Chronic Conditions Require Ongoing Treatment

Some people have suggested that the way to help more smokers quit is to offer treatment for a longer period--say from 6 to 8 months, as opposed to 6 to 8 weeks.  Will that work?

What happens when you begin treating someone for hypothyroidism and then have them stop taking levothyroxine? Their symptoms return with a vengeance.

But what if you slowly wean them off levothyroxine? Their symptoms return, bur at a slower pace. Then, when treatment stops altogether, the symptoms return with a vengeance.  Hypothyroidism is a chronic condition that requires ongoing treatment.

Many people who smoke are self-medicating chronic underlying conditions. The scientific literature shows that people with chronic depression, attention deficits, memory problems, and those who are being treated for schizophrenia have much lower rates of cessation than the rest of the population. Let’s think for a moment about why that is true.

The scientific literature also shows that nicotine helps to improve mood, concentration, and attention and also helps to alleviate side-effects of anti-psychotic medications. It stands to reason that those who have a chronic condition that is helped by nicotine will be impaired when they give up nicotine.

It doesn’t matter whether the nicotine-dependent person tapers down for 6 to 8 weeks or for 6 to 8 months. When nicotine intake stops, relapse follows. Sometimes relapse begins even earlier, when the process of tapering down triggers relapse because symptoms are not being controlled adequately.

The Institute of Medicine’s 2001 report, “Clearing the Smoke,” stated, “Indeed, it has been predicted that even with the most intensive application of the most effective programs for abstinence and cessation, at least 10 percent to 15 percent of adults in the United States would continue to smoke.” That's not 10 to 15 percent of smokers--that's 10 to 15 percent of the entire adult population, representing between 33 and 45 million people.

The 2007 report by the Tobacco Advisory Group of the Royal College of Physicians, “Harm reduction in nicotine addiction: Helping people who can't quit” pointed out that some people will never be able to give up all use of nicotine. The authors went on to say, “If nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved.”

Pharmaceutical nicotine products are a start, but they are often ineffective as a cigarette substitute. The FDA has purposely kept the nicotine dosage low in these products, in the belief that this will prevent new addictions. Millions of people have escaped from smoking by switching to a smoke-free alternative such as low-nitrosamine snus (a type of moist snuff), dissolvable tobacco products, or smoke-free electronic ‘cigarettes’.

“Clearing the Smoke,” had another important message: “… the best way for those who already smoke to minimize their health risks is to quit promptly.” This makes sense because the faster you can help smokers to stop inhaling smoke, the less irreversible damage will be done to their bodies. Encouraging inveterate smokers to switch to a much less hazardous alternative would be a life-saving course of action.

Regulation Stifles Technology Innovation

This oped in the Washington Times is centered on a different technology issue, but it applies quite nicely to the issue of regulation of electronic cigarettes, IMHO.

SWINDLE: Technological innovation is its own antitrust policy - Washington Times

Government regulation can stifle innovation and improvements when it is applied to rapidly-moving technologies.

I am afraid that many portions of the FSPTCA are inappropriate for regulation of a high-tech product such as e-cigarettes. Read the bill: Read The Bill: H.R. 1256 [111th] - GovTrack.us

For example, the FDA could apply item j of Section 905 to justify banning all e-cigarettes that were not being sold prior to Feb. 15, 2007.

We have seen many product improvements during the past four years. Even if the FDA were to be generous enough to grandfather in all devices being sold on the day that their regulation of e-cigarettes goes into effect, it would still bring innovation and product improvements to a screeching halt.

The first model that I used back in late 2008 produced very little vapor. I couldn't tell whether my cartridge was empty or not. Cartridges that held less than 0.5 mL of liquid cost $2 a piece. The batteries went dead within hours, so I needed to carry charged-up spares. The "high" level of nicotine topped out at 18 mg, (1.8%) leaving me still wanting to smoke a tobacco cigarette.

