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

E-Cigarettes: Dialog on Flavors and Poisoning Issues

During the Public Hearings on a bill that would have banned flavored liquid for electronic cigarettes, one health advocate testified:

The problem is that a lethal dose of nicotine for children is 10 mg and one of those cartridges contains 500 to over 1000 mg.

In our follow-up thank you to the committee members who had voted against the measure we endeavored to correct the misinformation that came out during the hearing. Regarding this particular statement we wrote:

This is false. Cartridges contain nicotine that has been purified (pharmaceutical grade), not “pure nicotine.” A cartridge contains no more than one gram (1000 mg) of a liquid solution of water, propylene glycol and/or vegetable glycerin, flavoring, and (optionally) nicotine. The “high dose” cartridges typically contain less than 2% nicotine (20 mg.)

We received a response:

In that statement I was referring to the refill containers that are used to refill the cartridges in the e-cigarettes. The information I gave in the committee hearing is correct for the refill containers. The containers do not have child-proof caps and come in candy flavors. This bill would ban those.

The text below is the reply from one of the CASAA Board Members.

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I thank you for opening a dialog on these issues.

We are in agreement that nicotine is poisonous and should be kept out of reach of small children.

The information you gave the committee is not necessarily correct for containers of refill liquid. The total quantity of nicotine in a refill bottle depends on two factors: 1) what percent of the solution is nicotine and 2) the size of the bottle. Given the 2% figure that I mentioned in my email, you would need a 50 ml bottle of refill liquid to reach a total of 1,000 mg of nicotine (1000 divided by 20). That’s well above average size for a refill bottle. If the bottle contains zero-nicotine liquid, there would be zero mg of nicotine, regardless of how large the bottle is.

However, a discussion of how much of a toxic chemical is in a container is beside the point. Most households contain many different products that are poisonous – bleach, nail polish remover, aspirin, drain cleaner, children’s cough medicine, mouthwash – to name a few. Should legislation be passed to ban all poisonous substances? Or should parents be expected to keep all poisons out of reach of children and pets?

Most toddlers can’t read, therefore catchy flavor names would be lost on them. Many of the substances that poison children are rather unpleasant tasting.

As my colleague Kristin pointed out, many smokers who switched to electronic cigarettes have lost their taste for tobacco smoke. It is very likely that the more pleasant flavors assist in the process of extinguishing a taste for smoke. Many smokers who quit by using other methods report that they still have cravings to smoke, even years later. We who quit smoking by switching to a reduced-harm product are experiencing no cravings to smoke. This is an important point, so I am going to repeat it: We have no cravings to smoke! Thus, when a famous Pediatrician announces that kids will begin using e-cigarettes and then “graduate” to smoking, we find the idea ludicrous.

There is zero evidence that pleasant flavors are enticing young people to take up nicotine use via e-cigarettes. If pleasant flavors are what they are after, they can get those without nicotine in an e-cigarette. Better yet, they can buy real candy, real cookies, real bubble-gum or some other food source of pleasant flavors. Those products will cost a lot less than an electronic cigarette.

There is zero evidence that—for whatever reason—any significant number of young people are buying these products. I’m attaching a copy of the CASAA Position Statement on Electronic Cigarettes. It contains some statistics on the age and smoking experience of consumers, substantiated by references. I’m also attaching a copy of the CASAA document, “8 Biggest Electronic Cigarette Myths”. It provides a more detailed explanation of some of the points discussed here.

These products are working for people who had lost all hope of ever being able to quit smoking. I’m 65. I smoked for 45 of those years and tried the patch, gum, lozenges, prescription nicotine inhaler, counseling, hypnosis, Nicotine Anonymous, and prescription smoking cessation drugs. When treatment stopped, relapse began. I didn’t just try these products once. I tried over and over, even using different combinations. If the definition of insanity is doing the same thing over and over again, expecting a different result, then I must have been insane.

On March 27, I will have been smoke-free for two years. To me, that’s the answer to a prayer—quite literally.

There are now hundreds of thousands of former smokers like me who did everything we were told to do and could not quit. We have finally found something that works. Then along come the groups that are supposed to be in favor of smoking cessation—health departments across the country, US Health and Human Services agencies, American Lung Association, American Heart Association, American Cancer Society, Campaign for Tobacco-Free Kids, WHO, and the AMA—and all of them want to ban outright the product that finally, at long last, worked for us. And when that doesn’t work, they want to make the products less effective by such actions as banning pleasant-tasting flavors. It boggles our minds.

What we really find insulting is when these organizations tell us that we should try the “safe and effective” smoking cessation methods. What they seem to be saying is “We want you to go back to beating your head against the wall.”

Again, I greatly appreciate that you are willing to discuss these issues. If you have additional questions or would like to discuss anything related to improving smoking cessation rates, I am including my mobile phone number.

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The two documents mentioned above can be downloaded from the CASAA web site:

CASAA Position Statement on Electronic Cigarettes
http://www.casaa.org/files/Casaa%20Position%20Statement.pdf
8 Biggest Electronic Cigarette Myths
http://www.casaa.org/files/8%20Biggest%20Electronic%20Cigarette%20Myths%282%29.pdf