NOT PEER REVIEWED In his critique, Stan Glantz, PhD interprets and presents our study as doing something we explicitly warned readers it was not intended to do. He argues that “the model is based on a series of assumptions that are inconsistent with empirical evidence.” However, we explicitly state and he reiterates, that the model is not meant to be predictive. In our previous work (Addiction 2017: NTR 2017), we presented a framework to help better understand the effects of e-cigarettes and argued that we need better information before we rush to judgement about the actual impact of e-cigarette use.
Our goal in writing this paper was simply to show that e-cigarettes could help us reach a real smoking and tobacco control endgame. In the US, we have made great progress applying traditional policies, such as tax increases, smoke-free air laws and media campaigns. However, SimSmoke models for the US and other countries indicate that traditional tobacco control policies can only get us partially to the endgame. We think that we can achieve more. Many countries have complied fully or near fully with the FCTC and still have unacceptably high rates of smoking prevalence. The point of our paper is to show that strategies shifting smokers to e-cigarettes can play a role in achieving the endgame.
While Glantz recognizes that we provide a “pessimistic” as well as an “optimistic” scenario, he dwells on the optimistic scenario. Many in the public health community see...
NOT PEER REVIEWED In his critique, Stan Glantz, PhD interprets and presents our study as doing something we explicitly warned readers it was not intended to do. He argues that “the model is based on a series of assumptions that are inconsistent with empirical evidence.” However, we explicitly state and he reiterates, that the model is not meant to be predictive. In our previous work (Addiction 2017: NTR 2017), we presented a framework to help better understand the effects of e-cigarettes and argued that we need better information before we rush to judgement about the actual impact of e-cigarette use.
Our goal in writing this paper was simply to show that e-cigarettes could help us reach a real smoking and tobacco control endgame. In the US, we have made great progress applying traditional policies, such as tax increases, smoke-free air laws and media campaigns. However, SimSmoke models for the US and other countries indicate that traditional tobacco control policies can only get us partially to the endgame. We think that we can achieve more. Many countries have complied fully or near fully with the FCTC and still have unacceptably high rates of smoking prevalence. The point of our paper is to show that strategies shifting smokers to e-cigarettes can play a role in achieving the endgame.
While Glantz recognizes that we provide a “pessimistic” as well as an “optimistic” scenario, he dwells on the optimistic scenario. Many in the public health community seem to think that supporting a thoughtful e-cigarette based harm reduction strategy could have horrible public health consequences. We included a pessimistic scenario with major differences from the optimistic scenario to incorporate the concerns of those most skeptical of e-cigarettes as a harm reduction tool. One of the main findings of this study was to show that even if a strategy that secured large shifts away from smoking sharply increased e-cigarette use among those who would otherwise quit all tobacco use and otherwise nonsmoking youth – and even if e-cigarettes also turned out to be much more harmful than currently available research indicates – an aggressive switching strategy would still secure large net public health benefits. Again, we are not claiming that we know the answer, but we are asking that tobacco control advocates keep an open mind towards strategies encouraging cigarette smokers to switch to e-cigarettes.
Glantz has indicated that he believes that there are alternative ways to achieve endgame goals in regard to smoking without prompting any large shifts from smoking to e-cigarettes. We would encourage Glantz to publish his ideas and estimates of a set of policies that could possibly move us to such an endgame without prompting shifts to e-cigarette use. Cigarette tax increases, graphic health warnings on cigarettes, more aggressive anti-smoking public education campaigns, and even much more novel and aggressive strategies such as minimizing nicotine levels or banning menthol will all directly reduce smoking. But they will also likely move many smokers to e-cigarette use. Among other things, our study shows that securing large smoking declines through such measures will secure large public health gains even if they do so primarily by shifting smokers first to e-cigarettes.
It is interesting that Glantz has ended with a quote from our article, “tobacco industry documents reveal an industry strategy of ‘divide and conquer’ focused primarily on fostering divisions within the tobacco control community regarding modified risk products.” It is important that we in tobacco control do not stray into pointless, divisive stances. We have made great progress in reducing cigarette use, but much more can be done, and we’ll get there faster if we work together.
NOT PEER REVIEWED The data, interpretations and implications of the data modelling exercise conducted by Levy et al(1) should not go unchallenged. Regardless of the number and confidence of the opinions voiced, and the observation of lower levels of selected toxicants in e-cigarette users that are alluded to, there is great uncertainty about the extent to which harm might be reduced by the exclusive use of electronic cigarette rather than combustible tobacco. On this background, to describe one of two models, a 95% harm reduction as optimistic and the second, still a substantial, hopeful estimate of 60% reduction as pessimistic betrays a bias at the outset. The use of this “pessimistic” descriptor would to a casual reader imply that the truth lay, inevitably, somewhere between the two estimates.
Then there is the detail of the model. Firstly, the use of Holford projections(2) overestimated 2015 smoking rates in the US by at least 10% compared to CDC data(3) - underestimating the recent rate of decline in smoking prevalence in men and women between 2005 and 2015 by one-third. A higher base rate and slower rate of decline exaggerate tobacco-related harms in the status quo – naturally favouring each of the modelled scenarios. Starting with lower, more accurate estimates of current smoking and rates of decline would also increase the counterbalancing harms from initiation in non-smokers.
There are other obvious problems. In the status quo, 20% of boys and 14...
NOT PEER REVIEWED The data, interpretations and implications of the data modelling exercise conducted by Levy et al(1) should not go unchallenged. Regardless of the number and confidence of the opinions voiced, and the observation of lower levels of selected toxicants in e-cigarette users that are alluded to, there is great uncertainty about the extent to which harm might be reduced by the exclusive use of electronic cigarette rather than combustible tobacco. On this background, to describe one of two models, a 95% harm reduction as optimistic and the second, still a substantial, hopeful estimate of 60% reduction as pessimistic betrays a bias at the outset. The use of this “pessimistic” descriptor would to a casual reader imply that the truth lay, inevitably, somewhere between the two estimates.