It was models like these that Prof. Tom Eissengberg of VCU employed with novice users and found that blood levels of nicotine didn't go up very much. When he tested experienced consumers using their own devices and choice of nicotine strength, he measured nicotine blood levels close to that seen in tobacco cigarette smokers.

While it is true that even no-nic e-cigs can be effective for some smokers, there is a certain portion of the smoking population that is dependent on the beneficial effects of nicotine. These folks, like me, will not be able to stop smoking unless we can supply them with adequate replacement levels of nicotine.

It would be a crying shame if the government takes a product line that might be made effective for up to 80% of smokers and regulates it down to being effective for 10 or 20% of smokers. That's a lot better than the effectiveness of most government-approved smoking-cessation products; but it still represents millions and millions of cases of COPD, other lung diseases, various cancers, heart attacks, and strokes that might have been prevented. That's buying a lot of misery for the sake of an unwarranted level of caution.

Inexpert Opinion

Often when writing an otherwise positive story on e-cigarettes, journalists go looking for someone in the medical profession to supply a quote in opposition to the devices. It’s just too bad that some of these experts don’t bother conducting a modicum of research to determine whether their opinion is supported by the facts.

Take Dr. Jonathan Whiteson of NYU Langone Medical Center. He was recently quoted in a story aired on NY1.  http://www.ny1.com/content/ny1_living/health/152836/health-experts--lawmakers-question--e-cigarette--safety

"I think that a lot of people who are promoting e-cigarettes say that it is a safer alternative but there is no evidence to suggest that it is,” stated Whiteson.

While there is no evidence that unequivocally proves that e-cigarettes are a safer alternative, there is evidence that suggests it. In population surveys, 90% of e-cigarette consumers are reporting that their health has improved.
http://tobaccoharmreduction.org/wpapers/011v1.pdf
https://www.surveymonkey.com/sr.aspx?sm=HrpzL8PN5cP366RWhWvCTjggiZM_2b8yQJHfwE9UXRNhE_3d

The medical world tends to disbelieve anything that has not been proven in double-blind, placebo controlled clinical trials. No large-scale clinical trials have been conducted yet; however, pilot studies are showing that using an e-cigarette does not raise blood pressure and does not rapidly increase blood levels of nicotine. No serious adverse effects have been reported.
http://www.casaa.org/files/Virgiania%20Commonwealth%20University%20Study.pdf
http://www.biomedcentral.com/1471-2458/11/786

According to Dr. Murray Laugesen, who summarized testing data from seven labs, a puff of e-cigarette vapor “delivers only 10% of the nicotine obtained from a similar puff of a Marlboro cigarette.” http://www.healthnz.co.nz/DublinEcigBenchtopHandout.pdf

Dr. Laugesen’s report also sheds light on the question of other chemicals in vapor. The vapor was tested for over 50 priority-listed cigarette smoke toxicants. None were found. Furthermore, since e-cigarettes are not burned, vapor does not contain tar, particulates, poisonous gasses, and thousands of chemicals created by the process of combustion. The lack of these hazardous elements probably explains why e-cigarette consumers are reporting health improvements.

So, while Dr. Whiteson’s first statement is at worst, debatable, his next statements are provably false. “As of now, we see it as delivering pure nicotine which is a dangerous drug in itself and it can cause people to become addicted to nicotine. So this is not a product sold to help people come away from cigarettes. It is a product that is sold to addict people to nicotine."

While the nicotine that is present is “pure” in the sense that it is pharmaceutical grade nicotine, e-cigarette liquid is far from 100% nicotine. A cartridge full of nothing but nicotine would be likely to kill the user. On average, nicotine represents about 1.8% of the total amount of liquid present in a cartridge.

Swiss researcher J.F. Etter, and New Zeland researcher Chris Bullen conducted an internet survey on e-cigarettes. Of 3,307 ever-users of e-cigarettes who responded, 187 used the devices without nicotine. Of 2,850 who used an e-cigarette that does contain nicotine, ONE was a never-smoker.  http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2011.03505.x/full

So the poor vendors have to sell 2,849 kits with nicotine and 137 kits without nicotine in order to hook one new nicotine user. At that rate, they will never hook every citizen in the US, because there are only 4 non-smokers to every smoker. If creating new nicotine addicts is the goal, it doesn't seem like a profitable business plan.

