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Limited Evidence To Support Vape As Harm Reduction Tool

Dr. Mohd Afiq Mohd Nor, President of IKRAM Health Malaysia, argues that the use of vape for tobacco harm reduction lacks evidence and is tainted by the tobacco industry’s influence.

BANGI, April 26 – There is a lack of compelling evidence to support the use of e-cigarettes and vapes as a viable harm reduction strategy, according to Dr. Mohd Afiq Mohd Nor, President of IKRAM Health Malaysia.

Dr. Mohd Afiq, who is also a clinical specialist and emergency physician at the University Malaya Medical Centre (UMMC), argued that the available data on the long-term health effects of e-cigarettes is limited and that new data demonstrates that e-cigarettes and heated tobacco products are more harmful than they initially appear to be.

“Definitely, there is a lot of evidence out there that speaks to the benefits of tobacco harm reduction. But if we look back and go through all the information that is available, all of the current evidence will conclude the limitations of the data in terms of long-term health effects, efficacy, and safety.

“We are only now starting to see data emerge from 2015, specifically from Indonesia, and even earlier from overseas, perhaps around 2010. Even data that has been hyped, such as Public Health England’s (PHE) claim that e-cigarettes are 95 percent less harmful, has been overshadowed by new findings from subsequent studies,” said Dr. Mohd Afiq during a roundtable discussion on the Control of Smoking Product for Public Health Bill 2023 and Implementation of the Generation End Game (GEG) on April 17.

In 2015, PHE published an independent evidence review that found e-cigarettes to be significantly less harmful to health than tobacco and have the potential to aid smokers in quitting. 

The review’s key findings in 2015 showed that e-cigarettes are estimated to be about 95 percent less harmful than smoking, with no evidence suggesting that e-cigarettes are acting as a route to smoking for children and non-smokers. 

However, a 2022 update of the report concluded that while vaping in the short and medium term poses only a fraction of the risks of smoking, vaping is not risk-free. Currently, there is still limited evidence on the longer-term effects of vaping, and studies with more consistent methodologies to assess such impacts are necessary, the report stated.

On nicotine, the report indicated that vaping carries a lower risk and severity of nicotine dependency compared to smoking, but this risk varies depending on the product’s characteristics, such as device type and nicotine concentration in e-liquids.

As for cancer, despite the challenges faced, the study concluded that cell and animal studies support the human study that vaping may trigger alterations in gene expression, but to a lower extent than that observed following exposure to tobacco smoke. 

While England has released vape kits to encourage more smokers to switch to cigarettes for cessation purposes, Dr. Mohd Afiq expressed concerns about the credibility of harm reduction studies.

Dr. Mohd Afiq referenced the 2015 Systematic Review of Health Effects of Electronic Cigarettes by the World Health Organization (WHO) and highlighted that 34 percent of the studies in the report have a conflict of interest. 

The report’s disclosure reveals that most studies with conflicts of interest were funded or supported by e-cigarette manufacturers. Although the WHO did not expect this conflict of interest to significantly affect the study, it did note that more studies with conflicts of interest primarily investigated the contents of e-cigarette fluid.

Dr. Mohd Afiq also raised concerns about the reliability of some of the reports, pointing out that the findings in 76 studies were inconsistent and often contradictory.

Additionally, he identified serious methodological issues with the studies and noted that no long-term follow-up was conducted.

“This is one of the most recent studies, which was reported to the WHO in 2015. There were 34 studies investigating e-liquid, 20 studies on adverse events, 21 human experimental studies, and one animal experimental study.

“However, in the majority of the studies, there were many methodological problems, small sample sizes, inconsistencies, and contradictions. Additionally, there was no long-term follow-up, so we don’t know the long-term effects.

“There is a substantial number of studies with a conflict of interest from tobacco sponsors. The report ultimately concludes that e-cigarettes can hardly be considered harmless, and they did not say it is safe. In fact, they could not say it is safe,” said Dr Mohd Afiq.

