Thursday, August 19, 2010

Central Michigan University: Just Keep Smoking, Kids

A Central Michigan University (CMU) official recommends that students stick with smoking real cigarettes. Shaun Holtgreive, associate director of Residence Life at CMU, announced that electronic cigarettes are banned for indoor use anywhere on campus. Holtgreive claims to have studied e-cigarettes and says, “research has shown they give off noxious chemicals in the vapor expelled when smoked.”

If the pronoun “they” refers to e-cigarettes, Mr. Holtgreive has a credibility problem. No such research exists.

Smoke contains tar, carbon monoxide, particles of ash, and thousands of chemicals created by the process of combustion. Many of these are present in exhaled tobacco smoke. The vapor from an e-cigarette does not contain any of these constituents because nothing is burned.

Research has shown that, in an e-cigarette cartridge containing nicotine extracted from tobacco, the liquid has trace amounts of tobacco specific nitrosamines. The FDA pointed this out when they announced the results of their testing. However, the agency neglected to mention that the same “carcinogens” are present in FDA-approved nicotine products, in roughly equivalent amounts. [1,2] A trace amount of a tobacco humectant, diethylene glycol was found in the liquid from one cartridge. The FDA did not find any harmful chemicals in the vapor. Numerous other laboratories have found no harmful chemicals in the vapor. [3]

Surveys of e-cigarette consumers have shown that a sizeable majority—up to 79%--of e-cigarette users become former smokers. [4] Holtgreive wants these former smokers to go the designated smoking area and be exposed to second-hand smoke when they use the device that is keeping them smoke-free. He said these regulations are to keep a safe environment for students and those around them.

These same surveys show that over 90% of users are reporting health improvements. “Positive effects reported with ecigarettes included their usefulness to quit smoking, and the benefits of abstinence from smoking (less coughing, improved breathing, better physical fitness),” stated researcher Jean-Fran├žois Etter. [5]

In the August 2010 issue of Cancer Epidemiology, Biomarkers & Prevention, researchers from Virginia Commonwealth University reported on a clinical trial comparing health effects of subjects’ own brand of cigarettes to two brands of electronic cigarettes and to sham smoking. Own brand and both brands of electronic cigarette significantly decreased tobacco abstinence symptom ratings. Like sham smoking, the two brands of electronic cigarettes had no significant impact on plasma nicotine levels, heart rate, or exhaled carbon monoxide. [6]

There have been numerous reports of people who had no intention of quitting smoking spontaneously losing their urges to smoke tobacco soon after they began using an e-cigarette. Allowing indoor use of e-cigarettes provides an incentive for continuing smokers to give the products a try. Treating e-cigarette users as though they were exhaling smoke sends a message: Just keep smoking, kids.

[1] Westenberger BJ. Evaluation of e-cigarettes. U.S. Food and Drug Administration.

[2] Laugesen M. Safety Report on the Ruyan® e-cigarette Cartridge and Inhaled Aerosol. Health New Zealand. (See “Comment 1” on page 7.)

[3] The Consumer Advocates for Smoke-Free Alternatives Association, Resources, Lab Reports.

[4] Heavner K, Dunworth J, Bergen P, Nissen C, Phillips CV. Electronic cigarettes (e-cigarettes) as potential tobacco harm reduction products: Results of an online survey of e-cigarette users. Tobacco Harm Reduction Yearbook 2010.

[5] Etter J. Electronic cigarettes: a survey of users. BMC Public Health 2010, 10:231.

[6] Vansickel AR, Cobb CO, Weaver MF, Eissenberg TE. A clinical laboratory model for evaluating the acute effects of electronic "cigarettes": nicotine delivery profile and cardiovascular and subjective effects. Cancer Epidemiol Biomarkers Prev. 2010 Aug;19(8):1945-53. Epub 2010 Jul 20.

Wednesday, August 11, 2010

What If We Told the Truth About Snus?

In a recently published study in the British Medical Journal Tobacco Control, Adrienne B Mejia, Pamela M Ling, and Stanton A Glantz state, “Promoting smokeless tobacco as a safer alternative to cigarettes is unlikely to result in substantial health benefits at a population level.”

The researchers used a Monte Carlo simulation to estimate the health effects of five different patterns of increased use of smokeless tobacco. Here we see the age-old principle of GIGO at work: Garbage In, Garbage Out.

Dr. Joel L Nitzkin, Chair, Tobacco Control Task Force of the American Association of Public Health Physicians questioned both the underlying assumptions applied in creating the computer models and the scoring arbitrarily assigned for various health effects.

One of the critical assumptions applied in the calculations was the rate at which smokers would be willing to substitute snus for Smoking. Dr. Nitzkin commented, “All of their data on switching rates in the United States is conditioned on the warning on smokeless tobacco products, in place in the USA since 1984, that this product is not a safe alternative to cigarettes. This purposely misleading warning has left over 80% of American smokers with the incorrect impression that smokeless tobacco products present the same risk of tobacco-related illness and death as cigarettes.”

How might those estimates change if we all told smokers (and their doctors) the truth?

What if the government changed the warning labels to read "THIS PRODUCT IS NOT A 100% SAFE ALTERNATIVE TO SMOKING"? See what a difference one tiny change can make? This would lead folks to ask, "Well if it's not 100% safe, how much safer is it?"

The way the message is worded now, 85% of the people who read it conclude it means that smokeless tobacco products cause just as much disease and premature deaths as smoking. [1] We know it isn't true. But smokers don't know that, now do they?

And then what if the American Cancer Society, American Heart Association, American Lung Association, American Medical Society, and the Centers for Disease Control and Prevention informed smokers that their excess risk of lung disease would be totally eliminated if they switched from smoking to smokeless? What if they provided comparisons between smoking and smokeless of the odds of developing various types cancers, having a heart attack or a stroke?

We know that users of smokeless tobacco products have a lower mortality rate from all these diseases than continuing smokers. [2,3] We know that for most diseases, the Swedish snus user's mortality risks are reduced to the level of those who gave up all use of tobacco. [4] We know all that. But the smokers do not know that.

Most smokers do not read medical journals. They rely on the popular press and information provided by respected organizations that claim to have public health as a mission.

Curiously, most physicians are just as misinformed as their smoking patients. What if the doctors were to learn that their patients could reduce their risk of developing a smoking-related disease by 90 to 99% if they switch completely to a smokeless form of tobacco? Might not more smokers give snus a try if their own doctor told them it was safer than smoking?

What if the FDA required the tobacco companies to develop and conduct advertising campaigns aimed at convincing smokers to switch to smokeless products?

What if we did all these things? What effect would that have on the number of U.S. smokers who switch and consequently on the smoking-related morbidity and mortality rates? Factor in truth-telling and run those Monte Carlo simulations again.


[1] Phillips, C.V. et al. You might as well smoke; the misleading and harmful public message about smokeless tobacco. BMC Public Health 2005, 5:31doi:10.1186/1471-2458-5-31.

[2] Accortt, N.A., et al. Chronic Disease Mortality in a Cohort of Smokeless Tobacco Users. American Journal of Epidemiology 2002; 156:730-737

[3] Roth, H.D. et al. Health Risks of Smoking Compared to Swedish Snus. Inhalation Toxicology, 17:741-748, 2005.

[4] Gartner C.E, et al., Assessment of Swedish snus for tobacco harm reduction: an epidemiological modeling study. Lancet. 2007 Jun 16;369(9578):2010-4