Nicotine--not a cause of relapse to smoking

Many folks believe that if a smoker switches to a different source of nicotine, it is inevitable that he or she will start smoking again. But is that true? 

It's true that people who use the pharmaceutical nicotine products like the patch, gum, lozenges and prescription inhalers are likely to start smoking again. But nicotine isn't the cause of these relapses. It's the absence of nicotine. These products come with directions to stop using them after 12 weeks. This is not because GlaxoSmithKline knows of any danger involved in using the products longer. It's because that's how long the testing lasted to obtain FDA approval. In real life, when treatment stops, relapse begins.  

Smokers who switch to e-cigarettes (or some other smoke-free source of nicotine) are unlikely to take up smoking again. In the largest population survey of e-cigarette users published, Etter and Bullen noted that 77% of daily user don't smoke at all, and those who are (currently) continuing to smoke have cut their consumption from 25 cigarettes per day to 15. It took me 20 years to reduce from 50 cigarettes per day to 10, and it only took a few days with an e-cigarette to eliminate those last 10 cigarettes. That was 2-1/2 years ago!  The number of e-cigarette consumers reaching 1 year, 2 years, and even 3 years of smoke-free living is growing exponentially. 

Sweden has the lowest smoking rate in the European Union (14%) and the lowest lung cancer rate. But Sweden doesn't have the lowest rate of tobacco use. Many of those former smokers switched to snus, a type of spit-free moist snuff. Swedish smokers who switch to snus tend to stick with it, because they are not inundated with false information telling them that snus is just as harmful as smoking. The facts are that smokers who switch to snus eliminate the elements that cause lung disease because they no longer inhale smoke, and their rates of cancer and heart disease are no higher than ex-smokers who don't use any form of nicotine. 

In the U.S., smokeless tobacco products carry warning labels stating, "This product is not a safe alternative to cigarettes" which 85% of the populace thinks means that using the product is no safer than smoking. So in essence, our warning labels are saying "You might as well smoke." Thus, the biggest roadblock to reducing smoking prevalence may well be the false information disseminated by the tobacco control community. How ironic...and sad!

“Perspective” Authors Promote Myths, Ignore Science

In a "Perspective" published in the July 21, 2011 issue of New England Journal of Medicine, Pulmonologist Nathan K. Cobb and David B. Abrams, PhD, director of the Legacy Foundation’s Schroeder Institute offered their opinions regarding an invention they know very little about: electronic cigarettes (e-cigarettes). Neither has conducted any first-hand research or bothered to speak to consumers who have used the products.

Perhaps opinion articles do not require the sort of rigorous peer-review process required of other types of articles in NEJM.

Cobb and Abrams make it clear that they view the e-cigarettes as a medicinal product, aimed at performing the same function as FDA-approved "smoking cessation" treatments: weaning the user down and off nicotine altogether. However, the products were never intended to treat the disease of nicotine addiction. By providing a less hazardous source of sufficient nicotine, the devices serve as an acceptable replacement for inhaling deadly tobacco smoke.

Cobb and Abrams are either unaware of, or refuse to believe, research showing that some smokers will never be able to give up using nicotine without experiencing severe problems. When these smokers quit using nicotine, they experience persistent difficulties with memory, attention, and concentration. Many also experience mood impairments that are corrected only when they resume using nicotine. A major U.S. government study released in 2006 showed that fewer than 50 percent of people become symptom-free on antidepressants, even after trying two different medications.

So what exactly do Cobb and Abrams expect these people to do?

Becoming smoke-free by switching to an alternative such as an e-cigarette or smokeless tobacco will save their lives. Becoming abstinent from nicotine will destroy the quality of their lives without adding any health benefits.  Decades of research in Sweden show that smokers who switch to snus (a spit-free type of smokeless tobacco) have the same health-adjusted life expectancy as smokers who quit nicotine use altogether.

