When federal science is muffling harm reduction by vaping

DOI: https://doi.org/10.4414/smw.2016.14331

The Swiss Medical Weekly paper by Gmel et al. “E-cigarette use in young Swiss men: is vaping an effective way of reducing or quitting smoking?” [1] contains errors and methodological bias. Meaningful data and context are hidden. The conclusion that there is no beneficial effect of vaping for smoking cessation or reduction is abusive.

Data used in the paper about vaping was collected only in the second questionnaire (the follow-up) of the C-SURF survey in 2013. No question about vaping was asked in the first part of the investigation. This study is not longitudinal on the subject of vaping, and cannot claim to measure respondents’ behavioural evolution on this issue [2]. At best this could be a cross-sectional study about vaping among young men in Switzerland in 2013, if it was about vapers [3].

The paper defines a vaper as someone who had used at least once an e-cigarette in the year before completing the questionnaire. Authors hid the frequency of use data, although it was collected in the questionnaire. This bias creates confusion between daily vapers and experimenters [4]. In contrast, a longitudinal study by Biener [5] shows that people vaping daily for at least 1 month are more likely to quit. Hitchman [6] found differences in quitting depending on the type and frequency of vaping used, in favour of daily use of “tank” devices (vs “cigalikes”).

The C-SURF survey data on vaping was published in August 2013 in the Journal of Epidemiology Community Health [7]. Daily vapers and people who just tried vaping are differentiated. Of 5081 participants, 249 (4.9%) had used an e-cigarette during the year. Of these, 30 young men were vaping daily, including 27 smokers and 3 ex-smokers. Why did these data disappear? “Unfortunately, despite the large sample size, prevalence rates in the present study were too small to distinguish between intensive and intermittent EC use”, is the justification in the SMW publication. The hidden fact is that 88% of the panel were smokers who were not regular vapers. So, for the vast majority, it seems right to say that keeping the smoking habit while vaping episodically is not beneficial for smoking cessation.

No question was asked in the C-SURF survey as to whether vaping liquids with or without nicotine was used by respondents. Nicotine is an aspect of the smoking addiction that the authors seem to know since they quote Fagerström’s test, even if it is his old 1991 version. Prof. Fagerström revised his test in 2012 [8]. The lack of information about the kind of vaping liquid used distorts understanding of the results. Even more confusing, there is no word in the study about the prohibition to sell vaping liquids with nicotine in Switzerland. The very special Swiss situation is simply ignored by the authors. We analysed, on the basis of Swiss [9] and English statistics [10], the deficit of tobacco quits generated by the federal policy [11]. The ratio between trial and adoption of vaping is six times lower in Switzerland than in England. Whereas 1 in 3 English smokers adopt vaping after trying it, only 1 in 20 Swiss smokers do. Of the million Swiss smokers who had tried vaping until 2014, there could have been 100'000 more quitters if they had easy local access for nicotine-containing liquids.

Epidemiological predictors such as the number of smokers among relatives, the attitude to smoking, social pressures, legal stigmas against vapers in Switzerland, health status, socio-professional status or concomitant use of other psychoactive substances, are not considered in the paper. Another bias is partly raised. The authors note that the panel consisted “only of men”. But no adjustment is made in the analysis. Not only women but older people and foreigners are also ignored. This massive selection bias should have led the authors to refrain from the universal claim they highlighted.

The evacuation of all health benefits of cigarette consumption reduction with vaping is based on only one reference. This reference is not about reducing smoking by vaping, but on the compensatory effect of smoking reduced-nicotine cigarettes [12]. There is no reason a priori to extend this to vapers continuing to smoke (dual-users). On the contrary, empirical evidence suggests that vaping with nicotine inhibits the craving for tobacco [13]. A Cochrane meta-analysis [14] showed that vaping with nicotine significantly increased reducing (RR = 1.31) and quitting (RR = 2.29) smoking rather than vaping without nicotine. This is consistent with evidence that nicotine substitutes reduce intake of tobacco smoke [15]. Reducing cigarette consumption alone is illusory for health benefits. But reducing smoke exposure with nicotine substitutes, like vaping, provides harm- and damage-reduction [16].

Other previous research on the topic is ignored in this paper. One study found that smoking reduction using vaping among asthmatics significantly reduced their lung disease [17]. Another showed that reducing smoked tobacco, with nicotine replacement therapy, increases up to four times the probability of future complete quitting [18]. In a real longitudinal survey, among smokers who were vaping daily at baseline, 46% had stopped smoking after 1 year [19].

