. Following a 12-hour nicotine abstinence, G2 and G3 users completed a 2-hour vaping session (ie, 5 min, 10-puff bout followed by ad libitum puffing for 115 min). Blood samples, subjective effects, device characteristics and e-liquid consumption were assessed.

Results Smokers, G2 and G3 users had similar baseline levels of cotinine, but smokers had 4 and 7 times higher levels of eCO (p<0.0001) and total 4-(Methylnitrosamino)-1-(3-pyridyl)-1-butanol (i.e., NNAL, p<0.01), respectively, than G2 or G3 users. Compared with G2s, G3 devices delivered significantly higher power to the atomiser, but G3 users vaped e-cigarette liquids with significantly lower nicotine concentrations. During the vaping session, G3 users achieved significantly higher plasma nicotine concentrations than G2 users following the first 10 puffs (17.5 vs 7.3 ng/mL, respectively) and at 25 and 40 min of ad libitum use. G3 users consumed significantly more e-liquid than G2 users. Vaping urges/withdrawal were reduced following 10 puffs, with no significant differences between device groups.

Discussion Under normal use conditions, both G2 and G3 devices deliver cigarette-like amounts of nicotine, but G3 devices matched the amount and speed of nicotine delivery of a conventional cigarette. Compared with cigarettes, G2 and G3 e-cigarettes resulted in significantly lower levels of exposure to a potent lung carcinogen and cardiovascular toxicant. These findings have significant implications for understanding the addiction potential of these devices and their viability/suitability as aids to smoking cessation.

Int. J. Environ. Res. Public Health 2017, 14(4), 382

Source DOI: 10.3390/ijerph14040382

Abstract:

Background: Although some studies have identified hazardous substances in electronic cigarette (EC) liquids and emissions, there is limited information about the health risks of using ECs.

Methods: In this study, the U.S. Environmental Protection Agency (EPA) health risk assessment model and findings of a literature review were used to determine and profile hazards. Focus was put on the toxicants reported in the literature on conventional cigarette (CC) smoke that most strongly associated with adverse health effects. To evaluate their health risks, dose-response relationships and standard-use conditions were used to estimate average hazard exposures and to calculate the overall health risks of ECs and CCs, benchmarked against international guideline levels for each hazard.

Results: Four hazards (acrolein, diethylene glycol, propylene glycol and cadmium) reported in EC emissions and seven hazards (acetaldehyde, acrolein, formaldehyde, cadmium, CO, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), N′-nitrosonornicotine (NNN)) reported in CC emissions had maximum exposure levels higher than the guideline levels. Two hazards (acrolein, propylene glycol) in EC emissions and five hazards (acetaldehyde, acrolein, formaldehyde, cadmium, NNN) in CC emissions had average exposure levels higher than the guideline levels.

Conclusions: Based on the conditions of use, ECs should be a safer nicotine-delivery product than CCs.

Discussion

Our findings provide evidence that supports the Public Health England statement but was arrived at by applying a different methodology. Although we are aware that some smokers had been smoking for decades, the main purpose of this study is to explore whether they will be exposed to a lower risk of harm by changing to vaping. Hence, no matter how long a smoker had smoked, the probable benefits of changing his/her source of nicotine consumption from CCs to ECs for a year should be very similar. This study leads to two conclusions: that the use of ECs presents a lower risk to health than the use of CCs, and that ECs are likely to be of low health risk to the user.

These results must be interpreted with caution: firstly, CCs have been used for more than a century and there are many more CC users than EC users worldwide. Therefore, far more information is available about the harms of CCs in regard to all criteria listed in the MCDA model. In contrast, ECs are very new products with far fewer users and have limited data available on long-term health consequences. This makes it difficult to assign scores to ECs in relation to criteria, such as product-specific mortality/morbidity and product-related mortality/morbidity. Therefore, the scores for ECs are likely to be less accurate and more biased towards lower risk levels than for CCs. Secondly, there were a number assumptions in our analyses: The daily consumption of CCs and ECs was assumed to be 11 cigarettes or a corresponding 11 vaping sessions over one year; the EC and CC usage patterns in the reviewed studies were assumed to reflect real world use patterns; all ECs and CCs were assumed to be similar in their ability to expose users to various hazards and to those tested in the reviewed studies; fourthly, we restricted our assessment to only 12 hazards and three groups of adverse health effects associated with exposure.

Conclusions

Implications

The findings of this study have different implications for different groups of people. For smokers, quitting smoking altogether is very likely to lead to great health benefits. However, ECs could be a safer substitute for CCs for those in the process of tobacco cessation.