Then there is the detail of the model. Firstly, the use of Holford projections(2) overestimated 2015 smoking rates in the US by at least 10% compared to CDC data(3) - underestimating the recent rate of decline in smoking prevalence in men and women between 2005 and 2015 by one-third. A higher base rate and slower rate of decline exaggerate tobacco-related harms in the status quo – naturally favouring each of the modelled scenarios. Starting with lower, more accurate estimates of current smoking and rates of decline would also increase the counterbalancing harms from initiation in non-smokers.
There are other obvious problems. In the status quo, 20% of boys and 14.8% of girls would commence smoking between ages 15 and 25. To achieve the effects modelled, 83% of the 15 year olds boys who would have commenced smoking and 70% of the pre-destined female smokers would have to be diverted to exclusive e-cigarette use. In the optimistic target, requiring the most complete diversion, there is no allowance for harms of “off target” initiation of e-cigarette use i.e. initiation in a young person otherwise destined not to smoke. This is irrational given that e-cigarette use in young people trebles smoking rates after allowance for predictors of smoking uptake(4). The harder e-cigarette use is pushed the more off-target use is likely unless magic is in operation. This detail is critical. Under the published “pessimistic” model for 15 year old girls, there is already a negative effect in terms of years of life lost; not a benefit.
It goes on. Ten years after the commencement of the model in 15 year olds, no individual appears to have ceased the use of e-cigarettes. In the real world, discontinuation is the norm, rather than the exception. Even in England, with ready availability and a favourable public discourse, a minority of smokers choose e-cigarettes to aid smoking cessation(5) . Assumed smoking cessation rates with e-cigarettes are greatly in excess of what is achieved in clinical trials and standard clinical practice. How an intervention that is rejected longer-term in most smokers and ineffective in short-term use will achieve the 5%/10% smoking rates as modelled is unclear but it does not affect the calculations in the model as under both scenarios the outcome in smoking rates is predetermined. The viability of the steps needed to achieve this outcome are not questioned.
It is not difficult to see where this is heading. The purported benefits could only ever be achieved if electronic cigarettes or other novel products were freely available, including to adolescents at or before the typical age of initiation of combustible tobacco use, and had low pricing/taxation amidst a generally liberal approach to their use in public places. This would need to be supported by strong and effective marketing, attractive packaging and advertising standards that permitted uncertain/unproven claims about long-term safety and health benefits. Products would need to be researched and designed that were more rewarding/addictive than combustible tobacco to prevent switch and interchange with smoking. One wonders what responsible corporate entity would develop such a product, potentially harming many of its consumers whilst removing their easy and free choice to cease its use.
References:
1. Levy DT, Borland R, Lindblom EN, et al. Potential deaths averted in USA by replacing cigarettes with e-cigarettes. Tobacco Control (online first; doi: 10.1136/tobaccocontrol-2017-053759)
2. Holford TR, Levy DT, McKay LA, et al. Patterns of birth cohort-specific smoking histories, 1965-2009. Am J Prev Med 2014;46:e31–7.
3. Jamal A, King BA, Neff LJ, Whitmill J, Babb SD, Graffunder CM. Current Cigarette Smoking Among Adults — United States, 2005–2015. MMWR Morb Mortal Wkly Rep 2016;65:1205–1211.
4. Soneji S, Barrington-Trimis JL, Wills TA et al. Association Between Initial Use of e-Cigarettes and Subsequent Cigarette Smoking Among Adolescents and Young Adults. A Systematic Review and Meta-analysis. JAMA Pediatr 2017; 171:788-797.
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The paper, “Potential deaths averted in USA by replacing cigarettes with e-cigarettes” by David Levy et al. published in Tobacco Control on October 2, 2017, attracted a moderate amount of attention with its conclusion that “Compared with the Status Quo, replacement of cigarette by e-cigarette use over a 10-year period yields 6.6 million fewer premature deaths with 86.7 million fewer life years lost in the Optimistic Scenario. … Our projections show that a strategy of replacing cigarette smoking with vaping would yield substantial life year gains, …”
This is a pretty impressive result until you consider that the Optimistic Scenario is based on a series of assumptions that are of which are inconsistent with empirical evidence to date:
Cigarette smoking prevalence drops from 17% to 5% in 10 years (from 19.3% to 4.6% in men and from $14.1% to 4.6% in women between 2016 and 2026).
The existence of e-cigarettes does not, on average, depress quitting cigarettes.
There is no relapse from e-cigarette use to cigarette smoking.
No youth who initiate with e-cigarettes progress to cigarette use.
No dual use of cigarettes and e-cigarettes.
The evidence free claim that e-cigarettes are 5% as dangerous as cigarettes.
(These assumptions were not clearly stated in the main paper; we figured them out based on the appendix and by examining the Excel spreadsheet of the model that the authors s...
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The paper, “Potential deaths averted in USA by replacing cigarettes with e-cigarettes” by David Levy et al. published in Tobacco Control on October 2, 2017, attracted a moderate amount of attention with its conclusion that “Compared with the Status Quo, replacement of cigarette by e-cigarette use over a 10-year period yields 6.6 million fewer premature deaths with 86.7 million fewer life years lost in the Optimistic Scenario. … Our projections show that a strategy of replacing cigarette smoking with vaping would yield substantial life year gains, …”
This is a pretty impressive result until you consider that the Optimistic Scenario is based on a series of assumptions that are of which are inconsistent with empirical evidence to date:
Cigarette smoking prevalence drops from 17% to 5% in 10 years (from 19.3% to 4.6% in men and from $14.1% to 4.6% in women between 2016 and 2026).
The existence of e-cigarettes does not, on average, depress quitting cigarettes.
There is no relapse from e-cigarette use to cigarette smoking.
No youth who initiate with e-cigarettes progress to cigarette use.