Dr. Mohd Afiq also reinforced the possibility of adverse long-term health effects by sharing the results of the overview titled “An Updated Overview of E-Cigarette Impact on Human Health.” The objective of the review was to summarise the primary conclusions regarding the potential long-term impacts of e-cigarette use on human health.

“This is a study published in 2021 that found several compounds that were not present in the e-liquid. When heated, these compounds formed and carried a risk of carcinogenic effects that can increase the risk of cancer.

“All of these factors, in the end, can cause inflammation, respiratory complications, and an increased risk of cardiovascular problems,” Dr Mohd Afiq added.

The review revealed that heating e-liquids creates new chemical compounds that were not present in the liquid before heating, indicating that the heating process produces unknown compounds with potential consequences.

The analysis identified three carbonyl compounds, namely formaldehyde, acetaldehyde, and acrolein, with known high toxicity. Additionally, acetamide, a potential human carcinogen, was found in aerosols.

Dr. Mohd Afiq used a table comparing the safety of e-cigarettes and traditional cigarettes from the study to demonstrate that although the effects of e-cigarettes are less severe than those of traditional cigarettes, they can still have negative health impacts.

“In this table, they compare e-cigarettes and conventional cigarettes. If you look at the plus and two plus, e-cigarettes have one plus and conventional cigarettes have two plus. The report says ‘safer option’, but there is still a plus there. The negatives aren’t a lot, so e-cigarettes are a safer option, but not completely safe. There are still dangers.

“In the end, the report says that all the effects from e-cigarettes are lower than conventional cigarettes, which suggests that e-cigarette consumption could be a safer option. But at the same time, it is not clear, so there are still dangers,” said Dr Mohd Afiq.

The review concluded that while e-cigarette consumption appears to be less toxic than tobacco smoking, it does not guarantee that they are entirely devoid of hazardous effects. 

As a smoking cessation tool, the review discovered that the e-cigarette group had twice the abstinence rate compared to the nicotine replacement therapy group. 

However, it should be noted that the incidence of throat and mouth irritation was higher in the e-cigarette group than in the nicotine replacement therapy group. 

On the other hand, adherence to treatment after one year of abstinence was 80 per cent in the e-cigarette group, while it was only 9 per cent in the nicotine replacement therapy group.

Vape As A Gateway To Smoking

Dr Mohd Afiq pointed to several studies that suggest e-cigarette use can lead to an increased risk of combustible tobacco cigarette smoking. 

A 2018 review by the United States National Academies of Sciences, Engineering, and Medicine found “substantial evidence” of a positive transition from never to ever-combustible tobacco cigarette smoking among youth and young adults who use e-cigarettes. 

The Current Opinion in Pediatrics journal published a 2020 article stating that teens who use e-cigarettes are more likely to use combusted tobacco and that these products are heavily marketed to adolescents with an emphasis on discreet use and exposure to high levels of nicotine and other chemicals. 

The JAMA Pediatrics journal also found a greater risk for subsequent cigarette smoking initiation and past 30-day cigarette smoking among e-cigarette users in a review titled “Association Between Initial Use of e-Cigarettes and Subsequent Cigarette Smoking Among Adolescents and Young Adults”

Dr. Mohd Afiq concluded that the evidence suggests that e-cigarette use can increase the risk of transitioning into regular cigarettes.

“There is plenty of evidence that suggests that e-cigarettes can become a gateway to smoking. As the prevalence of smokers decreases among teenagers, the prevalence of e-cigarette use among teenagers increases.”

Dr. Mohd Afiq argued that while there has been a decrease in smoking rates, it cannot be solely attributed to e-cigarettes. He believes that the tightening of smoking laws could also be a contributing factor to this decline.

Furthermore, there is substantial evidence that e-cigarettes serve as a gateway to smoking. 

He also pointed out that the products’ appeal to youth does not support the harm reduction argument.

“When we look at the products being sold, we should ask ourselves: are they promoting harm reduction, targeting existing smokers, or encouraging smokers to switch to vaping?

“Unfortunately, some companies are promoting their products to children through exciting flavours and other marketing materials. This ultimately increases children’s exposure to e-cigarettes,” Dr Mohd Afiq said.

