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.

---

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.

---

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

WHO Opinion Not More Important than Voter Experience

Recently, a member of the Consumer Avocates for Smoke-Free Alternatives Association (CASAA) who lives in New Jersey contacted me for help in responding to a letter he received from his State Senator Robert M. Gordon, District 38. The CASAA member--I'll call him "Tom" to protect his identity--had written to Senator Gordon to ask that the senator reconsider the inclusion of electronic cigarettes in indoor smoking bans.

About half of Senator Gordon's letter focused on the FDA's efforts to drive the products totally out of the marketplace. Senator Gordon appeared to be unaware that the FDA's July 2009 press conference regarding FDA's testing of 18 cartriodges was a carefully crafted "spin job".

Senator Gordon had bought into the idea that e-cigarettes cause cancer, because he had not learned that the FDA neglected to mention that it only detected 8 ng/g (parts per billion) of tobacco-specific nitrosamines ("carcinogens") in the e-cigarette liquid. The FDA-approved nicotine patch also contains 8 ng/g and 4-mg nicotine gum contains 2 ng/g in each piece. These products carry no cancer warnings because such miniscule quantities of nitrosamines carry no cancer risks. The FDA was purposely being misleading by referring to them as "carcinogens." Apparently Senator Gordon was also unaware that a pack of cigarettes typically contain over 100,000 ng/g.

He did know that the quantity of diethylene glycol (DEG) FDA detected in the liquid of one cartridge was 1%, but did not appear to understand the utter harmlessness of such a miniscule quantity. A 150-pound adult woud need to drink the liquid from 6804 cartridges in a single day to be poisoned. Two problems with this: (1) Consumers don't drink the liquid; they inhale the vapr. (2) The FDA did not find DEG or any other harmful chemical in any of the vapor tested. Dozens of labs have tested the liquid and the vapor, both before and after the FDA's test, and no other lab has ever detected DEG.

FACT: The FDA looked for, but did not find, any chemicals in the vapor in quantities that would endanger the health of users or bystanders. Thus there is no justification for lumping electronic cigarettes into laws that were intended to protect air quality.

So I helped Tom by reviewing his letter and supplying some links to research supporting Tom's statements. A few day's later, I noticed a statement in Senator Gordon's letter that was not addressed in Tom's reply: “I also came across a statement from the World Health Organization in 2008 which said that it does not consider e-cigarettes to be a legitimate therapy for smokers trying to quit.”

The person who made that statement on behalf of the WHO was pharmacologist Jack Henningfield, PhD, whose appointment to the FDA Tobacco Products Scientific Advisory Committee is being challenged for conflict of interest. Henningfield has performed consulting services for the pharmaceutical companies that manufacture the nicotine-cessation products. A continuing source of confusion between tobacco harm reduction advocates and the rest of the world is the pervasive belief that smoking = nicotine. Their definition of “quit smoking” is that you give up using nicotine. So when Henningfield says “smokers trying to quit,” he doesn’t mean smokers trying to quit inhaling smoke. He means smokers trying to quit using nicotine.

It is unfortunate that the vast majority of the public does not know that nicotine does not cause the smoking-related diseases—it’s the smoke!

E-cigarette users replace the nicotine that they used to get from smoking with vaporized nicotine that is not accompanied by the harmful components of smoke. Users who want to go on to reduce their nicotine intake can do so, but doing so is not required to enjoy the health improvements that come from eliminating smoke.

E-cigarettes are not intended to be therapy and they are not intended to treat nicotine addiction. Nicotine abstinence is unworkable for the majority of smokers. The proof lies in the 93% to 98% failure rate of the nicotine patch, gum, lozenges, and prescription inhalers that have contributed to Jack Henningfield's income.

All these products direct the user to reduce their nicotine intake to zero over the course of about 12 weeks. The fact that the failure rate for these products is so high is what keeps smokers coming back and buying more Nicoderm, Nicorette, and Nicotrol. It keeps the money flowing into the pharmaceutical companies’ coffers, into Jack Henningfield’s pockets, and the pockets of several other members of the FDA TPSAC. Unfortunately, it also keeps the consumers of these products relapsing back to smoking—and feeling guilty about it, when the true cause of the failure actually lies with the “experts” who insist on nicotine abstinence.