No dual use of cigarettes and e-cigarettes.
The evidence free claim that e-cigarettes are 5% as dangerous as cigarettes.
(These assumptions were not clearly stated in the main paper; we figured them out based on the appendix and by examining the Excel spreadsheet of the model that the authors shared with us in response to an email. Their Pessimistic Scenario is based on similar assumptions, albeit with a higher e-cig risk.)
It is important to recognize that the authors don’t even pretend that their estimates are based on reality. In their Discussion they state: “Unlike previous models of e-cigarette use, our model was not developed to predict future e-cigarette and cigarette use based on past trends. Rather the aim was to examine a hypothetical endgame strategy of reducing cigarette use through switching to e-cigarettes. ”
I used their model to investigate the lives saved if cigarette use dropped along the same trajectory that the authors assumed because of increased smokefree laws, anti-smoking media, higher taxes and achieving smokefree movies without anyone even using an e-cigarette. Doing so (without e-cigarettes) would have saved even more lives – 7.0 million fewer lives lost and 91.4 million fewer life years lost.
The centrality of the first assumption is demonstrated by the fact that, using the Levy et al model (which they provided me as a spreadsheet) requires that e-cigarettes be more dangerous than cigarettes (about 120-130% more dangerous) to end up having a net negative population health impact. This is because they assume huge drops in smoking cigarettes.
In other words, all that this paper shows is that if a lot fewer people smoke, there will be a lot fewer premature deaths from smoking. It contributes absolutely nothing to the discussion of the efficacy of e-cigarettes for harm reduction.
It would be like someone asking what would happen to melting ice sheets if we were to be able to bring greenhouse gasses back to pre-industrial levels in 10 years. The calculation is possible but the results would not contribute anything to public policy because, like the Levy paper, the assumptions are discordant with reality.
Finally, in the Conclusion of their paper Levy et al state that “tobacco industry documents reveal an industry strategy of ‘divide and conquer’ focused primarily on fostering divisions within the tobacco control community regarding modified risk products. Indeed, the tobacco control community has had divided approaches to e-cigarettes, and in the process may have lost focus on cigarettes, the most deadly form of nicotine delivery ... Most important, an e-cigarette substitution strategy provides the justification to redouble efforts to target cigarette use, as called for by the WHO Framework Convention for Tobacco Control.” The authors are, of course, welcome to their opinion. But nothing in this paper provides an empirical support for this argument.
NOT PEER REVIEWED It is disappointing that Robert Proctor’s advocacy for tobacco abolition, so clearly expressed in his magisterial ‘Golden Holocaust’ (2011) and, indeed, in Tobacco Control (1), appears to have been diluted to the same degree that he now seems in favour of diluting the concentration of nicotine in cigarettes. And this in spite of the various potential difficulties he points out in implementing the proposal to reduce nicotine in cigarettes to sub-addictive levels, not least that it could well result in decades-long delays before such cigarettes might eventually replace conventional ones.
I also have argued that the only realistic way to deal with the tobacco problem is through abolition (2). This is easier than it might seem, because, as Robert Proctor himself has said (1):
‘[S]moking is not a recreational drug; most smokers do not like the fact they smoke and wish they could quit.’
Is it not time for tobacco abolition, rather than ‘control’, to become part of the debate?
NOT PEER REVIEWED The United Kingdom government is now recommending e-cigarettes as important tools in helping individuals to quit smoking (http://www.bbc.co.uk/news/health-41339790). It is widely acknowledged that, for many, smoking tobacco is detrimental to health. However, it is perhaps less widely appreciated that we have only a limited understanding of why smoking tobacco is bad for our health. Why, for example, might you be 40 times more likely of succumbing to lung cancer if you are a persistent heavy smoker? What is it in tobacco or in the act of smoking which is damaging to health? These are the enigmas of smoking tobacco which have remained largely unanswered. We are interested in the myriad ways that humans are exposed to aluminium in everyday life (http://pubs.rsc.org/en/content/articlepdf/2013/em/c3em00374d). Intriguingly one such way is smoking tobacco and the main reason for this is the presence of significant amounts of aluminium in tobacco (http://www.amjmed.com/article/S0002-9343(05)00710-2/pdf).When tobacco is smoked its components form an aerosol which is taken down into the lung before it is eventually expired. Anyone who has set up a ‘smoking machine’ to investigate this will no doubt have been impressed by the efficiency with which a surrogate lung fluid transforms th...
NOT PEER REVIEWED The United Kingdom government is now recommending e-cigarettes as important tools in helping individuals to quit smoking (http://www.bbc.co.uk/news/health-41339790). It is widely acknowledged that, for many, smoking tobacco is detrimental to health. However, it is perhaps less widely appreciated that we have only a limited understanding of why smoking tobacco is bad for our health. Why, for example, might you be 40 times more likely of succumbing to lung cancer if you are a persistent heavy smoker? What is it in tobacco or in the act of smoking which is damaging to health? These are the enigmas of smoking tobacco which have remained largely unanswered. We are interested in the myriad ways that humans are exposed to aluminium in everyday life (http://pubs.rsc.org/en/content/articlepdf/2013/em/c3em00374d). Intriguingly one such way is smoking tobacco and the main reason for this is the presence of significant amounts of aluminium in tobacco (http://www.amjmed.com/article/S0002-9343(05)00710-2/pdf).When tobacco is smoked its components form an aerosol which is taken down into the lung before it is eventually expired. Anyone who has set up a ‘smoking machine’ to investigate this will no doubt have been impressed by the efficiency with which a surrogate lung fluid transforms the black smoke coming out of the cigarette into the white wispy vapour which is eventually expired. The surrogate lung fluid, on the other hand, changes from a clear solution to one which is tinged with yellow. We found that a significant amount of aluminium (ca 50(micro)g/L), presumably originating from the tobacco, was retained by the surrogate lung fluid and we speculated that this aluminium could contribute towards tobacco-related illnesses.
