Sep­a­rat­ing fact from vape fic­tion

The tobacco in­dus­try says va­p­ing is 95% safer than smok­ing. The truth may be a lit­tle less clear

Mail & Guardian - - Health - Joan van Dyk

The elec­tronic cig­a­rette and tobacco in­dus­tries may be us­ing dodgy, old data about the safety of e-cig­a­rettes in pub­lic pleas for kinder reg­u­la­tion. E-cig­a­rettes are de­vices that al­low users to in­hale so­lu­tions that usu­ally con­tain nico­tine in a colour­less liq­uid such as propy­lene gly­col — an ad­di­tive typ­i­cally found in food and cos­met­ics, the United States Cen­tres for Dis­ease Con­trol ex­plain. This so­lu­tion is heated in the hand-held ma­chines and pro­duces a vapour, which is why smok­ing e-cig­a­rettes is some­times called “va­p­ing”.

The na­tional health depart­ment’s new tobacco con­trol Bill pro­poses stiff reg­u­la­tion for e-cig­a­rettes and their tra­di­tional coun­ter­parts, in­clud­ing ad­ver­tis­ing re­stric­tions, plain packaging and pub­lic smok­ing bans.

Since the Bill’s July re­lease, the Vapour Prod­ucts As­so­ci­a­tion (VPA), which rep­re­sents e-cig­a­rette man­u­fac­tur­ers and re­tail­ers, has pub­licly claimed that e-cig­a­rettes are 95% safer than con­ven­tional cig­a­rettes and may even help tra­di­tional smok­ers to quit. Strict reg­u­la­tion of va­p­ing, it ar­gues, risks rob­bing cit­i­zens of the op­por­tu­nity to ac­cess a safer al­ter­na­tive to tobacco cig­a­rettes or a smok­ing ces­sa­tion tool. These calls have been backed by the in­dus­try-funded Tobacco In­sti­tute of South­ern Africa.

But the re­search be­hind the claims is mixed, and some warn that it’s too early to claim that va­p­ing is safer than smok­ing or that it could help smok­ers to kick the habit.

For decades, pub­lic health ex­perts and the tobacco lobby have faced off over the in­dus­try’s use of bad sci­ence to sup­port claims that their prod­ucts were safer than they were. For in­stance, a 2001 re­view of leaked in­dus­try doc­u­ments pub­lished in the Amer­i­can Jour­nal of Pub­lic Health showed how tobacco com­pa­nies set up a non-profit or­gan­i­sa­tion in 1988 to fund sci­en­tific re­search that would con­tra­dict the link be­tween sec­ond­hand smoke and can­cer.

But now, a third group cham­pi­oning “harm re­duc­tion” has emerged from some­where in be­tween. Harm re­duc­tion refers to ways that peo­ple try to mit­i­gate the dan­gers or harms as­so­ci­ated with a par­tic­u­lar act. For in­stance, giv­ing peo­ple who in­ject drugs ac­cess to clean nee­dles is a harm re­duc­tion strat­egy be­cause it re­duces the HIV and hep­ati­tis C risk as­so­ci­ated with drug use given the pos­si­bil­ity of shar­ing nee­dles.

Now some sci­en­tists are ar­gu­ing that, just as clean nee­dles help drug users to avoid in­fec­tions, va­p­ing can help cig­a­rette smok­ers to steer clear of health risks such as can­cer by re­duc­ing how much they smoke.

Last week, more than 70 nico­tine spe­cial­ists ap­pealed to the World Health Or­gan­i­sa­tion (WHO) to in­clude va­p­ing as a rec­om­mended harm re­duc­tion method in the WHO’s tobacco con­trol guide­lines.

But re­search into va­p­ing’s harm re­duc­tion po­ten­tial and safety is mixed and con­tro­ver­sial.