The authors claim, "Smokers attempting to use e-cigarettes as quitting aids will most likely find them ineffective." The research says otherwise. Population surveys indicate that electronic cigarettes are much more effective than currently available smoking cessation treatments. Heaver et al. surveyed over 300 e-cigarette consumers and found that 79% were using the e-cigarette as a complete replacement for smoking, 17% had significantly reduced the number smoked, and only 4% still smoked as much as before. The most recent published survey by Etter and Bullen surveyed 3,587 subjects, median age 41, of which 2,850 used e-cigarettes with nicotine, and 112 used e-cigarettes without nicotine. Among 2,896 daily users, 2,234 (77%) no longer smoked at all, and the median duration of smoking abstinence was 152 days.

These statistics indicate that Cobb and Abrams are mistaken about e-cigarettes functioning as a bridge product that delays smoking abstinence. Contrast the e-cigarette success rates with the products being recommended by Cobb and Abrams. A comprehensive review of approved nicotine replacement therapy (NRT) products found a success rate of 7% at six months, which dropped to 5% at 12 months, and to 2% after 20 months.

All population surveys of e-cigarette users show that they tried pharmaceutical nicotine products in the past, multiple times, without lasting success. Cobb and Abrams want e-cigarette users to stop using the one thing that finally did work, and go back to products that never worked in the past. That recommendation is unsound, to put it mildly.

Cobb and Abrams seem to be stuck in a time-warp when it comes to e-cigarette safety. They keep bringing up the FDA’s 2009 testing without acknowledging any of the following facts:

• An approved nicotine patch contains the same amount of ‘carcinogens’ as the FDA found in e-cigarettes.
• A quantity of 0.01 ml of diethylene glycol is totally harmless.
• FDA found nothing at all harmful in the vapor.

More recent testing confirms the absence of substances that could endanger health. Zachary Kahn of U.C. Berkeley and Dr. Michael Siegel of Boston University School of Public Health reviewed 16 studies that comprehensively characterized the content of e-cigarette liquid and vapor and determined "few, if any, chemicals at levels detected in electronic cigarettes raise serious health concerns." They concluded, "a preponderance of the available evidence shows them to be much safer than tobacco cigarettes and comparable in toxicity to conventional nicotine replacement products."

If e-cigarettes are so ineffective, why do they work so well for so many people? If the products are as unsafe as Cobb and Abrams try to imply, how do they explain the fact that there have been no serious adverse events reported during the four years the products have been sold in the United States? Why do they prefer that smokers switch to products such as Chantix that has caused suicides, violent behavior, murders, and heart attacks, or to Zyban/Wellbutrin that is also linked to suicides as well as to seizures?

There is no evidence whatsoever that young people are using e-cigarettes as a starter product. The only isolated reports of someone under 18 trying the products have involved young smokers looking for a way to quit. 

Boston Public Health Commission's Facebook Page

Started a new discussion topic: http://www.facebook.com/topic.php?topic=14716&uid=47308341278#!/topic.php?uid=47308341278&topic=14716

Achieving Smoking Abstinence

I notice that the Commission is promoting the idea of using the patch to quit smoking. True, using nicotine reduction/weaning therapy does double the 3% success rate achieved by going cold turkey, but why is 6% or 7% considered good enough? Success rates using a harm reduction approach are 10 times higher. How can a harm reduction approach be implemented?

The first step is to recognize that while nicotine is the substance that keeps smokers lighting up, it isn't the substance that causes smoking-related diseases. Smoke contains tar, carbon monoxide, particulates, and thousands of chemicals created by the process of combustion. These, not the nicotine, are what cause the cancer, lung disease, and heart disease triggered by smoking.

The next step is to recognize that all addictions are not created equal. There are no laws against driving while under the influence of nicotine because nicotine is not intoxicating. Nicotine doesn’t impair physical reflexes, nor the ability to concentrate, remember, and make sound judgments. In fact it enhances these abilities. That’s one reason why nicotine is so difficult for the majority of tobacco users to give up. Another reason is because nicotine helps to control symptoms of depression and anxiety, which are problems for about 20% of smokers.