The arrival of e-cigarettes encouraged us to repeat our previous experiments. In the first instance we measured the aluminium content of many commercially-available e-liquids. Their aluminium content ranged from 26(micro)g/L for pure propylene glycol (the usual vehicle for e-liquids) to 147(micro)g/L (<0.2ppm) for a Virginian e-liquid with high nicotine content. Nevertheless even the higher figure is considerably lower than the aluminium content of tobacco (ca 2.0ppm) and so we were not expecting e-cigarettes to be a significant source of aluminium to lung fluids. However, we were to be surprised! When a 0.5mL volume of e-liquid was ‘smoked’ to completion through 50mL of a surrogate lung fluid the aluminium content of the lung fluid varied between 2000 and 9000(micro)g/L which equated to between 100 and 500(micro)g of aluminium per 0.5mL of e-liquid. Further experiments where the branded e-liquid was replaced with propylene glycol (which contains only 26(micro)g/L aluminium) produced results up to 13000(micro)g/L aluminium in the surrogate lung fluid, equivalent to approximately 700(micro)g of aluminium per 0.5mL of propylene glycol vehicle.
Smoking e-cigarettes is potentially much more hazardous with respect to potential toxicity due to aluminium than smoking tobacco. The source of the aluminium is the e-cigarette itself and not the e-liquid though the latter may contribute towards the dissolution of aluminium from various components of the e-cigarette.
We do not know if some of the health-related effects of smoking tobacco are attributable to aluminium in tobacco. However, if they are then such will not be addressed by smoking e-cigarettes.
NOT PEER REVIEWED The authors point out that rates of adolescent ever use of e-cigarettes are substantial and increasing, but rates of regular use remain low. Yet it is also worth placing these rates of adolescent use in the context of other groups of e-cigarette users. In particular, a recent systematic review colleagues and I published into sociodemographic differences in e-cigarette use gives further salience to Conner et al’s findings. Although the availability of UK evidence for our review was limited, some very clear patterns emerged internationally. For instance, within the 38 studies reporting ever use and the 22 reporting current use, these outcomes were particularly prevalent in older adolescents and younger adults (versus younger children and older adults respectively). This therefore lends further weight to Conner et al’s recommendations around regulating the marketing and sale of e-cigarettes to minors in countries which lack sufficient legislation in this area. Both papers also show the importance of future studies stratifying findings by sociodemographic variables such as age to ensure more subgroup analyses are possible.
1) Hartwell G, Thomas S, Egan M, et al E-cigarettes and equity: a systematic review of differences in awareness and use between sociodemographic groups Tobacco Control Published Online First: 21 December 2016. doi: 10.1136/tobaccocontrol-2016-053222
NOT PEER REVIEWED In the second column of this article, the author describes findings from a survey in Japan (Tabuchi et al, 2016, reference 15). However, there is a misinterpretation of Tabuchi et al’s table 2 which leads to wrong percentages for having tried heat not burn products in Caputi’s article. The figures 8.4% and 7.8% are not the percentages who had ever tried these products in the population but instead percentages out of those respondents who had ever tried an e-cigarette or a heat not burn product.
The actual figures for the population are therefore about 0.6% for iQOS (8.4% of 6.6%) and 0.5% for Ploom (7.8% of 6.6%).
Further information on the ever use of different products by age, gender and smoking status (about 1% of 15-19 year olds had tried each of the two heat not burn products), is found in supplementary table 3 of Tabuchi et al.
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Without citing any sources or providing any related analysis or explanation, this paper makes several sloppy and misleading statements about the scope and impact of federal preemption relating to state and local restrictions of flavored tobacco products.
We know from the preemption provisions in the federal Tobacco Control Act that state and local governments may not regulate the ingredients or characteristics of a tobacco product if the state or local regulation is “different from, or in addition to” an FDA tobacco product standard. [Sec. 916(a)(2)] But we do not yet know how FDA or the courts will interpret or apply that “different from, or in addition to” phrase. For example, it could mean that state and local governments are free to prohibit or limit the use of certain flavorings in certain types of tobacco products unless or until FDA prohibits or limits flavorings for those same types of tobacco products. To assert and publish a more restrictive interpretation of federal preemption with no qualification or clarification is not only misleading but promotes a more restrictive interpretation than necessary or desirable.
The paper also fails to note that the courts have ruled that the Tobacco Control Act’s preemption provisions leave state and local governments free to restrict the sale of flavored tobacco products within their boundaries. [See, e.g., U.S. Smokeless Tobacco v. City of New York, 708 F.3d 428 (2nd Cir., 2013).] The...
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Without citing any sources or providing any related analysis or explanation, this paper makes several sloppy and misleading statements about the scope and impact of federal preemption relating to state and local restrictions of flavored tobacco products.
We know from the preemption provisions in the federal Tobacco Control Act that state and local governments may not regulate the ingredients or characteristics of a tobacco product if the state or local regulation is “different from, or in addition to” an FDA tobacco product standard. [Sec. 916(a)(2)] But we do not yet know how FDA or the courts will interpret or apply that “different from, or in addition to” phrase. For example, it could mean that state and local governments are free to prohibit or limit the use of certain flavorings in certain types of tobacco products unless or until FDA prohibits or limits flavorings for those same types of tobacco products. To assert and publish a more restrictive interpretation of federal preemption with no qualification or clarification is not only misleading but promotes a more restrictive interpretation than necessary or desirable.
The paper also fails to note that the courts have ruled that the Tobacco Control Act’s preemption provisions leave state and local governments free to restrict the sale of flavored tobacco products within their boundaries. [See, e.g., U.S. Smokeless Tobacco v. City of New York, 708 F.3d 428 (2nd Cir., 2013).] These rulings suggest that state or local laws that restricted the sale of any tobacco products that contained more than a specified amount of certain flavorings would not be preempted (at least if they did not totally prohibit their sale). The tobacco industry would certainly bring legal challenges against any such state or local law and argue for a more restrictive interpretation. But unless the courts actually adopt the tobacco industry’s preferred view of the Tobacco Control Act’s preemption provisions, it is inaccurate and counterproductive for publications in Tobacco Control to present that restrictive view as current law.