If men like Henningfield were truly concerned about the health of smokers, they would applaud any product or method that resulted in 80% of users being able to stop inhaling smoke. I believe they are much more concerned with their own wealth than with the health of smokers and the continued health of former smokers who rely on e-cigarettes or other reduced-harm alternatives such as snus to maintain their abstinence from smoking.

If men like Senator Gordon were truly concerned about the health of their constituents, they would stop to consider whether WHO's opinion is what really counts.

Legislators should place a much larger value on the experiences of the people who elected them, instead of relying on the unsupported opinions of self-proclaimed “experts.” Most of these "experts" have conducted no research on the products themselves and refuse to even talk to people who actually have used the products. I attempted to talk to Jack Henningfield at the Society for Research on Nicotine and Tobacco (SRNT) conference last year to explain how the products have helped so many of us. As soon as he heard the words “electronic cigarette” he couldn’t get away fast enough. He was downright rude about it.

My Way or the Die Way

An Open Letter to New York Assemblymember Linda Rosenthal:


“If I can do it, anyone can do it.”

In 1990, there were 43.8 million cigarette smokers in the U.S. Twenty years later, the number of cigarette smokers stands at 46 million. Ooops. Maybe it isn’t as easy to quit as you want to believe. Maybe all human beings do not have bodies that are exact duplicates of yours.

Do you inject insulin every day? No? Do you feel morally superior to those who do, simply because your pancreas works better than theirs? Of course not. Then why are you so smug about having quit smoking 20 years ago and so scornful of those who are not able to quit by using your method?

All of the FDA-approved “smoking cessation” products are based on a model of weaning smokers totally off nicotine. You used the patch. You may not be aware of the fact that the success rate for nicotine weaning products such as the patch, when used as directed, is only 7% at six months, 5% at one year, and down to 2% after two years. When treatment ends, relapse begins. Now here is an eye opener: 30% of the smokers who have stopped smoking altogether by using nicotine gum are still using the gum, years later. They managed to stop smoking only because they ignored the directions. Instead of practicing the recommended nicotine weaning therapy, they are practicing self-directed nicotine maintenance therapy.

Let’s talk about nicotine “addiction” for a moment. Have you ever heard of a motorist being charged with “Driving under the Influence of Nicotine”? No. And you never will. All of the drugs that result in a DUI charge (e.g., alcohol, marijuana, heroin, etc.) impair the driver’s ability to concentrate, pay attention, use good judgment, and react quickly.

What are the effects of nicotine? Here is what a meta-analysis revealed: “We found significant positive effects of nicotine or smoking on six domains: fine motor, alerting attention-accuracy and response time (RT), orienting attention-RT, short-term episodic memory-accuracy, and working memory-RT (effect size range = 0.16 to 0.44).” (Heishman SJ, Kleykamp SA & Singleton EG. 2010. Meta-analysis of the acute effects of nicotine and smoking on human performance. Psychopharmacology 210 (4): 453-469 http://www.ncbi.nlm.nih.gov/pubmed/20414766)

Nicotine also has positive effects on mood. Unlike drugs such as alcohol, it does not create a false state of euphoria. Instead, it helps to relieve depression and anxiety. If you don’t have depression and anxiety, it does not have much effect on your mood.

Think about this: If you were someone who had problems concentrating, remembering things, staying awake in boring situations, or who had a family or personal history of depression and/or anxiety, and nicotine was keeping the symptoms under control, what would happen to you if you stop using nicotine? Those symptoms would go out of control, wouldn’t they? All of these conditions are caused by imbalances in brain chemistry. And since none of these can be 100% controlled by sheer will-power, they would not be likely to magically go away on their own.