The third step is to learn about smoke-free alternatives. Modern smokeless tobacco products can reduce the risk of smoking-related diseases by up to 99%. Decades of research in Sweden on snus, a type of moist tobacco treated to reduce nitrosamines, show that smoking-related lung disease risks are eliminated, and rates of cancer and heart disease are equal to those of former smokers who don’t use any form of tobacco. Swedish snus users have the same life expectancy as those who have become abstinent from all tobacco products. The FDA is considering whether to approve long-term use of approved nicotine products such as the patch, gum, lozenges, and the prescription inhalers. These may prove acceptable as permanent substitutes for smoking, especially if the FDA takes it a step further and permits higher nicotine content in these products. Finally, electronic cigarettes mimic the experience of smoking but remove the hazards of inhaling smoke. Even the “high” dose of e-cigarette liquid contains the same quantity of nitrosamines in a one-day supply as an FDA-approved nicotine patch (about 8 nanograms), while a pack of cigarettes may contain more than 100,000 nanograms.

The fourth step is to compare the success rates of switching to reduced-harm smoke-free alternatives with success rates for the traditional approach of weaning down and off nicotine. When used as directed, FDA-approved nicotine products have a 7% success rate at 6 months, 5% at one year, and dropping to 2% at 20 months. In Sweden, where the public is given truthful information about the relative harm of smoking versus smokeless products, 66% of snus users are former smokers. Surveys of e-cigarette users show success rates range as high as 82% for consumers who are given advice about equipment and supplies and guidance on how to use the devices properly. Keep in mind that these success rates apply to achieving smoking abstinence. There is no additional health benefit to be gained by insisting on nicotine abstinence.

The fifth and final step is for public health experts to provide truthful information about relative risks of various sources of nicotine to smokers and to the general public. Warning labels that state “This product is not a safe alternative to cigarettes” are misleading half-truths. No product could ever be proven 100% safe. But the labels imply that the health risks of this smokeless product are equal to the health risks of smoking. Nothing could be farther from the truth. Stop talking about “tobacco-related diseases” when 99% of these diseases are caused by inhaling smoke. Stop worrying about curing nicotine addiction, when nicotine without the smoke is about as harmful as caffeine. Stop striving for tobacco abstinence and focus on helping smokers achieve abstinence from smoking.

Americans for Some Nonsmokers' Rights

Proposed legislation that keeps popping up in states and municipalities across the United States contains strangely similar wording calling for e-cigarettes to be included in smoking bans. I tracked down the source of this wording to "Model Legislation" posted on the web site of Americans for Nonsmokers Rights. http://www.no-smoke.org/document.php?id=229
I left the following message on their Contact Us page:

Can you help to protect my right to avoid exposure to smoke, as well as my right to remain a non-smoker? I smoked for 45 years and tried over and over to quit using patches, gum, lozenges, Rx inhaler, bupropion, and even hypnosis. Each time, when treatment ended, relapse began. What was causing the problem? For many smokers nicotine abstinence causes protracted cognitive deficiencies, attention deficits, memory problems, depression, and other mood disorders. I have been smoke-free since I switched to an electronic cigarette on 3/27/2009. This Chinese invention delivers nicotine in a vapor created by the same safe chemical used in artificial fog machines. My wheezing and morning cough are gone, I can laugh out loud without going into a coughing fit—and I didn’t have to sacrifice my cognitive and emotional health. Some lawmakers are proposing laws that would force me to go stand in the smoking area when I use the product that keeps me smoke-free. Vapor is not smoke. Can you help?

Today, I received the following response:

Thank you for contacting Americans for Nonsmokers’ Rights (ANR) to share your story with us. We are always happy to hear success stories from people who were able to quit smoking cigarettes. Unfortunately, we are not supportive of electronic cigarette usage, even though it's not quite the same as cigarette smoke. There is still a vapor that comes off of the device is that is not proven to be safe.