In 2015, the Bri­tish gov­ern­ment agency Pub­lic Health Eng­land (PHE) pub­lished a con­tro­ver­sial re­view of al­most 100 stud­ies and re­ports that claimed e-cig­a­rettes were 95% safer than tobacco cig­a­rettes. The fig­ure came from only one pa­per in which an ex­pert panel rated 12 nico­tine prod­ucts in­clud­ing pipes, cigars and nico­tine patches over two days based on how harm­ful they were. But the com­mit­tee also ad­mit­ted that it lacked hard ev­i­dence about most prod­ucts un­der its re­view — a fact that an ed­i­to­rial of the ed­i­tors at The Lancet med­i­cal jour­nal later pointed out the PHE’s study failed to men­tion.

The pub­li­ca­tion also raised ques­tions about pos­si­ble con­flicts of in­ter­est be­cause some au­thors of the stud­ies cited in PHE’s work had links to the tobacco in­dus­try.

In a writ­ten re­sponse to The Lancet, the lead re­searcher of the dis­puted pa­per, Im­pe­rial Col­lege Lon­don’s Pro­fes­sor David Nutt, hit back by ar­gu­ing that some­one with bias “could not have had any mean­ing­ful in­flu­ence”.

Nutt’s co-au­thor was Kgosi Let­lape, the former South African Med­i­cal As­so­ci­a­tion chair­per­son and cur­rent pres­i­dent of the Health Pro­fes­sions Coun­cil of South Africa. Let­lape told Bhek­i­sisa that ar­gu­ments about con­flicts of in­ter­est are ir­rel­e­vant. In­stead, he says, de­trac­tors should fo­cus on repli­cat­ing the panel’s re­sults.

“You re­fute sci­ence by com­ing out with your own re­sults. None of this has been done. You don’t just ex­press an opin­ion from thin air.”

Let­lape co­founded the African Harm Re­duc­tion Al­liance with Delon Hu­man. EuroSwiss Health, Hu­man’s health con­sult­ing com­pany, partly funded Nutt’s 2015 study.

Hu­man ad­mits to hav­ing links to the tobacco in­dus­try.

“The re­al­ity is my com­pany has done harm re­duc­tion work for the al­co­hol, food and tobacco in­dus­tries. Our aim is to help elim­i­nate smok­ing of com­bustibles [con­ven­tional cig­a­rettes] — that re­futes any ar­gu­ment that this is an in­dus­try mouth­piece.”

But most tobacco com­pa­nies also sell e-cig­a­rettes, South African Med­i­cal Re­search Coun­cil spe­cial­ist sci­en­tist Cather­ine Egbe says. Egbe works with the coun­cil’s Al­co­hol, Tobacco and Other Drug Re­search Unit.

She be­lieves the re­view is not only a “dis­ser­vice to pub­lic health” but is now also out­dated af­ter sev­eral stud­ies — in­clud­ing 2015 re­search in the Jour­nal of the Amer­i­can Med­i­cal As­so­ci­a­tion — showed that e-cig­a­rettes make young peo­ple more likely to use tobacco cig­a­rettes too.

Even when sci­en­tists used the “op­ti­mistic” as­sump­tion that e-cig­a­rettes were 95% less harm­ful than tobacco cig­a­rettes, a 2018 mod­el­ling study in the jour­nal PlosOne found that va­p­ing was over­all more harm­ful than ben­e­fi­cial for pop­u­la­tion health. In fact, they found e-cig­a­rette use in 2014 would lead to about 1.6-mil­lion years of life lost in the US alone.

Egbe ex­plains: “If the in­dus­try is so con­cerned about their cus­tomers, they should re­duce the amount of nico­tine in cig­a­rettes.”

To­day, the United King­dom’s health depart­ment ac­tively pro­motes e-cig­a­rettes as a way to stop smok­ing. PHE also con­tin­ues to de­fend its sta­tis­tics in an ev­i­dence up­date re­leased in 2018.

South Africa’s tobacco and va­p­ing lob­bies have lauded the UK’s reg­u­la­tions for e-cig­a­rettes as among the most pro­gres­sive in the world.

Mean­while, VPA has launched a so­cial me­dia cam­paign called Save the Vape based on this in­for­ma­tion and has gar­nered over 10000 pub­lic com­ments and anec­dotes — both pos­i­tive and neg­a­tive. The inputs, along with a com­pi­la­tion of the “lat­est sci­en­tific re­search on va­p­ing”, were sent to the health depart­ment in re­sponse to its new Bill, VPA chief ex­ec­u­tive Zodwa Velle­man says.

