While scientists and the lay public are daily confronted with a large volume of often conflicting information about tobacco dependence and harm reduction, experts at the global E-cigarette Summit in Washington DC agreed that from six months onwards, a combustible cigarette smoker’s chances of quitting altogether increased when using sufficient nicotine-delivering e-cigarettes properly.
The E-Cigarette Summit describes itself as a neutral meeting point for scientists, regulators, industry, public health and practitioners “to explore the latest research on e-cigarettes and facilitate respectful debate on what remain highly controversial issues”. Owned by Smooth Event Management in the United Kingdom, the summits are held in Britain or the United States, funded through delegate ticket sales. There is no sponsorship or funding from commercial or government organisations, and no commercial links or involvement with the tobacco, pharmaceutical or e-cigarette industries.
The updated Cochrane Review of evidence on smoking cessation with e-cigarettes shows that 70% of smokers who quit combustible cigarettes exclusively for nicotine e-cigarettes stay with their new electronic device for at least six months, writes Chris Bateman for MedicalBrief. The Cochrane living systematic review of electronic cigarettes for smoking cessation is supported through Cancer Research UK’s International Tobacco Advisory Group and is considered the one of the most authoritative sources of scientific data world-wide.
Professor Jamie Hartmann-Boyce, of the Centre for Evidence-Based Medicine and Cochrane Tobacco Addiction Group at Oxford University told the summit that exclusive e-cigarette use was associated with lower levels of biomarkers of potential harm than exclusive use of combustible tobacco – or the use of a combination of combustible tobacco and e-cigarettes. She said this was consistent with other studies and broad scientific consensus that the greatest improvements in health came from ceasing combustible tobacco use entirety and that, although not completely without risk, e-cigarettes were a safer alternative.
Hartmann-Boyce’s group pooled data on a proportion of people using electronic cigarettes at six months or longer, combining data from the intervention arms of 16 studies in which participants were given a nicotine electronic cigarette at study start, and no other pharmacotherapy. A broad range of harm reduction studies in April 2021 and September 2021 also showed moderate certainty evidence of benefit but had limitations.
“We did not detect any clear evidence of harm from nicotine electronic cigarettes, but the longest follow up was two years and the overall number of studies was small,” she added.
A preliminary analysis of studies investigating the effect of electronic cigarette flavours on smoking cessation over time showed no clear links between flavours and harm. There was “some flavour switching”, although this was hard to measure due to a lack of individual participant data.
Ignore ‘stubborn’ smokers at your peril
The summit was also told that researchers who ignore “stubborn” smokers who declare they have no plans to quit, do so at their peril, because a significant number change their minds.
Professor Andy Hyland, Principal Scientific Investigator for the US National Institutes of Health and the US Food & Drug Administration. Hyland cited a cohort study of 1,600 adult daily cigarette smokers who did not initially use e-cigarettes and said that they had no plans to quit smoking.
However, the main outcomes at follow-up included a significant discontinuation of cigarette smoking. One in six people who were smoking combustible tobacco daily and not vaping initially avowed that they had no plans to quit.
However, the study showed that 13.2% changed their minds, saying they wanted to quit smoking within the next six months. Just over 6% said they had quit smoking altogether while 2% had taken up vaping and were much more likely to report wanting to give up smoking combustible tobacco, the study showed.
“This is consistent with other studies on those provided with alternative nicotine devices,” said Hyland. “Smokers with no intention of quitting should be included when assessing the public health impact of alternative nicotine devices.”
Hyland said this called for far greater consideration of smokers who declared they were not planning to quit when evaluating the risk-benefit potential of e-cigarettes for smoking cessation.
Parsing fact from fiction in the tobacco science ‘infosphere’
The Summit also focused attention on how harm reduction and tobacco dependence were heavily contested areas of research between powerful vested interests, both commercial and scientific.
Dr Ray Niaura, a Professor of Social and Behavioural Health at New York University and co-director of its tobacco research laboratory, says that whom to trust and why is difficult in an environment where scientists at large are often unregulated and critically appraised topics are “as biased as anything”. While bias could not be avoided, it could be mitigated, he argued.
Niaura said the global research community lived in a pyramid hierarchy with systematic reviews, critically-appraised topics and individual articles, randomised control studies, cohort studies and case-controlled studies in descending order, leaving Cochrane Review studies and meta-analyses of randomised control studies as the rare reliable exceptions.
“There was even an editorial in the British Medical Journal last year lamenting the fraud prevalent in biomedical literature and saying that peer review was a crappy way to detect fraud,” he added. However, fraud in the harm reduction space was generally not as big a problem, except in the “grey zone between error and misconduct”.
“There’s a reproducibility and statistical crisis and even digging the truth out of the data emerging from the, (five year long), Population Assessment of Tobacco and Health, (PATH), study conducted by the US Centers for Disease Control, can be hard,” he said.
To illustrate, he showed a slide analysis of differing conclusions reached from the 20 PATH studies on e-cigarettes and smoking cessation in adult smokers. Eight of them were negative with some studies by the same authors yielding positive and negative results.
A third, highly prevalent level of difficulty was “spin”, and how people interpreted results. While there were systems to rate scientific papers for degrees of spin, a common tactic was to claim results implied a causal relationship.
His fourth-rated offender was the sheer weight of information. Niaura said a Pubmed search he did of scientific publications on e-cigarettes rose from virtually none in 2009 to 8,092 in 2019. Social media like Facebook, Twitter, Tik-Tok and Meta created an ever-greater flood of information, “much of it sewage”.
He warned that propagandists did better during long periods of scientific debate when it was easier to influence policy using lots of small, underpowered studies with equivocal results. “If you torture the data long enough, it will confess,” he quipped.
Transparency key
Solutions lay in open data, sharing results with other scientists, public registering protocols before a study was conducted, and openly collaborating with other research groups, while using sound reporting guidelines.
“We have to look at the positive and negative incentives for scientists. Truth and understanding moral responsibility, altruism, human advancement, credibility, esteem and eminence, monetary and regulatory gain, lawsuits, sociopolitical influences, publication, citations, academic and other advancement, research funding and grant awards. The first-mentioned incentives are more critical and harder to change,” Niaura said.
Niaura, is a co-investigator on several NIH grant awards, and in 2019 he reviewed grant proposals related to tobacco harm reduction studies for the Foundation for a Smoke Free World. He shared some fascinating comparative figures on the historical prevalence of smoking versus vaping in the US.
These showed an accelerated decline in smoking from 14% in 2013 to 5% in 2019 and then further, to 1,9% last year. In stark contrast, vaping rose from 5% in 2013 to 27,5% in 2019, declining to 11,3% last year.
This is the first of Chris Bateman’s coverage for MedicalBrief of the Summit. The second article can be accessed here:
E-cigarette Summit: Vaping improves odds of quitting tobacco smoking