Here is a link to our page on electronic cigarettes so you can get a better idea of our position: http://www.no-smoke.org/learnmore.php?id=645 You can also find other informative links on that same page.

Thank you again for contacting us.

Best regards,
ANR staff

Perhaps it was not the wisest move on their part to direct me to their page on electronic cigarettes. Here's what I wrote back.

Dear ANR Staff:

It would be helpful if your page on electronic cigarettes provided a balanced picture of the research on electronic cigarettes. To do so, you would need to include and provide descriptions of the studies and lab tests that produced favorable results. I will provide you with some references below. Meanwhile let's examine the negative reports about e-cigarette on your page.

Although the FDA announced with great fanfare in July 2009 that it found “carcinogens” and “antifreeze” in e-cigarettes, the FDA hid the fact that the quantity of “carcinogens” found is equivalent to the quantity in an FDA-approved nicotine patch (8 ng). FDA also failed to mention that the amount of diethylene glycol detected in just one cartridge (0.01 g) is thousands of times below the toxic level. The FDA’s press conference was nothing less than a PR stunt, aimed at discrediting the products of the two companies that had the audacity to file a law suit against the Agency. Any purported toxicology report that lacks a quantitative analysis is incomplete and inconclusive. Promoting the FDA's fiction as fact does a disservice to both science and public health.

The Berkeley study published in February 2010 looked at residue from smoke exposed to nitrous acid produced by unvented gas appliances. What about homes with properly vented gas appliances? What about all electric homes? So even the dangers of smoke residue may be overblown. Worse yet, it was unethical and unscientific for co-author James Pankow to suggest that his experiment should raise concerns about the safety of electronic cigarette vapor. Dr. Pankow was free to conduct tests to determine whether e-cigarette vapor deposits any residue on surfaces, and, if so, whether that residue produces nitrosamines. He chose not to do so.

Conjecture is not scientific proof, whether that conjecture concerns nicotine residue or the fiction about flavors aimed at children. There is zero evidence that yummy flavors are tempting kids to purchase e-cigarettes. There is zero evidence that any significant number of kids are buying e-cigarettes. If the kids want yummy flavors and nicotine, they can always buy Nicorette gum and lozenges more easily and for less money. They aren't doing that, either. So maybe the whole "flavors attract children" theory is just a lot of...smoke.

Those who constructed and conducted the survey on public support for e-cigarette laws apparently failed to provide the respondents with sufficient information to make intelligent decisions.

• Were they told that the FDA used clever propaganda techniques such as selective omission and name-calling to frighten the public about non-existent dangers of e-cigarettes?


• Were they told that in 2008, Dr. Murray Laugesen of Health New Zealand tested e-cigarette vapor for over 50 cigarette smoke toxicants and that none were found?


• Were they told that the FDA is so hell-bent on banning e-cigarettes that it refuses to protect public health by regulating the products under the FSPTCA?


• Were they informed that the most likely outcome is that, unless the vendor makes medical claims, the FDA will be forced by the Federal courts to regulate e-cigarettes as tobacco products?

Obviously not, since the only scenario the questionnaire put forth for regulating the products was under the Food, Drug, and Cosmetics Act. The survey never even mentioned the Tobacco Act.

Dr. Michael Siegel of Boston University School of Public Health worked with Berkeley researcher Zachery Cahn to review the research on electronic cigarettes. They concluded, “A preponderance of the available evidence shows them to be much safer than tobacco cigarettes and comparable in toxicity to conventional nicotine replacement products.” Additionally, consumer surveys consistently report that more than 90% of e-cigarette users experience improvements in their health—especially their lung function.

If people that directly inhale e-cigarette vapor experience health improvements, is it remotely possible that the vapor they exhale can endanger bystanders? There is no biological rationale for such a theory. Numerous labs have tested electronic cigarettes and could not find any substances in the vapor that might endanger the health of users or bystanders.