“Our mes­sage is that you should be able to choose some­thing safer. We’re not say­ing e-cig­a­rettes are a mag­i­cal prod­uct, but it is an al­ter­na­tive.”

She also warns that the Bill may not only re­strict ac­cess to va­p­ing but also spawn un­safe coun­ter­feits with its de­mand for plain or un­branded packaging.

Al­though South Africa will be­come the first coun­try to im­pose plain packaging for e-cig­a­rettes, coun­tries such as Canada, France and Aus­tralia have en­forced this type of packaging for tobacco cig­a­rettes. A year af­ter Aus­tralia im­ple­mented the rule, a 2014 study pub­lished in the Bri­tish Med­i­cal Jour­nal found no ev­i­dence that the packaging was linked to an in­crease in il­le­gal prod­ucts.

Both VPA and the African Harm Re­duc­tion Al­liance say they re­main con­fi­dent in PHE’s con­clu­sion that e-cig­a­rettes are at least 20 times safer than tra­di­tional cig­a­rettes. Tisa did not re­spond to Bhek­i­sisa’s ques­tions about al­le­ga­tions that the data it bases its ar­gu­ments on, is old. Chief ex­ec­u­tive Fran­cois van der Merwe did how­ever point out that “e-cig­a­rettes are a mi­nus­cule por­tion of my mem­bers’ busi­ness”. In an in­ter­view with Bhek­i­sisa in Septem­ber, he re­it­er­ated his sup­port for Nutt’s 95% fig­ure and the role elec­tronic cig­a­rettes could play in smok­ing ces­sa­tion.

Richard van Zyl-Smit is the head of the Univer­sity of Cape Town’s Lung Clin­i­cal Re­search Unit. He says that, al­though the method­ol­ogy of Nutt’s was rea­son­ably sound, more con­fir­ma­tory re­search is needed be­fore it can be used to back pol­icy change.

Van Zyl-Smit doesn’t doubt that va­p­ing is safer than smok­ing, al­though he warns that the dif­fer­ence in safety lev­els may still not be enough to war­rant sep­a­rate reg­u­la­tion.

Tobacco cig­a­rettes kill half of the peo­ple who use them, the WHO es­ti­mates.

“If e-cig­a­rettes killed 40% of the peo­ple who used them, they would al­ready be safer,” he says. “E-cig­a­rettes need to be no more dan­ger­ous than fresh air to be a con­sumer prod­uct for non-smok­ers. Oth­er­wise, they just re­main as an ex­pen­sive way to main­tain an ad­dic­tion.”

Mean­while, the UK’s lax va­p­ing laws and its po­si­tion on e-cig­a­rettes as a harm re­duc­tion tool may not be go­ing as well as the tobacco in­dus­try had hoped.

When Bri­tish sci­en­tists an­a­lysed pop­u­la­tion sur­veys rang­ing from 2006 to 2016, they found no ev­i­dence that e-cig­a­rettes or nico­tine re­place­ment ther­apy medicines such as patches or gum had an im­pact on how much peo­ple smoke. The re­search was pub­lished in the Bri­tish Med­i­cal Jour­nal this year.

In South Africa, the newly pro­posed Bill will put the coun­try in line with WHO rec­om­men­da­tions for tobacco and nico­tine con­trol. But the Univer­sity of Cape Town’s eco­nom­ics of tobacco con­trol project re­searcher Zunda Chisa says it also re­flects the avail­able ev­i­dence on va­p­ing’s harms and ben­e­fits.

Strong op­po­si­tion to reg­u­la­tion is noth­ing new, says Van Zyl-Smit.

“We’ve seen this show be­fore with tobacco — now with more money and more per­son­al­i­ties … [but] more is at stake if we al­low his­tory to re­peat it­self.”

Smoke­screen: E-cig­a­rettes are be­com­ing more pop­u­lar but are they safe?

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