Additionally, Dr. Mohd Afiq also brings up the issue of dual-use — where people are both smoking and vaping. Thus, far from it being used as a method of cessation, the device becomes yet another entree. 

“Furthermore, when considering the use of e-cigarettes in addition to traditional cigarettes, users are exposing themselves to even more nicotine and chemicals found in e-liquids.

“In fact, it is estimated that 40.8 per cent of e-cigarette users in the US are also traditional cigarette smokers, making them dual users,” Dr Mohd Afiq said.

According to a study titled “Respiratory Symptom Incidence Among People Using Electronic Cigarettes, Combustible Tobacco, or Both” published in the American Journal of Respiratory and Critical Care Medicine, dual users of electronic nicotine delivery systems and combustible tobacco have significantly higher odds of experiencing respiratory symptoms compared to exclusive users of either.

This highlights the severity of health complications that can arise from dual use.

Dr Mohd Afiq believes that switching to e-cigarettes alone is insufficient, since nicotine dependence or addiction caused by both smoking and vaping has severe known consequences.

“The effects of smoking and vaping are well-known, but the effects of nicotine are not normal. They have significant impacts on cardiovascular health, development, and mental health, as well as causing withdrawal effects. 

“It is not enough to simply switch from smoking to e-cigarettes. Even if someone switches, they are still fully dependent on nicotine,” explained Dr Mohd Afiq.

Dr Mohd Afiq referenced a 2022 US-Canadian study titled “Indicators of Dependence and Efforts to Quit Vaping and Smoking Among Youth in Canada, England, and the US” to support his claim. 

The study revealed that the prevalence of dependence symptoms among young e-cigarette users increased between 2017 and 2019, particularly in Canada and the US compared to England.

Although the prevalence of dependence symptoms was lower for e-cigarettes than smoking, the gap has narrowed over time. 

The study also found that symptoms of dependence, including frequent strong urges to vape, feelings of addiction, and unsuccessful quit attempts, are increasingly prevalent among young e-cigarette users. 

The use of high nicotine concentration salt-based products was identified as a possible explanation for the relatively larger increase in dependence symptoms in Canada and the US.

Tobacco Industry’s Influence On The Harm Reduction Argument

Dr Mohd Afiq pointed out that the tobacco industry has a significant influence on the harm reduction argument, as it is primarily based on shifting from one form of smoking to another, rather than entirely giving up nicotine products.

“Behind the harm reduction campaign, there are influences from the tobacco industry that play a big role because in the end, it still encourages switching from smoking to another smoking product, instead of completely stopping the use of products that endanger oneself.” 

Dr Mohd Afiq noted that the arguments for vaping as a harm reduction tool are not new, but rather a resurfacing of past approaches. 

He referred to a research paper titled “The Origins of Tobacco Harm Reduction in the UK: The ‘Product Modification Programme’ (1972–1991),” which highlighted how the British government, in collaboration with the tobacco industry, sought to investigate safer smoking through a product modification program between 1972 and 1991. 

The Independent Scientific Committee on Smoking and Health (ISCSH) provided advice to the government, and they came up with four premises for safer smoking, including reducing toxicity and collaborating with the tobacco industry. 

However, these premises often undermined tobacco control, and current tobacco harm reduction policies and premises supported by the British government and leading public health organisations may reflect the historical influence of the tobacco industry.

“If we look at history, it’s the same. History is coming back. As I have said before, they promote low-tar, low-nicotine cigarettes, filters, but all of that does not work or gives a different effect. They are still addicted to nicotine, but there is no reduction in cigarette use. 

“It’s coming back with the same theme, but another approach, another strategy to continue addiction among users and attract new ones. So, the real motive is profit.”

Dr Mohd Afiq said that despite the global decline in cigarette sales, the tobacco industry is investing in and developing new nicotine and tobacco products to prevent smokers from quitting altogether and to attract new users.

He maintained that cigarettes will remain the industry’s primary product for the foreseeable future.

Source: Code Blue

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