For current EC users, it is important to be aware that using some low quality EC products may expose them to a higher risk of harm. EC brands and products with more rigorous quality authentication should be selected. Currently, regulations on EC manufacturing standards and quality are few and far between. Standards for ECs quality and contents should be introduced to prevent low-quality ECs from being sold.

Some health professionals are unclear whether they should recommend ECs to their patients who are smokers. For those patients unable to fully quit smoking or those who refuse to use approved nicotine replacement therapy, ECs could be recommended as an option to reduce exposure to the hazards in CC smoke.

Further Research

Standardised methods for assessing EC exposures are needed. By setting standard EC usage patterns (e.g., puff volume, puff frequency, puff duration, puff number per session and so on) and standard EC hazard exposure assessments (e.g., hazard detection limits), EC hazard exposure levels could be compared between different studies. In addition, by setting detection limits in smoking/vaping simulation tests, the hazard exposure levels in EC or CC emissions could be determined more accurately.

Concluding Statement

The health effects of using ECs are still not well understood, but current evidence points to ECs being less harmful than CCs. Using ECs to replace CCs as nicotine delivery products could lead to millions of lives saved and significant reductions in the burden of many smoking-related diseases.

Lion Shahab, PhD; Maciej L. Goniewicz, PhD; Benjamin C. Blount, PhD; Jamie Brown, PhD; Ann McNeill, PhD; K. Udeni Alwis, PhD; June Feng, PhD; Lanqing Wang, PhD; Robert West, PhD

Published: Ann Intern Med. 2017;166(6):390-400.

Source DOI: 10.7326/M16-1107

Abstract

Background:  Given the rapid increase in the popularity of e-cigarettes and the paucity of associated longitudinal health-related data, the need to assess the potential risks of long-term use is essential.

Objective: To compare exposure to nicotine, tobacco-related carcinogens, and toxins among smokers of combustible cigarettes only, former smokers with long-term e-cigarette use only, former smokers with long-term nicotine replacement therapy (NRT) use only, long-term dual users of both combustible cigarettes and e-cigarettes, and long-term users of both combustible cigarettes and NRT.

Design: Cross-sectional study.

Setting: United Kingdom.

Participants: The following 5 groups were purposively recruited: combustible cigarette–only users, former smokers with long-term (≥6 months) e-cigarette–only or NRT-only use, and long-term dual combustible cigarette–e-cigarette or combustible cigarette–NRT users (n = 36 to 37 per group; total n = 181).

Measurements: Sociodemographic and smoking characteristics were assessed. Participants provided urine and saliva samples and were analyzed for biomarkers of nicotine, tobacco-specific N-nitrosamines (TSNAs), and volatile organic compounds (VOCs).

Results: After confounders were controlled for, no clear between-group differences in salivary or urinary biomarkers of nicotine intake were found. The e-cigarette–only and NRT-only users had significantly lower metabolite levels for TSNAs (including the carcinogenic metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol [NNAL]) and VOCs (including metabolites of the toxins acrolein; acrylamide; acrylonitrile; 1,3-butadiene; and ethylene oxide) than combustible cigarette–only, dual combustible cigarette–e-cigarette, or dual combustible cigarette–NRT users. The e-cigarette–only users had significantly lower NNAL levels than all other groups. Combustible cigarette–only, dual combustible cigarette–NRT, and dual combustible cigarette–e-cigarette users had largely similar levels of TSNA and VOC metabolites.

Limitation: Cross-sectional design with self-selected sample.

Conclusion: Former smokers with long-term e-cigarette–only or NRT-only use may obtain roughly similar levels of nicotine compared with smokers of combustible cigarettes only, but results varied. Long-term NRT-only and e-cigarette–only use, but not dual use of NRTs or e-cigarettes with combustible cigarettes, is associated with substantially reduced levels of measured carcinogens and toxins relative to smoking only combustible cigarettes.

Primary Funding Source: Cancer Research UK.

PLoS ONE 12(3): e0173055. doi:10.1371/journal.pone.0173055

This study was reviewed by Dr. Konstantinos Farsalinos, Onassis Cardiac Surgery Greece, Department of Pharmacology, University of Patras, Greece: Study titled “Benzene formation in e-cigarettes” found that air has more benzene than e-cigs

Of course, the press statement promotes this headline: Cancer-causing benzene found in e-cigarette vapors operated at high power, which Dr. Farsalinos points out as:

It is very interesting to once again see the inconsistency between the study findings and the press statement.