So just because you get along fine without nicotine does not mean that everyone is better off without it. Harmful effects of nicotine are trivial, on a par with the harmful effects of caffeine – a temporary increase in heart rate and blood pressure that normalizes 20 minutes later. Nicotine does not cause cancer, heart attacks, strokes, or lung disease. Smoke does. So doesn’t it make sense to help those who become dysfunctional without nicotine by changing the method that delivers their nicotine to something that does not involve inhaling tar, carbon monoxide, particles of partly burned paper and tobacco, and thousands of chemicals created solely by the process of combustion?

I smoked for 45 years and tried over and over again to stop. I used the patch 20 years ago, too. The difference between you and me is that you did not become dysfunctional after following the directions. I did, and stayed that way for 6 long, miserable months, during which I wanted to commit suicide. Antidepressant medication relieved the mood impairments to a large extent, but I was told there was nothing they could prescribe that would relive the cognitive impairments, and I was about to lose my job. The patch at that time was only available by prescription, so it was not a long-term maintenance option. But when it became available OTC, I tried that. However, I developed a nasty rash wherever I put the patch. When they finally began manufacturing Nicorette gum in pleasant flavors (instead of the original flavor that tasted like an ashtray), regular use of the gum helped me to reduce the number of tobacco cigarettes I smoked. Unfortunately, it has a tendency to upset my stomach if I chew more than 4 or 5 pieces a day. When I discovered the electronic cigarette, it was literally the answer to a prayer. I used to lie in bed at night, kept awake by the sound of my wheezing, and pray to God to send me a way to stop smoking without becoming dysfunctional. I switched over to inhaling vapor on March 27, 2009. The wheezing is gone, as is the “productive” morning cough.

If self-medicating to remain a functioning, productive member of society is somehow immoral, then I guess everyone who buys a double latte at Starbucks every morning, and everyone who pops some Advil when they pull a muscle should admit to being immoral. But IMHO it is immoral to take away a tool that can save the health and the lives of millions. I ask you to reflect on the information I have provided and then to consider amending A1468 to remove Section 2. Allow former smokers who rely on these products to remain abstinent from smoking. Do not deny continuing smokers access to an extremely effective tool that can save their health and their very lives. “Quit (my way) or die” is an inhumane stance.

Elaine Keller

WHO FCTC May Kill Millions of Smokers

It is shocking to read that the Parties to the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) want to prevent the use of two of the most effective methods for achieving smoking abstinence. (http://www.scoop.co.nz/stories/WO1011/S00426/tobacco-convention-agree-on-stronger-smoking-controls.htm)

Smoking prevalence rates have stagnated. The United States Centers for Disease Control and Prevention as stated: ““To further reduce disease and death from cigarette smoking, declines in cigarette smoking among adults must accelerate.” (CDC MMWR Vol. 59 / No. 35 http://www.cdc.gov/mmwr/PDF/wk/mm5935.pdf)

When used as directed to wean down and off nicotine, medicinal nicotine products have a success rate of 7% at 6 months, 5% at one year, and only 2% at 20 months. (Moore D, et al. Effectiveness and safety of nicotine replacement therapy assisted reduction to stop smoking: systematic review and meta-analysis. BMJ 338:b1024 2009 http://www.bmj.com/content/338/bmj.b1024.full.pdf+html)

The main reason medicinal nicotine products are so ineffective is that they require sustained nicotine abstinence. As soon as treatment ends, relapse begins. Dr. Brad Rodu of the University of Louisville states, ““Given that the outcome measure for all smoking cessation trials in the U.S. is complete abstinence, it is no wonder that most cessation methods are deemed failures. For successful tobacco regulation, the FDA must break the public health community’s addiction to abstinence promotion.“ (http://rodutobaccotruth.blogspot.com/2010/10/noteworthy-news-from-norway-snus-is.html)

Let’s compare the success rate of medicinal nicotine to methods that do not require nicotine abstinence.

