By Sally Satel
Early last week, the nation’s new Surgeon General, Dr. Vivek Murthy, said health officials are “in desperate need of clarity” on electronic cigarettes to help guide policies. The technology should be embraced, he said, if evidence shows e-cigarettes are able to help those who otherwise have trouble quitting smoking.
Dr. Murthy is right to ask for more evidence – though the fact that e-cigarette vapor contains no deadly tar is reason enough to encourage smokers to switch if other methods have failed them. But the most urgent need is for an honest discussion; this is nearly impossible as the drum beat of disinformation seems to be getting louder.
I’m referring not only to superficial media reports written by harried reporters with no expertise in health journalism but also to willful distortion of the scientific record by public health experts.
Let’s start with the media, specifically, the breathless media coverage of a misleading report appearing last month in the New England Journal of Medicine entitled “Hidden Formaldehyde in E-Cigarette Aerosols.”
The report described what happened when researchers used two different voltage settings on the vaping device. When they tested a tank system at a realistic voltage setting of 3.3V, no formaldehyde — a carcinogen — was detected. But at an unrealistically high temperature setting of 5.0V, formaldehyde concentrations five- to fifteen-fold that of cigarettes were measured. This tells us that when overheated, vaping devices yield unacceptable levels of formaldehyde.
Such news sounds worrisome indeed. But there was no surprise here: the formaldehyde-laden vapor produced at high temperatures would be so noxious and irritating to the airway, that no one would inhale it anyway. There’s nothing “hidden” about it. Implications made in the Journal’s press release regarding elevated cancer risk from e-cigarettes were bogus.
Now, we’ll move on to a willfully slanted portrayal of the evidence to date. This woeful spectacle is on display in a brand new report by the California Department of Public Health entitled, “A Community Health Threat.” The document contains alarmist rhetoric, cherry-picked evidence, blatant falsehood about gateway effects, and a thorough disregard for the welfare of smokers to whom these devices are aimed and to whom public health agencies have a duty as well as to children. Most derelict is the report’s failure – willful avoidance, one must conclude – to acknowledge that e-cigarettes need to be viewed in relation to standard cigarettes.
Here are some misleading items from the report by Director of California Department of Public Health and State Health Officer, Ron Chapman, MD, MPH.
1. “E-cigarettes contain nicotine, a highly addictive neurotoxin. E-cigarettes do not emit water vapor, but a concoction of chemicals toxic to human cells in the form of an aerosol.” This statement from the report is ripped from it proper context. Nicotine is only dangerous in overdose or if applied to the skin or ingested. The same is true of many household products. Child-proof packing is the answer here. As far as being a “concoction” of toxic chemicals, the relevant issue is how vapor compares to cigarette smoke.
The risk, if any, of long-term inhalation of propylene glycol, the common substrate used for the nicotine solution, is not known—the devices have simply not been around long enough. In limited exposure, however, the U.S. Food and Drug Administration generally regards propylene glycol as safe; it is used in toothpaste, some foods, cosmetics, and in asthma inhalers.
E-cigarette vapor may also contain traces of nitrosamines, which are known carcinogens, but they are present at levels comparable to medicinal products, such as nicotine gum and patches, and at concentrations 500 to 1,400 times lower than in regular cigarettes. Cadmium, lead and nickel may be in the vapor, too, but in amounts and forms considered nontoxic. Nicotine itself is generally benign for healthy people who are not pregnant or nursing.
2. “There is no scientific evidence that e-cigarettes help smokers successfully quit traditional cigarettes.” The California report relies on a study by Katrina Vickerman to conclude that users are a third less likely to quit cigarettes. Boston University professor of public health, Michael Siegel, explains why the Vickerman study can’t be used to make inferences about value of e-cigarettes in quitting. (“Instead, it estimated quit rates among many smokers who were not using e-cigarettes in their quit attempt at all!” writes Siegel.) Vickerman, herself, agrees.
As for evidence that e-cigarettes do facilitate quitting, there are few randomized controlled studies, but the results, thus far, are encouraging. A recent Cochrane Collaboration Report finds “emerging evidence that smokers who use electronic cigarettes can stop or reduce their smoking.” The results of surveys are decidedly positive, see here and here, for example.
3. “Research suggests that kids who may otherwise have never smoked cigarettes are now becoming addicted to nicotine through the use of e-cigarettes and other e-products.” Another troubling statement. In support of it, the California report cites a survey that found that e-cigarette use in teens is associated with higher and more sustained levels of smoking. But the study was really a cross-sectional survey and thus could not determine whether teens who used e-cigarettes smoked first and then used e-cigarettes or vice versa. What’s more, if e-cigarette use had preceded smoking, what are the odds that vaping actually caused smoking – that is would these teens have become smokers regardless of their prior e-cigarette experience? This is a difficult question to answer, but impossible to approach with one-point-in-time data.
The authors of that study even admit that causal information can’t be gleaned from their paper, yet the California report doubles down. “These data suggest that a new generation of young people will become addicted.”
In truth, adolescent patterns of smoking and e-cigarette use suggest the opposite trend: that teen smokers are switching to vaping. But there is no evidence at this time for a “gateway” phenomenon. True, use of e-cigs by teens is growing. The government’s just-released Monitoring the Future Study (MTF) found that 17.1 percent of seniors reported using an e-cigarette in the past month. And data from the Centers for Disease Control show an unmistakable pattern of increase since 2011 with the percentage of high school students who used e-cigs at least once within 30 days.
The less-heralded but nonetheless excellent news is that smoking rates in teens are at an historic low. The MTF found that past-month cigarette smoking in seniors was 13.6 percent—lower than ever before in the history of the survey, which began in 1975.This means, at the very least, that use of e-cigarettes among teens does not prevent declines in smoking –and, possibly, that teens are vaping as a gateway from smoking.
On one point, however, the California report makes sense. It underscores “the lack of manufacturing standards, quality control, and external oversight” by the FDA for e-cigarette products. Overblown reports about dangers combined with legitimate worries about counterfeit and shoddy products have blossomed in this regulatory vacuum. The answer, as I and others have recommended, is for the FDA to reassure skeptical smokers of the considerable relative safety of switching by quickly publishing interim guidelines on manufacturing practices, child-proof packing, warnings, and proper voltage and temperature conditions.
It is stunning that a public agency entrusted with the health of the population of California would promote such a one-sided, scientifically impoverished document. If the Surgeon General wants clarity on e-cigarettes, he should tell the public what we don’t know (e.g., the long term effects of propylene glycol; whether the youth smoking will continue to fall in the presence of e-cigarettes) and what we do know (e.g., that tar released by burned tobacco is much more harmful than e-cigarette aerosol; that vaping is cheaper than smoking; the nicotine is generally benign in adults).
Most important, Dr. Murthy must use his bully pulpit to promote scientific integrity and to emphasize the concept of “trade-offs” in policy-making. Public health officials like California’s Dr. Chapman – who stepped down from his office last Friday, two days after releasing the report, due to charges that he failed to investigate complaints about nursing homes — owe their constituents responsible interpretation of the data instead of misguided warnings about “health threats.”