Finally, the paper also implies that state and local governments cannot use chemical testing to determine the quantities of added flavorings in specific tobacco products as part of their enforcement efforts to establish violations of their (not preempted) laws restricting the sale of flavored tobacco products. But there is a big difference between directly regulating the amount of flavorings in certain types of tobacco products (possibly subject to preemption) and measuring the amount of flavorings in a tobacco product to develop evidence that it is a flavored tobacco product being sold in violation of a state or local sales restriction (not subject to preemption). For example, federal preemption could not possibly apply to a state or local enforcement agency using chemical analysis to show that a tobacco product has as much or more cherry flavoring than tobacco products previously marketed and sold as cherry flavored in order to establish that the sale of the tobacco product at regular retail outlets violates a (not-preempted) state or local law that allows the sale of tobacco products with a characterizing flavor of cherry only at licensed, adult-only tobacconists.
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Background
E-cigarette is a delusive name for what the product actually is; an electronic vaporization device. Basic parts of an e-cigarette include: a tank containing the liquid to be vaporized, some sort of heating element, a battery to power the device, and a mouth piece. The liquid, often referred to as e-liquid, usually contains a base (for production of thick vapor) and flavor. E-liquid may or may not contain nicotine. The heating element converts the e-liquid into aerosol, which is then inhaled by the user. While many models resemble a conventional cigarette, others look nothing alike. Colloquially referred to vaporizers, such models have become more common in the recent years.
In the western world e cigarettes proposed as a tobacco control strategy for possible nicotine reduction and stressed on policy appraisals of harm and safety on regulation of other ingredients of the products. The related conflicts and controversies of e cigarettes as a contemporary tobacco control are discussed (1).
E-cigarettes began to appear in the Indian market around 2010. Today, E-cigarettes pose a complex challenge for the tobacco stricken country. According to Global Adult Tobacco Survey (GATS) 2010, 34.6% of the Indian adults were current tobacco users with 14% of adults indulging in current tobacco smoking (5.7% current cigarette smokers, 9.2% current bidi smokers) (2). Global Youth Tobacco Survey (GYTS) 2009 estimated current toba...
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Background
E-cigarette is a delusive name for what the product actually is; an electronic vaporization device. Basic parts of an e-cigarette include: a tank containing the liquid to be vaporized, some sort of heating element, a battery to power the device, and a mouth piece. The liquid, often referred to as e-liquid, usually contains a base (for production of thick vapor) and flavor. E-liquid may or may not contain nicotine. The heating element converts the e-liquid into aerosol, which is then inhaled by the user. While many models resemble a conventional cigarette, others look nothing alike. Colloquially referred to vaporizers, such models have become more common in the recent years.
In the western world e cigarettes proposed as a tobacco control strategy for possible nicotine reduction and stressed on policy appraisals of harm and safety on regulation of other ingredients of the products. The related conflicts and controversies of e cigarettes as a contemporary tobacco control are discussed (1).
E-cigarettes began to appear in the Indian market around 2010. Today, E-cigarettes pose a complex challenge for the tobacco stricken country. According to Global Adult Tobacco Survey (GATS) 2010, 34.6% of the Indian adults were current tobacco users with 14% of adults indulging in current tobacco smoking (5.7% current cigarette smokers, 9.2% current bidi smokers) (2). Global Youth Tobacco Survey (GYTS) 2009 estimated current tobacco use among Indian students at 14.6%, with 4.4% students reported to be current cigarette smokers (3). Alarmingly, the survey revealed that 56.2% of students who bought cigarettes in a store were not refused purchase because of their age. Allowing e-cigarettes to remain unregulated in such a setting is assumed by many to be be a recipe for disaster. However, a blanket ban without considering any potential health benefits also not without its cons. The smoking community is likely to feel further marginalized, deprived of what is perceived as an alternative with lower risk profile. (4–6)
E cigarettes in India
Initially, E-cigarettes were available only in a select smoke shops in metropolitan cities. They were generic, low quality models mostly imported from China, where the production had first begun in 2003. Over the years, a wide variety e-cigarettes and vaporizers have become available in many shops across urban areas. It isn’t uncommon to see a couple of low end models stocked in the neighborhood smoke shop.
Internet are rife with e-cigarette listings as well. The price ranges anywhere from 200 INR (~ 3 USD) for disposable models to 10,000 INR (~150 USD) for rechargeable imported ones. The price of entry level models doesn’t pose a significant barrier for adults or for students. A google search yielded more than 20 websites within first 5 pages of results, catering to sale of e-cigarettes and vaporizers, as well as related paraphernalia (7). These are not including the major online marketplaces like Amazon.in and Flipkart.com that too contain a number of listings for e-cigarettes. They can also be easily imported from other countries.
When ITC, the major tobacco player in India, released its first e-cigarette products (under ION brand) in 2014, it did so without seeking any prior approval (8). Earlier during the same year, India’s national carrier, Air India faced an inquiry for advertisement and sale of e-cigarettes to airline customers (9).
Legal Status in India
Under Poisons act, 1919, Nicotine is classified as a poisonous substance. In the form of Tobacco products, its sale is regulated under Cigarette and Other Tobacco Products Act (COTPA, 2003). Sale of Nicotine gums as a method of cessation is regulated under Drugs & Cosmetics Act, 1940. Since COTPA deals exclusively with Tobacco Products, and D&C Act doesn’t explicitly mention electronic Nicotine delivery devices, there exists an unregulated gray space for both the sale and advertisement of e-cigarettes in India.