Continuing his review of the actual study and data, he reveals:

The results of the study are very interesting. At the recommended setting of 6 W with the EVOD (I repeat, at 5 second puffs), they found from non-detected levels (in most of the samples) to 0.16 μg/g liquid consumption (keep these numbers). At 13 W (dry puffs), they found up to 24 μg/g. With the Subtank, they found either non-detected or up to 0.19 μg/g even at the extreme power settings.

What do the findings mean? It depends on how you want to look at it. The authors calculated the concentration of benzene in inhaled air, and report levels up to 5000 μg/m³ air (at dry puffs of course). Compared to the ambient levels of 1 μg/m³ of benzene, everyone would think that this is a disaster.

But not really, this methodology suffers from a major problem. Humans take about 12 breaths per minute, i.e. 17,000 (thousand) breaths per 24 h. The volume of air inhaled in 24 h is 20 m³. So, the daily exposure to benzene from ambient air is 20 μg. Even if you assume that Subtank at 25 W with 5-second puffs represent realistic conditions (they are not), you need to consume 105 mL e-liquid per day in order to be exposed to the same levels of benzene as breathing ambient air. For the EVOD under normal vaping conditions, you need to vape 125 mL e-liquid per day.

The press statement mentions that: “The power levels used in the study were still far below those accessible to users on some devices, which can exceed 200 watts”. This statement is similar to saying that: “We crashed with a car in Trafalgar Square with a speed of 100 mph, but still that was far below the 150 mph speed that cars can reach”. Another similar statement would be: “Eating 5 kg of vegetables in one meal can lead to death, but that is still below the tens of kg available in grocery store where customers buy their vegetables”.

I understand it is frustrating to desperately try to find a problem but fail. And this is not the first time, we’ve seen it in the past (and recently) with formaldehyde and other toxic aldehydes (just wait for a couple of papers that will be published soon). However, this still does not prevent the mispresentation of evidence and science. Also, scientists completely ignore the dry puff phenomenon and instead of them verifying realistic conditions in their experiments, they consider theoretical the criticism they get for their own omission! What a disappointment for the scientific community…

In conclusion: “Benzene formation in e-cigarettes: it does not exist…”

So it appears that we have another “Formaldehyde” scare…  THANK YOU DR. FARSALINOS! We’ve always been able to count on his honest research and analysis to tell us the the full story, be it good, bad OR ugly.

Source DOI: 10.1093/ntr/ntx056

Abstract

Introduction:

To date, no studies have explored how different regulatory environments may influence the effectiveness of ECs as a smoking cessation aid.

Objective:

This study compares the real-world effectiveness of adult smokers using ECs for quitting compared with quitting unassisted or quitting with NRT and/or prescription medications in two countries with restrictive policies towards ECs (i.e., Canada and Australia) versus two countries with less restrictive policies (i.e., US and UK).

Methods:

Data were drawn from the International Tobacco Control Four Country surveys, from the US and Canada (2 waves, n=318 and 380, respectively), the UK (3 waves, n=439) and Australia (4 waves, n=662), collected 2010–2014. Smokers at baseline wave who reported making a quit attempt at follow-up were included. The primary outcome was self-reported abstinence for at least 30 days regardless of smoking status at follow-up assessment. Data across waves were combined and analysed using generalised estimating equations.

Results:

Compared to unassisted quitting (i.e. no medications or ECs), smokers who used ECs for quitting from countries with less restrictive EC policy environments were more likely (OR=1.95, 95%CI=1.19-3.20, p<0.01), whereas smokers who used ECs for quitting from countries with more restrictive EC policies were less likely (OR=0.36, 95%CI=0.18-0.72, p<0.01), to report sustained abstinence for at least 30 days.

Conclusion:

Use of ECs in the real world during a quit attempt appears only effective for sustaining smoking abstinence in a less restrictive EC environment suggesting that the benefits of ECs for smoking cessation are likely highly dependent on the regulatory environment.

Implications:

What this study adds: This is the first study to examine the impact of regulatory environment for electronic cigarettes (ECs) on their real-world effectiveness for smoking cessation. This study shows that in a less restrictive EC regulatory environment, use of ECs during a quit attempt facilitates, but in a more restrictive environment, it inhibits, short-term sustained abstinence. The findings underscore the need for careful consideration on how best to regulate this emerging product so that EC benefits for smoking cessation are maximised and its risks to public health are minimised.