The surveys that looked at health effects also revealed that up to 80% of regular users of e-cigarettes have substituted them for all their tobacco smoking. At least two studies with human subjects showed that e-cigarettes reduce cravings to smoke. And yet your page states that there is no evidence they can help smokers quit.

A study conducted by Garvey, et al reported that approximately one third of abstinent patients at 1 year were still using nicotine gum in a study of high- and low-dependence smokers. Similarly, e-cigarette users rely on regular, frequent use of their devices to maintain their own smoking abstinence. They should not be subjected to punishment because an organization such as yours disapproves of the method they use to remain smoke-free.

Sending former smokers to the designated smoking area is at odds with the purpose of the clean air ordinances and with the stated mission of Americans for Nonsmokers' Rights. Unless you are willing to protect the rights all nonsmokers, your organization is a fraud. So I do hope you will reconsider your position. If not, you could at least rename your organization "Americans for Some Nonsmokers' Rights" just to avoid confusion.

Here are the promised links to additional research:

Bullen, et al, Effect of an electronic nicotine delivery device on nicotine delivery device (e cigarette) on desire to smoke and withdrawal. Tobacco Control. http://www.healthnz.co.nz/2010%20Bullen%20ECig.pdf
Cahn and Siegel. Electronic cigarettes as a harm reduction strategy for tobacco control. Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy 1–16. http://www.hsph.harvard.edu/centers-institutes/population-development/files/article.jphp.pdf
Consumer Advocates for Smoke-Free Alternatives Association. Lab Reports http://www.casaa.org/resources/lab.asp
Consumer Advocates for Smoke-Free Alternatives Association. Informal User Survey Results. https://www.surveymonkey.com/sr.aspx?sm=HrpzL8PN5cP366RWhWvCTjggiZM_2b8yQJHfwE9UXRNhE_3d
Etter, et al. Electronic cigarettes: a survey of users. BMC Public Health. http://www.biomedcentral.com/content/pdf/1471-2458-10-231.pdf
Exponent Health Sciences. Technical Review and Analysis of FDA Report: "Evaluation of e-cigarettes." http://www.casaa.org/files/Exponent%20Response-to-the-FDA-Summary.pdf
Garvey A, Kinnunen T, Nordstrom B. Effects of nicotine gum dose by level of nicotine dependence. Nicotine Tobacco Res 2000;2:53-63. http://www.ncbi.nlm.nih.gov/pubmed/11072441
Health New Zealand, E-cigarette mist harmless inhaled or exhaled. http://www.healthnz.co.nz/ECigsExhaledSmoke.htm
Heavner, et al. Electronic cigarettes (e-cigarettes) as potential tobacco harm reduction products: Results of an online survey of e-cigarette users. Tobacco Harm Reduction 2010 Yearbook. http://tobaccoharmreduction.org/wpapers/011v1.pdf
Laugesen M, Health New Zealand Ltd. Report on the Ruyan® e-cigarette Cartridge and Inhaled Aerosol.
http://www.healthnz.co.nz/RuyanCartridgeReport30-Oct-08.pdf
Laugesen M. Health New Zealand. Poster Presentation at the Society for Research on Nicotine and Tobacco conference, Dublin, April 30, 2009. http://www.healthnz.co.nz/DublinEcigBenchtopHandout.pdf
Siegel, et al. Electronic Cigarettes as a Smoking-Cessation Tool: Results from an Online Survey. American Journal of Preventive Medicine. http://www.ajpm-online.net/webfiles/images/journals/amepre/AMEPRE3013.pdf
Ben Thomas Group report: No cancer-causing chemicals in NJOY vapor.
http://www.casaa.org/files/Study_TSNAs_in_NJOY_Vapor.pdf
Vansickel AR, et al. A Clinical Laboratory Model for Evaluating the Acute Effects of Electronic “Cigarettes”. Cancer Epidemiology, Bio. & Prevention
http://www.casaa.org/files/Virgiania%20Commonwealth%20University%20Study.pdf