Several State governments (Punjab, Chandigarh, Karnataka, Kerala and Maharashtra) have since issued a ban against the sale/intent of sale of e-cigarettes (10,11). Impact of these bans remains questionable despite the initial conviction receiving considerable media coverage (11). This is in part due to extensive availability of vaping products in online marketplaces.
When marketed as only flavor delivery devices, containing no nicotine whatsoever, there exists no regulation for manufacture/sale/possession/advertisement of e-cigarettes. This is often used by manufacturers/sellers to circumvent the rudimentary regulations that do exist to restrict sale of nicotine containing products, while offering an end-product with unknown risk profile and no health benefits. Popular online marketplaces like Amazon and Flipkart are flooded with such products.
The Dilemma
A balanced approach into this matter is warranted. COTPA should be appropriately revised to include e-cigarettes. Increasing delay is likely to lead to establishment of a more robust supply chain and consumer base. Furthermore, relevant inquiries must be made to assess the public and individual health impact of e-cigarettes in India.
As of now, it would be imprudent to classify it as anything more than a nicotine and/or delivery product. If anything, such a clean starting position allows us to adequately examine what this product means to different populations, and how closely do these images correlate with the reality.
References
1. Malone RE. Tob Control 2017;26:e1–e2
2.Global Adult Tobacco Survey (GATS) India: 2009-2010. [Last accessed on 20117 Mar 29]. available from: http://www.searo.who.int/LinkFiles/Regional_Tobacco_Surveillance_System_.... published by IIPS, Mumbai and funded by the Ministry of Health and Family Welfare, GOI 2010 .
3. Gajalakshmi V, Kanimozhi CV. A Survey of 24,000 Students Aged 13–15 Years in India: Global Youth Tobacco Survey 2006 and 2009. Tobacco Use Insights. 2010;3:23–3.
4. Berg CJ, Stratton E, Schauer GL, Lewis M, Wang Y, Windle M, et al. Perceived Harm, Addictiveness, and Social Acceptability of Tobacco Products and Marijuana Among Young Adults: Marijuana, Hookah, and Electronic Cigarettes Win. Subst Use Misuse [Internet]. 2015 Jan;50(1):79–89. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4302728&tool=p...
5. Brose LS, Brown J, Hitchman SC, McNeill A. Perceived relative harm of electronic cigarettes over time and impact on subsequent use. A survey with 1-year and 2-year follow-ups. Drug Alcohol Depend. 2015 Dec;157:106–11.
6. Tomashefski A. The perceived effects of electronic cigarettes on health by adult users: A state of the science systematic literature review. J Am Assoc Nurse Pract. 2016 Sep;28(9):510–5.
7.Google.Lovelites.in, littlegoa.com, vapeadda.com, vapourindia.com, litejoy.co.in, ecigindia.com, purevapors.in, evolvevapors.com, smokefree.in, planetion.in, indiabongs.com, evapeshop.in, esutta.com, ivape.in, vapecircle.com, tygrtygr.in, greenvapo.com, indianvapegarage.in, ecigarettecart.com, vape.co.in, vapin.in, epuff.in, ivapeindia.com, beyondvapeindia.com
[Retrieved 2017 Apr 1]
8.http://www.business-standard.com/article/companies/itcs-e-cigarettes-lik... Business Standard. 2014. [Retrieved 2017 Apr 1]
9.http://timesofindia.indiatimes.com/india/E-cigarette-sale-on-Air-India-f... Times of India. 2014 [Retrieved 2017 Apr 1]
NOT PEER REVIEWED
The editors of this journal, Tobacco Control, and specifically the authors of the editorial “Blog fog? Using rapid response to advance science and promote debate” [1] highlight the need - or requirement, depending on the viewpoint - of utilising a specified platform to debate the finer points of an article.
From an academic standpoint, individuals that have an interest in a specific field of study - such as Tobacco Control - will see, and respond to, such articles in the appropriate manner. However, one of the pitfalls prevalent in any rapid response platform, and this isn’t limited to the journal Tobacco Control, is the necessity of the journal’s guidelines to adhere to a specific writing format. This does have some advantages in keeping the debate over an article related exclusively to the article. However, there are some respondents that prefer to write an unabridged version of a critique lest the comment not pass the rapid response system for publication.
There are several advantages to publishing a critique of an article outside the rapid response system [2] that allows for a broader audience to read and respond to both the article content and the critique.
Personal blogs often reflect the style of the author, and also allow for greater freedom of expression including the use of imagery to illustrate vital points that many readers find both enjoyable and informative.
Providing a platform within the journal must allo...
NOT PEER REVIEWED
The editors of this journal, Tobacco Control, and specifically the authors of the editorial “Blog fog? Using rapid response to advance science and promote debate” [1] highlight the need - or requirement, depending on the viewpoint - of utilising a specified platform to debate the finer points of an article.
From an academic standpoint, individuals that have an interest in a specific field of study - such as Tobacco Control - will see, and respond to, such articles in the appropriate manner. However, one of the pitfalls prevalent in any rapid response platform, and this isn’t limited to the journal Tobacco Control, is the necessity of the journal’s guidelines to adhere to a specific writing format. This does have some advantages in keeping the debate over an article related exclusively to the article. However, there are some respondents that prefer to write an unabridged version of a critique lest the comment not pass the rapid response system for publication.
There are several advantages to publishing a critique of an article outside the rapid response system [2] that allows for a broader audience to read and respond to both the article content and the critique.
Personal blogs often reflect the style of the author, and also allow for greater freedom of expression including the use of imagery to illustrate vital points that many readers find both enjoyable and informative.
Providing a platform within the journal must allow for reasoned debate, including contrary opinions. It is widely regarded within non-academic circles that some responses don’t get published due in large part to the contrary nature of the response. Would the editors of the journal be comfortable with constructive guidance for non-academic parties to respond to articles published?
