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Controversy continues over benefits and risks of e-cigarettes

A new study shows no significant difference in the quitting rates between smokers who use e-cigarettes and those who don’t. The finding, however is not definitive.

E-cigarettes represent for many researchers “the best hope so far to put a stop to smoking-related death and disease by replacing deadly cigarettes with a safer alternative,” says Peter Hajek, director of the Tobacco Dependence Research Unit at the Barts and The London School of Medicine and Dentistry.
REUTERS/Toby Melville

Increasingly, smokers are turning to e-cigarettes as a way to quit the dangerous habit once and for all.

It would be helpful, therefore, to have some good evidence, one way or the other, about whether these battery-powered devices, which create a nicotine-infused vapor but not smoke filled with cancer-causing tar, actually enable smokers to reach that all-important goal.

That’s why a new study, published Monday in JAMA Internal Medicine by researchers at the Center for Tobacco Control Research and Education at the University of California, San Francisco, has received such widespread attention. It found that people who use e-cigarettes are no more likely to quit smoking — or even reduce their cigarette consumption — over a period of a year than those who smoke traditional cigarettes.

The finding is based on self-reported survey data collected from 949 smokers in November 2011 and then again in November 2012. Of those smokers, 88 said they used e-cigarettes.

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At the end of the year, 13.5 percent of all the smokers had quit smoking, but only 9.7 percent of the e-cigarette users had.

Statistically, this suggests no difference in the rate of quitting between people who smoke traditional cigarettes and those who use e-cigarettes, say the study’s authors.

Important caveats

Unfortunately, however, that finding, although interesting, is not definitive.

To begin with, the low number of e-cigarette users in the study, particularly those who quit smoking (nine in all) limits drawing a statistically significant conclusion about a relationship between e-cigarette use and quitting — something the study’s authors themselves acknowledge in their paper.

In addition, although the study collected data on the participants’ overall intentions to quit smoking, it lacked data on whether the users of the e-cigarettes had turned to the devices specifically to help themselves kick the habit.

That means that the study may not have been comparing two equivalent groups in terms of their motivations to quit smoking.

In fact, as Dr. Michael Siegel, a professor of community health sciences at Boston University School of Public Health, angrily notes on his blog, “It is quite apparent from the study itself that the authors knew that the overwhelming majority of the 88 electronic cigarettes ‘users’ in their study had little or no interest in quitting and were not using these products as part of a quit attempt.”

Siegel takes the study’s authors to task for this:

In the Table, the authors report that of the 88 e-cigarette “users,” only 8.0% reported that they were trying to quit at that time (that is, within the next 30 days). And only 39.8% of the e-cigarette users had any intention of quitting in the next six months. This means that we actually know for a fact that the majority of e-cigarette users in this study were not using these products as part of a quit attempt.

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What this indicates is that this is not simply junk science. Rather, it is a deliberate attempt on the part of the investigators to misuse data. They are using these data to draw a conclusion about whether electronic cigarettes are effective in helping smokers quit, yet they are knowingly drawing upon data from smokers who are using e-cigarettes for other reasons, who may have simply tried an electronic cigarette once, and who most definitely were not using these products as part of a current quit attempt.

In other words, 92% of the e-cigarette users in the study were not trying to quit. We know for a fact that 92% of the e-cigarette users were not making a quit attempt. And yet the study authors interpret the data as if these smokers were trying to quit using e-cigarettes, but failed!

Controversy continues

Peter Hajek, director of the Tobacco Dependence Research Unit at the Barts and The London School of Medicine and Dentistry, shares Siegel’s skepticism about the study, although he’s more diplomatic about it — at least he was when talking to Nature reporter Daniel Cressey.

E-cigarettes represent for many researchers “the best hope so far to put a stop to smoking-related death and disease by replacing deadly cigarettes with a safer alternative,” Hajek told Cressey.

Thus, those researchers are going to want stronger evidence of e-cigarettes’ ineffectiveness in quitting smoking than that offered in the new study.

Hajek also said, according to Cressey, “that the new paper shows only that e-cigarettes appeal to smokers who are heavily dependent on tobacco. The same results would be obtained if the survey looked at smokers who try nicotine-replacement treatments, he says, and the results have no bearing at all on whether e-cigarettes are or are not an effective method of smoking cessation.”

Still, there’s no strong evidence that e-cigarettes do help smokers quit, either. So the authors of the JAMA Internal Medicine study have a point when they write that “regulations should prohibit advertising claiming or suggesting that e-cigarettes are effective smoking cessation devices until claims are supported by scientific evidence.”

Major concern: teens

The major concern about the growing popularity of e-cigarettes is, of course, their appeal to young people. Another survey-driven study published earlier this month in the journal Pediatrics concluded that the “use of e-cigarettes does not discourage, and may encourage, conventional cigarette use among U.S. adolescents.”

But that study’s methodology has also been called into question. Its data could not determine if the e-cigarettes were a “gateway” to smoking or if the teens had switched to the devices after becoming addicted to traditional cigarettes.

“The authors seem to have an ax to grind,” Siegel told Reuters reporter Toni Clarke. “I could equally argue that what this study shows is that people who are heavy smokers are attracted to e-cigarettes because they are looking to quit.”

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A poison danger

What is clear and non-controversial, however, is that the liquid in e-cigarettes poses a poison danger to children. Last week the Minnesota Poison Control System reported a 10-fold increase in reports of young people being poisoned by “e-juice” that had been swallowed, inhaled or spilled onto the skin.

Five such poisonings were reported in the state in 2012. That number jumped to 50 in 2013. None of those poisonings resulted in serious injury, but, as Stacey Bangh, clinical supervisor at the Hennepin Regional Poison Center, stated in a press release, “Given this rate of increase, it’s not a matter of if a child will be harmed by these products, but when.”

Not only is e-juice not required to be contained in child-proof packaging, it often contains flavorings, such as “bubble gum” and “cotton candy,” that appeal to young children.

Health officials strongly urge e-cigarette users to keep the substances out of the reach of children.

As for e-cigarettes’ usefulness in quitting smoking, stay tuned.