Dr. Karl Erik Lund compared quit rates, defined as the percentage of ever smokers who are now former smokers, among snus users and never users of snus in seven previously published Norwegian surveys. The results were published in Addiction magazine. (http://www.ncbi.nlm.nih.gov/pubmed/2088345)

Lund Survey No.	Quit Rate - Snus Users (%)	Quit Rate - Never Snus Users (%)
1	80	52
2	55	23
3	81	63
4	62	53
5	75	45
6	90	50
7	73	43

It is important to note that not all smokeless tobacco products are alike. Swedish snus is formulated to reduce cancer-causing nitrosamines. Studies show that the health risks associated with Swedish snus use are significantly lower than the health risks of continued smoking. An assessment by Gartner, et al published in Lancet found “There was little difference in health-adjusted life expectancy between smokers who quit all tobacco and smokers who switch to snus (difference of 0.1-0.3 years for men and 0.1-0.4 years for women). For net harm to occur, 14-25 ex-smokers would have to start using snus to offset the health gain from every smoker who switched to snus rather than continuing to smoke. Likewise, 14-25 people who have never smoked would need to start using snus to offset the health gain from every new tobacco user who used snus rather than smoking.” (http://www.ncbi.nlm.nih.gov/pubmed/17498798)

As for electronic cigarettes, most of the world-wide panic has been generated by a very misleading press conference held by the U.S. Food and Drug Administration regarding their testing of 18 electronic cigarette cartridges made by the two companies engaged in a lawsuit against the agency (a strong signal of bias).

The FDA failed to point out that the highest quantity of “carcinogens” detected in a cartridge is equal to the quantity in an FDA-approved nicotine patch (8 nanograms). The quantity of diethylene glycol detected was so miniscule that a 150 pound person would need to ingest the contents of 100,000 cartridges in a single day to be poisoned. So why all the panic? Electronic cigarettes are about as dangerous as FDA-approved nicotine products, which makes them several orders of magnitude safer than smoking.

Critics keep claiming that there is no proof that electronic cigarettes help people to stop smoking. If by “stop smoking” they mean “achieve total abstinence from nicotine” then the critics are correct. However, if what they mean by “stop smoking” is to stop inhaling smoke and to enjoy all the resulting health benefits, then the critics are wrong. Surveys of electronic cigarette users consistently show that a large majority of users are able to substitute the electronic cigarette for all of their smoked cigarettes.

Survey #	# Subjects	Quit Rate
Heavner K, et al. Electronic cigarettes (e-cigarettes) as potential tobacco harm reduction products: Results of an online survey of ecigarette users, Tobacco Harm Reduction Yearbook 2010.	303	79%
Etter JF. Electronic cigarettes: a survey of users. BMC Public Health 2010, 10:231.	81	63%
The Consumer Advocates for Smoke-Free Alternatives Association, online survey of e-cigarette users.	2217	80%

Here is a summary of the success rates for the three methods of achieving smoking abstinence:

Method	Success Rates
NRT	Best Case: 10-15% As directed: 2-7%
Swedish Snus	55-90%
Electronic Cigarettes	63-80%

If the WHO FCTC succeeds in pushing electronic cigarettes and smokeless products such as Swedish snus off the market, they will have succeeded in making a significant contribution to the death of millions of smokers who could have quit smoking by switching to a safer source of nicotine.

Reality Faces Off Against Unfounded Fears

Compare and contrast reality with fears about electronic cigarettes voiced by people who have never seen one, never talked to anyone who used one, and never bothered to read the available studies.

The Fears - As reported in the Annals of Internal Medicine, Volume 153, Number 9, p. 607-609 (“E-Cigarettes: A Rapidly Growing Internet Phenomenon”):

We contend that the e-cigarette boom presents important public health concerns on at least 3 fronts. First, e-cigarettes may pose a risk as starter products for nonusers of tobacco. Although candy-flavored tobacco products and e-cigarettes were recently banned by the FDA in efforts to hinder marketing toward children, the posturing of e-cigarettes as “green” and “healthy” could deceptively lure adolescents. E-cigarettes also may represent a way for adolescents and adults to skirt smoke-free indoor air laws.