This seems to be an unlikely proposition and will only serve to reinforce a lack of trust and transparency in the journal. Blogging is a good practice at writing in an accessible way, academic publications should be accessible too.
References:
[1] O’Connor R, Gartner C, Henriksen L, et al Blog fog? Using rapid response to advance science and promote debate Tobacco Control 2017;26:121 - http://tobaccocontrol.bmj.com/content/26/2/121
NOT PEER REVIEWED In his critique, Stan Glantz, PhD interprets and presents our study as doing something we explicitly warned readers it was not intended to do. He argues that “the model is based on a series of assumptions that are inconsistent with empirical evidence.” However, we explicitly state and he reiterates, that the model is not meant to be predictive. In our previous work (Addiction 2017: NTR 2017), we presented a framework to help better understand the effects of e-cigarettes and argued that we need better information before we rush to judgement about the actual impact of e-cigarette use.
Our goal in writing this paper was simply to show that e-cigarettes could help us reach a real smoking and tobacco control endgame. In the US, we have made great progress applying traditional policies, such as tax increases, smoke-free air laws and media campaigns. However, SimSmoke models for the US and other countries indicate that traditional tobacco control policies can only get us partially to the endgame. We think that we can achieve more. Many countries have complied fully or near fully with the FCTC and still have unacceptably high rates of smoking prevalence. The point of our paper is to show that strategies shifting smokers to e-cigarettes can play a role in achieving the endgame.
While Glantz recognizes that we provide a “pessimistic” as well as an “optimistic” scenario, he dwells on the optimistic scenario. Many in the public health community see...
Show MoreNOT PEER REVIEWED The data, interpretations and implications of the data modelling exercise conducted by Levy et al(1) should not go unchallenged. Regardless of the number and confidence of the opinions voiced, and the observation of lower levels of selected toxicants in e-cigarette users that are alluded to, there is great uncertainty about the extent to which harm might be reduced by the exclusive use of electronic cigarette rather than combustible tobacco. On this background, to describe one of two models, a 95% harm reduction as optimistic and the second, still a substantial, hopeful estimate of 60% reduction as pessimistic betrays a bias at the outset. The use of this “pessimistic” descriptor would to a casual reader imply that the truth lay, inevitably, somewhere between the two estimates.
Then there is the detail of the model. Firstly, the use of Holford projections(2) overestimated 2015 smoking rates in the US by at least 10% compared to CDC data(3) - underestimating the recent rate of decline in smoking prevalence in men and women between 2005 and 2015 by one-third. A higher base rate and slower rate of decline exaggerate tobacco-related harms in the status quo – naturally favouring each of the modelled scenarios. Starting with lower, more accurate estimates of current smoking and rates of decline would also increase the counterbalancing harms from initiation in non-smokers.
There are other obvious problems. In the status quo, 20% of boys and 14...
Show MoreNOT PEER REVIEWED
The paper, “Potential deaths averted in USA by replacing cigarettes with e-cigarettes” by David Levy et al. published in Tobacco Control on October 2, 2017, attracted a moderate amount of attention with its conclusion that “Compared with the Status Quo, replacement of cigarette by e-cigarette use over a 10-year period yields 6.6 million fewer premature deaths with 86.7 million fewer life years lost in the Optimistic Scenario. … Our projections show that a strategy of replacing cigarette smoking with vaping would yield substantial life year gains, …”
This is a pretty impressive result until you consider that the Optimistic Scenario is based on a series of assumptions that are of which are inconsistent with empirical evidence to date:
Cigarette smoking prevalence drops from 17% to 5% in 10 years (from 19.3% to 4.6% in men and from $14.1% to 4.6% in women between 2016 and 2026).
The existence of e-cigarettes does not, on average, depress quitting cigarettes.
There is no relapse from e-cigarette use to cigarette smoking.
No youth who initiate with e-cigarettes progress to cigarette use.
No dual use of cigarettes and e-cigarettes.
The evidence free claim that e-cigarettes are 5% as dangerous as cigarettes.
(These assumptions were not clearly stated in the main paper; we figured them out based on the appendix and by examining the Excel spreadsheet of the model that the authors s...
Show MoreNOT PEER REVIEWED It is disappointing that Robert Proctor’s advocacy for tobacco abolition, so clearly expressed in his magisterial ‘Golden Holocaust’ (2011) and, indeed, in Tobacco Control (1), appears to have been diluted to the same degree that he now seems in favour of diluting the concentration of nicotine in cigarettes. And this in spite of the various potential difficulties he points out in implementing the proposal to reduce nicotine in cigarettes to sub-addictive levels, not least that it could well result in decades-long delays before such cigarettes might eventually replace conventional ones.
I also have argued that the only realistic way to deal with the tobacco problem is through abolition (2). This is easier than it might seem, because, as Robert Proctor himself has said (1):
‘[S]moking is not a recreational drug; most smokers do not like the fact they smoke and wish they could quit.’
Is it not time for tobacco abolition, rather than ‘control’, to become part of the debate?
symonds@tokyobritishclinic.com
1. Proctor RN. Why ban the sale of cigarettes? The case for abolition. Tobacco Control 2013;22:i27-i30.
2. http://nicotinemonkey.com/?p=1702
NOT PEER REVIEWED The United Kingdom government is now recommending e-cigarettes as important tools in helping individuals to quit smoking (http://www.bbc.co.uk/news/health-41339790). It is widely acknowledged that, for many, smoking tobacco is detrimental to health. However, it is perhaps less widely appreciated that we have only a limited understanding of why smoking tobacco is bad for our health. Why, for example, might you be 40 times more likely of succumbing to lung cancer if you are a persistent heavy smoker? What is it in tobacco or in the act of smoking which is damaging to health? These are the enigmas of smoking tobacco which have remained largely unanswered. We are interested in the myriad ways that humans are exposed to aluminium in everyday life (http://pubs.rsc.org/en/content/articlepdf/2013/em/c3em00374d). Intriguingly one such way is smoking tobacco and the main reason for this is the presence of significant amounts of aluminium in tobacco (http://www.amjmed.com/article/S0002-9343(05)00710-2/pdf).When tobacco is smoked its components form an aerosol which is taken down into the lung before it is eventually expired. Anyone who has set up a ‘smoking machine’ to investigate this will no doubt have been impressed by the efficiency with which a surrogate lung fluid transforms th...