Conclusion

Until the 1990s, heroin exit peaked at rates similar to those of smoking, around one success in ten tries. The epidemiological paradigm changed when the terms on which substitutes work to offer a better way out for addicts were studied [20]. It established good practice for creating an environment favourable to harm reduction in the encounter between user and the withdrawal means. Unfortunately, official federal science remains ideologically blind to this point for tobacco control in Switzerland. The result of this anti-harm-reduction political ideology is shown by the C-SURF survey: 46.7% smokers for only 0.5% daily vapers in young Swiss men [7]. Whereas there are already more than six million Europeans who stopped smoking with the help of vaping [21].

References

1 Gmel G, Baggio S, Mohler-Kuo M, Daeppen J-B, Studer J. E-cigarette use in young Swiss men: is vaping an effective way of reducing or quitting smoking? Swiss Med Wkly. 2016;146:w14271. http://www.smw.ch/content/smw-2016-14271/

2 Siegel M. “Study that Purports to Show Vaping Causes Smoking Initiation and Impedes Cessation is a Complete Sham” in http://tobaccoanalysis.blogspot.ch/2016/01/study-that-purports-to-show-vaping.html

3 Helvetic Vape “Dénonciation de la campagne d’influence politique contre le vapotage menée sous le couvert de la science”, http://helveticvape.ch/denonciation-de-la-campagne-dinfluence-politique-contre-le-vapotage-menee-sous-le-couvert-de-la-science/

4 McNeill A, Etter J-F, Farsalinos K, Hajek P, le Houezec J, McRobbie H. A critique of a World Health Organization-commissioned report and associated paper on electronic cigarettes. Addiction. 2014;109(12):2128–34.

5 Biener L,Hargraves JL. A longitudinal study of electronic cigarette use among a population-based sample of adult smokers: association with smoking cessation and motivation to quit. Nicotine Tob Res. 2015;17(2):127–33.

6 Hitchman SC, Brose LS, Brown J, Robson D, McNeill A. Associations Between E-Cigarette Type, Frequency of Use, and Quitting Smoking: Findings From a Longitudinal Online Panel Survey in Great Britain. Nicotine Tob Res. 2015;17(10):1187–94.

7 Douptcheva N, Gmel G, Studer J, Deline S, Etter JF. Use of electronic cigarettes among young Swiss men. J Epidemiol Community Health. 2013;67(12):1075–6. doi:10.1136/jech-2013-203152

8 Fagerström K. Determinants of Tobacco Use and Renaming the FTND to the Fagerström Test for Cigarette Dependence. Nicotine Tob Res. 2012;14(1):75–8. doi: 10.1093/ntr/ntr137

9 Monitorage Suisse des addictions (Août 2015) http://www.suchtmonitoring.ch/docs/library/gmel_0xzwmk3ao6hl.pdf

10 Action on Smoking and Health (ASH – UK). Fact sheet May 2015 on Use of vapourisers.

11 http://vapolitique.blogspot.ch/2015/10/vape-en-stats.html

12 Strasser AA, Lerman C, Sanborn PM, Pickworth WB, Feldman EA. New lower nicotine cigarettes can produce compensatory smoking and increased carbon monoxide exposure. Drug Alcohol Depend. 2007;86(2–3):294–300.

13 Etter J-F, Bullen C. Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy. Addiction. 2011;106(11):2017–28.

14 McRobbie H, et al. Electronic cigarettes for smoking cessation and reduction. Cochrane Database Syst Rev, 2014. 12: p. CD010216

15 Benowitz NL, Zevin S, Jacob P 3rd. Suppression of nicotine intake during ad libitum cigarette smoking by high-dose transdermal nicotine. J Pharmacol Exp Ther. 1998;287:958–62.

16 Jacques Le Houezec, audition publique de la Fédération Française d'Addictologie, 8 avril 2016, Paris.

17 Polosa R, Morjaria J, Caponnetto P, Caruso M, Strano S, Battaglia E, et al. Effect of smoking abstinence and reduction in asthmatic smokers switching to electronic cigarettes: evidence for harm reversal. Int J Environ Res Public Health. 2014;11(5):4965–77. doi:10.3390/ijerph110504965

18 Klemperer EM1, Hughes JR. Does the magnitude of reduction in cigarettes per day predict smoking cessation? A qualitative review . Nicotine Tob Res. 2016;18(1):88–92. doi: 10.1093/ntr/ntv058

19 Etter JF, Bullen C. A longitudinal study of electronic cigarette users. Addict Behav. 2014;39:491–4.

20 Ball JC, Ross A. The effectiveness of methadone maintenance treatment. New York, Springer-Verlag, 1991.

21 Farsalinos KE, Poulas K, Voudris V, Le Houezec J. Electronic cigarette use in the European Union: analysis of a representative sample of 27 460 Europeans from 28 countries. Addiction. 2016 Jun 24. doi: 10.1111/add.13506. [Epub ahead of print].