E-cigarettes: alternatives to smoking or transition to a nicotine-free life? Are we missing the point?

Vaping is here to stay, as mentioned David Hammond (1). But what should it be? Clearly, as as a harm reduction strategy, a Anything But Cigarettes (ABC), it brings a safer alternative to combustible tobacco alternatives.

The latest data, regarding the JUUL system, from the ADJUUST trial looking at 55,000 users, pointed to 51% of users being able to totally move away from cigarettes (cigs) after 12 months (2). It also was shown, in those having challenges to stop smoking (3) to be a more effective strategy than existing options such as nicotine replacement therapy. The extent of the data on its role as a smoking alternative to cigs, as in the Cochrane review (4), is building up: their findings support that electronic cigarettes containing nicotine could increase the number of people who stop smoking compared to nicotine replacement therapy (NRT) – such as chewing gum and patches – and compared to no treatment, or electronic cigarettes without nicotine.?The conclusion is that such superiority is of moderate certainty in comparing e-cigs to NRT.

While many authors and activists are using the absence of long-term safety as an argument against the use of e-cigs, in the concept of the continuum of risk we should look at what we are comparing them to. Cigs kill half a million USA smokers every year (5), costing our society tens of billions a year to public health. This fact cannot be denied, and even Big Tobacco has agreed with this terrible reality as they settled with states through the Master Settlement (6) to cover the negative impacts of cigs on lives and public health.

Do we have the long-term safety data on vaping to define them as safe? Not at all, but trying to claim these as safe is beyond the point. Ultimately, beyond a smoke-free society, our objective should also be a nicotine-free one. Therefore, it is short-term safety that we should consider as a valid endpoint for e-cigs. On that aspect, the data is convincing, enough that Public Health England (PHE) has incorporated e-cigs in their smoking cessation strategy. By reducing exposure to toxic agents by 95% compared to cigs (7), e-cigs have proved a much safer nicotine delivery alternative.

In reaching our objective of a smoke-free society, an ABC (anything but cigarettes) strategy should be our short-term target. And data clearly show that doing so leads to reductions of toxicities after 6 months of usage to levels comparable to those not using heated tobacco products (8).

With the advent of e-cigs, we have seen an acceleration of cigs smoking, to levels never seen before (9). In countries where e-cigs are available, fewer smokers than ever are seen, but in adults and also the younger population (10). Indeed, in the USA, cigarettes are at their lowest usage ever and the trend to reduction has accelerated with the advent of e-cigs. 1.6% of teens (middle school) and 4.6% in high school used cigs in the last 30 days. As for e-cigs, demonstration of a reduction in curiosity, from 2019 to 2020, we saw a marked reduction in usage: middle school students (4.7%) reported in 2020 that they used e-cigarettes in the past 30 days—a decrease from 10.5% in 2019 while high school students 19.6% reported in 2020 that they used electronic cigarettes in the past 30 days—a decrease from 27.5% in 2019. The situation in Canada is similar with about a 5% reduction in vaping in younger Canadians (1). Strategies like the one seen put forth by PHE (11), while innovative in many ways, are perceived as the best ones to help smokers move away from tobacco first, and nicotine later.

The WHO has taken a more drastic approach where it favours the QUIT or DIE approach without supporting harm reduction strategies that would incorporate e-cigs. Some activist groups like the Bloomberg Philanthropies have taken significant anti-vaping actions throughout the world, lobbying to such extent in countries like the Phillippines that it had violated USA laws, and created a backlash in that country (12). These lobbying actions are only making smoking more attractive by downplaying alternative nicotine products. Basically, Bloomberg`s strategies are Big Tobacco like in the sense that they will favour cigs

Many actions in trying to limit access of these products to teens have led to some strategies that may put adult users at risk of moving back to cigs. Eliminating flavours, reduction of nicotine levels, increased taxes and some form of prohibition / ban have been put forth with dismal results. As an example, in San Francisco (13), such actions led to increases in smoking in both adults and younger users. The ban in Massachusetts (14) saw no changes in usage of vaping products as alternative sources were found to bypass such lack of access. The danger of prohibition can also lead to illicit / black market access to products of questionable quality. The situation with EVALI (15), this vaping disease that killed too many individuals, came as a result of vaping THC products that were laced with vitamin E acetate, a product never found in legal vaping e-liquids.

Is it time to rethink how we should look at e-cigs? Very likely, yes. But this reflection should go one step further. While an ABC approach is warranted, we should look at e-cigs as more than only a replacement product for cigarettes. We should see them as a transition product away from nicotine addiction and therefore a transient state. In doing so, the long-term safety issues do become less of a concern, if one it is.

Access to higher levels of nicotine should be under strict surveillance. While the prescription model (16) of e-cigs suggested in Australia presents issues, to see doctors involved in prescribing higher nicotine levels could be an option. This would an optimal model if we could train doctors on better smoking cessation strategies where misinformation remains an issue as well as some negative biais towards smokers making them the responsible party of such addiction (17), but are more open-minded regarding other addictions like alcohol and opioids. The same misinformation issue is also seen in pharmacists that could play an important in smoking cessation if properly equipped to do so (18).

Novel approaches and strategies from the e-cig industry should also be put in place. Could we move away from starter kits to some form of a longer-term strategy of end of smoking kits. Is the bundling that some manufacturers of tobacco products also selling vaping products a hindrance towards innovative and better products? Indeed, at the level of some national account, here in Canada, one player offers a 5% rebate in protecting their shelf space and blocking novel entries.

Smaller players are developing novel new vaping devices that could help waining off nicotine: indeed Ditch Labs and Evapro have systems with dual chambers that could, through an AI application, deliver either nicotine or placebo in helping users to totally move away from their nicotine addiction. But these buddling strategies put forth by one player could block entry of these products from smaller companies without the means to by themselves in the market.

References

1)https://www.cbc.ca/radio/whitecoat/how-the-pandemic-impacted-vaping-and-smoking-rates-and-why-it-showed-vaping-is-here-to-stay-1.6068729

2)https://ajhb.org/wp-content/uploads/2021/04/AJHB_JUUL_Special_Issue.pdf

3)https://pubmed.ncbi.nlm.nih.gov/34187081/

4)https://www.cochrane.org/news/updated-cochrane-review-shows-electronic-cigarettes-can-help-people-quit-smoking

5)https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm

6)https://www.publichealthlawcenter.org/topics/commercial-tobacco-control/commercial-tobacco-control-litigation/master-settlement-agreement

7)https://pubmed.ncbi.nlm.nih.gov/34205612/

8)https://pubmed.ncbi.nlm.nih.gov/34196886/

9)https://www.euro.who.int/en/health-topics/disease-prevention/tobacco/news/news/2019/12/tobacco-use-declining-globally-but-set-to-miss-targets

10)https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm

11)https://publichealthmatters.blog.gov.uk/2020/03/05/8-things-to-know-about-e-cigarettes/

12)https://www.vapingpost.com/2021/02/13/bloomberg-funding-to-philippines-fda-may-have-violated-us-laws/

13)https://jamanetwork.com/journals/jamapediatrics/fullarticle/2780248

14)https://pubmed.ncbi.nlm.nih.gov/33952270/

15)https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease/healthcare-providers/index.html

16)https://www.tga.gov.au/media-release/tga-confirms-nicotine-e-cigarette-access-prescription-only

17)https://pubmed.ncbi.nlm.nih.gov/33978533/

18)https://pubmed.ncbi.nlm.nih.gov/34188579/

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