Show MoreNOT PEER REVIEWED The authors point out that rates of adolescent ever use of e-cigarettes are substantial and increasing, but rates of regular use remain low. Yet it is also worth placing these rates of adolescent use in the context of other groups of e-cigarette users. In particular, a recent systematic review colleagues and I published into sociodemographic differences in e-cigarette use gives further salience to Conner et al’s findings. Although the availability of UK evidence for our review was limited, some very clear patterns emerged internationally. For instance, within the 38 studies reporting ever use and the 22 reporting current use, these outcomes were particularly prevalent in older adolescents and younger adults (versus younger children and older adults respectively). This therefore lends further weight to Conner et al’s recommendations around regulating the marketing and sale of e-cigarettes to minors in countries which lack sufficient legislation in this area. Both papers also show the importance of future studies stratifying findings by sociodemographic variables such as age to ensure more subgroup analyses are possible.
1) Hartwell G, Thomas S, Egan M, et al E-cigarettes and equity: a systematic review of differences in awareness and use between sociodemographic groups Tobacco Control Published Online First: 21 December 2016. doi: 10.1136/tobaccocontrol-2016-053222
NOT PEER REVIEWED In the second column of this article, the author describes findings from a survey in Japan (Tabuchi et al, 2016, reference 15). However, there is a misinterpretation of Tabuchi et al’s table 2 which leads to wrong percentages for having tried heat not burn products in Caputi’s article. The figures 8.4% and 7.8% are not the percentages who had ever tried these products in the population but instead percentages out of those respondents who had ever tried an e-cigarette or a heat not burn product.
The actual figures for the population are therefore about 0.6% for iQOS (8.4% of 6.6%) and 0.5% for Ploom (7.8% of 6.6%).
Further information on the ever use of different products by age, gender and smoking status (about 1% of 15-19 year olds had tried each of the two heat not burn products), is found in supplementary table 3 of Tabuchi et al.
NOT PEER REVIEWED
Without citing any sources or providing any related analysis or explanation, this paper makes several sloppy and misleading statements about the scope and impact of federal preemption relating to state and local restrictions of flavored tobacco products.
We know from the preemption provisions in the federal Tobacco Control Act that state and local governments may not regulate the ingredients or characteristics of a tobacco product if the state or local regulation is “different from, or in addition to” an FDA tobacco product standard. [Sec. 916(a)(2)] But we do not yet know how FDA or the courts will interpret or apply that “different from, or in addition to” phrase. For example, it could mean that state and local governments are free to prohibit or limit the use of certain flavorings in certain types of tobacco products unless or until FDA prohibits or limits flavorings for those same types of tobacco products. To assert and publish a more restrictive interpretation of federal preemption with no qualification or clarification is not only misleading but promotes a more restrictive interpretation than necessary or desirable.
The paper also fails to note that the courts have ruled that the Tobacco Control Act’s preemption provisions leave state and local governments free to restrict the sale of flavored tobacco products within their boundaries. [See, e.g., U.S. Smokeless Tobacco v. City of New York, 708 F.3d 428 (2nd Cir., 2013).] The...
Show MoreNOT PEER REVIEWED
Show MoreBackground
E-cigarette is a delusive name for what the product actually is; an electronic vaporization device. Basic parts of an e-cigarette include: a tank containing the liquid to be vaporized, some sort of heating element, a battery to power the device, and a mouth piece. The liquid, often referred to as e-liquid, usually contains a base (for production of thick vapor) and flavor. E-liquid may or may not contain nicotine. The heating element converts the e-liquid into aerosol, which is then inhaled by the user. While many models resemble a conventional cigarette, others look nothing alike. Colloquially referred to vaporizers, such models have become more common in the recent years.
In the western world e cigarettes proposed as a tobacco control strategy for possible nicotine reduction and stressed on policy appraisals of harm and safety on regulation of other ingredients of the products. The related conflicts and controversies of e cigarettes as a contemporary tobacco control are discussed (1).
E-cigarettes began to appear in the Indian market around 2010. Today, E-cigarettes pose a complex challenge for the tobacco stricken country. According to Global Adult Tobacco Survey (GATS) 2010, 34.6% of the Indian adults were current tobacco users with 14% of adults indulging in current tobacco smoking (5.7% current cigarette smokers, 9.2% current bidi smokers) (2). Global Youth Tobacco Survey (GYTS) 2009 estimated current toba...
NOT PEER REVIEWED
The editors of this journal, Tobacco Control, and specifically the authors of the editorial “Blog fog? Using rapid response to advance science and promote debate” [1] highlight the need - or requirement, depending on the viewpoint - of utilising a specified platform to debate the finer points of an article.
From an academic standpoint, individuals that have an interest in a specific field of study - such as Tobacco Control - will see, and respond to, such articles in the appropriate manner. However, one of the pitfalls prevalent in any rapid response platform, and this isn’t limited to the journal Tobacco Control, is the necessity of the journal’s guidelines to adhere to a specific writing format. This does have some advantages in keeping the debate over an article related exclusively to the article. However, there are some respondents that prefer to write an unabridged version of a critique lest the comment not pass the rapid response system for publication.
There are several advantages to publishing a critique of an article outside the rapid response system [2] that allows for a broader audience to read and respond to both the article content and the critique.
Personal blogs often reflect the style of the author, and also allow for greater freedom of expression including the use of imagery to illustrate vital points that many readers find both enjoyable and informative.
Providing a platform within the journal must allo...
Show MorePages