The Reality - As reported in Chapter 19 of the Tobacco Harm Reduction Yearbook 2010 (“Electronic cigarettes (e-cigarettes) as potential tobacco harm reduction products: Results of an online survey of e-cigarette users”):

All respondents previously smoked and 91% had attempted to stop smoking before trying ecigarettes. About half (55%) were 31-50, while 32% were >50 years old. Most (79%) of the respondents had been using e-cigarettes for <6 months and reported using them as a complete (79%) or partial (17%) replacement for, rather than in addition to (4%), cigarettes. The majority of respondents reported that their general health (91%), smoker’s cough (97%), ability to exercise (84%), and sense of smell (80%) and taste (73%) were better since using e-cigarettes and none reported that these were worse. Although people whose e-cigarette use completely replaced smoking were more likely to experience improvements in health and smoking caused symptoms, most people who substituted e-cigarettes for even some of their cigarettes experienced improvements.

Similar results were seen in two other surveys of users. J.F. Etter’s “Electronic cigarettes: a survey of users,” published in BMC Public Health reported, “Our results suggest that most people who buy these products are current and former smokers who use ecigarettes to help quit smoking, just as they would use NRT.” The median age was 37, ranging from 19 to 65 years. An unpublished survey conducted by the Consumer Advocates for Smoke-Free Alternatives Association (casaa.org) found that 50.9% of the 2,217 responders were between ages 30 and 49 years and 27.4% were older than 50 years, and 99.6% had been smokers.

Thus, reality certainly does not match the fears that e-cigarettes will be “starter products” geared towards adolescents and children. It is interesting that critics of e-cigarettes accuse manufacturers of offering flavors as a means of attracting children, but do not accuse the makers of Nicorette gum of luring children to their products via White Ice Mint, Cinnamon Surge, and Fruit Chill flavors.

Lastly, reality faces off against fear #3. E-cigarettes are not burned. Therefore they produce no smoke. Expressing fears that people will use them to “skirt smoke-free indoor air laws” is as ridiculous as fearing that children will purchase root beer as a means of defying laws against sales of alcohol to minors. Root beer isn’t an alcoholic beverage, and vapor isn’t air-polluting smoke.

Authors Yamin, Bitton, and Bates end their Annals of Internal Medicine essay with this statement: "Although the safety and efficacy of e-cigarettes is uncertain, we believe that clearly counseling patients against e-cigarette use, as well as other tobacco use, is prudent." Presumably, the authors would prefer that smokers stick with the FDA-approved smoking-cessation products that have a success rate that ranges from 2% to 7% when used as directed.

It is estimated that there are now a million former smokers who achieved their smoking abstinence by switching to e-cigarettes. It isn't at all prudent to recommend that they stop using e-cigarettes and risk relapse, nor is it prudent to steer current smokers away from a product that has a success rate that ranges from 63% to 80% based on the three surveys mentioned above.

Biological Basis of the Need for Nicotine

Nicotine is neither a nutrient nor a naturally occurring substance in the body. However, nicotine mimics the effects of acetylcholine (ACh) throughout the body, and ACh is a naturally-occurring substance. Although brain disorders can be caused by injury or strokes, most of them are caused by imbalances in neurotransmitters.

And nicotine appears to provide a corrective action for some of these imbalances.

Nicotine is being studied for treating Attention Deficit Disorder, chronic pain disorders, depression, anxiety, and memory impairments. It also works to prevent some of the nastier side-effects of medications used to treat schizophrenia. Nicotine prevents the build-up of alpha synuclean protein deposits in the brain which has implications for the prevention of dementia and Parkinson's Disease.

Many of the diseases that we used to call “mental” or “behavioral” we now know have a basis in biochemistry. There is still a tendency, I think, for people to hold those who have a brain disorder responsible for healing themselves. The “crazy people” should be able to “control themselves” better, the reasoning goes.

How many kids with true hyperactivity disorders were beaten for their misbehavior? And look how long we blamed those with stomach ulcers for being “too uptight” and "refusing" to relax — when in reality the cause of their disorder was a bacterial infection!

So I’m asking you to open yourself to the possiblity that feeling ill in the absence of nicotine and experiencing symptom improvement in the presence of nicotine is not necessarily a moral failing. It just might have a biological basis. This would explain why some folks need nicotine and others do quite well without it.