Riker/Hahn e-cig review article [NCNA]

[Tom09]

CA Riker, K Lee, A Darville, EJ Hahn (2012): E-Cigarettes: Promise or Peril? Nursing Clinics of North America, 47(1), 159-171.

[Abstract] Electronic cigarettes (e-cigarettes) use a heating element to vaporize nicotine and other ingredients, simulating the visual, sensory, and behavioral aspects of smoking without the combustion of tobacco. An ever-growing number of companies around the world manufacture a wide variety of e-cigarette brands, despite scant information on the safety of the ingredients for human inhalation. This article provides an overview of the history, production, and marketing of e-cigarettes, the contents of e-cigarettes and vapor, how they are used, public health concerns, and implications for nursing practice, research, and policy development.

Well, this abstract reads nearly innocent. Outline includes topic “The role of E-cigarettes in the “harm reduction” debate” and there it might get interesting - but article is behind a paywall.

On this occasion, it’s certainly worth to recall authors’ previous, highly polemic opinion piece: Hahn & Riker in 2011 called a user interest group the problem. “By refuting research on potential dangers and attacking public-health professionals, these groups derail effective interventions to reduce tobacco use and exposure to secondhand smoke, such as FDA-approved cessation treatments and smoke-free laws.” (see OP-Eds: Hahn & Riker attack, Kristin (CASAA) response).

 

[Vocalek]

Although it wasn't written for the purpose of a rebuttal to Hahn & Riker's earlier Op-Ed, this recent Expert Review certainly does a wonderful job of it.

The emerging phenomenon of electronic cigarettes

Caponnetto P, Campagna D, Papale G, Russo C, Polosa R.

Expert Rev Respir Med. 2012 Feb;6(1):63-74

The need for novel and more effective approaches to tobacco control is unquestionable. The electronic cigarette is a battery-powered electronic nicotine delivery system that looks very similar to a conventional cigarette and is capable of emulating smoking, but without the combustion products accountable for smoking’s damaging effects. Smokers who decide to switch to electronic cigarettes instead of continuing to smoke would achieve large health gains. The electronic cigarette is an emerging phenomenon that is becoming increasingly popular with smokers worldwide. Users report buying them to help quit smoking, to reduce cigarette consumption, to relieve tobacco withdrawal symptoms due to workplace smoking restrictions and to continue to have a ‘smoking’ experience but with reduced health risks. The focus of the present article is the health effects of using electronic cigarettes, with consideration given to the acceptability, safety and effectiveness of this product to serve as a long-term substitute for smoking or as a tool for smoking cessation.

The emerging phenomenon of electronic ... [Expert Rev Respir Med. 2012] - PubMed - NCBI

I now have a copy of the full article. The journal, Expert Reviews in Respiratory Medicine, did a wonderful job of layout, including several colorful figures and tables.

Here is the caption for one of the figures.

Figure 3. Medical infograph. The infograph was developed by the Consumer Advocates for Smoke-free Alternatives Association to provide medical service providers with a comparison of the potential health risks of cigarette smoke with the health risks of vapor. Since electronic cigarette liquid contains only propylene glycol, vegetable glycerin, flavorings and nicotine, the resulting vapor is unlikely to present any more disease risk than medicinal nicotine products – the risk of nicotine addiction. The many more toxic and carcinogenic ingredients in tobacco smoke are linked to numerous health problems.
COPD: Chronic obstructive pulmonary disease.
Adapted with permission from the Consumer Advocates for Smoke-free Alternatives Association (CASAA).

 

[azzaman]

This information was really useful. Thanks for the post.

 

[dordas23]

I was able to access the article through another source. I didn't find it positive, although I confess that I found it boring. Here is a quote from the concluding paragraph:

"In conclusion, nurses need to direct tobacco users to evidence-based quit strategies and cessation products; support inclusion of e-cigarettes in smoke-free policies and prohibiting sales to minors; and advocate for further research and surveillance of the use and marketing of e-cigarettes."

Sounds like we should just go chew on tooth-picks to stay off cigs.

 

[Thulium]

Sounds like we should just go chew on tooth-picks to stay off cigs.

Sorry, there is no evidence that toothpicks are an effective cessation strategy.

If you don't use a strategy or product that has been proven to safely and effectively ensure that 1.6% of users will be able to completely quit for more than 20 months, the 8.6 million Americans who suffer from a chronic disease caused or worsened by smoking could drop dead faster than new smokers will start...and the market for Bronchodilators, Anti-inflammatories, Antibiotics, Quick-Relief Medications, Devices for Inhaled Medications, Metered-dose inhalers, dry powder inhalers and nebulizers could vanish! If people aren't spending $Billions on smoking cessation drugs, Trillions on these drugs, and they aren't even buying cigarettes with over 100% taxes and settlement fees applied to them--how will the Robert Wood Johnson Foundation (owners of $6B in Johnson & Johnson stock) stay in business?!? Think of the children!!

 

[Placebo Effect]

I was able to access the article through another source. I didn't find it positive, although I confess that I found it boring. Here is a quote from the concluding paragraph:

"In conclusion, nurses need to direct tobacco users to evidence-based quit strategies and cessation products; support inclusion of e-cigarettes in smoke-free policies and prohibiting sales to minors; and advocate for further research and surveillance of the use and marketing of e-cigarettes."

Sounds like we should just go chew on tooth-picks to stay off cigs.

If you could send it to board@casaa.org, it'd be much appreciated.

 

[dordas23]

If you could send it to board@casaa.org, it'd be much appreciated.

I got it from a site where you have to log in (with your account #) to see the stuff, so I'm afraid that if I sent it to you, the antis would claim that vaping leads to piracy.

 

[Chasm]

I was able to access the article through another source. I didn't find it positive, although I confess that I found it boring. Here is a quote from the concluding paragraph:

"In conclusion, nurses need to direct tobacco users to evidence-based quit strategies and cessation products; support inclusion of e-cigarettes in smoke-free policies and prohibiting sales to minors; and advocate for further research and surveillance of the use and marketing of e-cigarettes."

Sounds like we should just go chew on tooth-picks to stay off cigs.

in re: smoking cessation --- "evidence based" <==> profit-driven

 

[Vocalek]

I can translate:

"In conclusion, nurses need to direct tobacco users to evidence-based quit strategies and cessation products; support inclusion of e-cigarettes in smoke-free policies and prohibiting sales to minors; and advocate for further research and surveillance of the use and marketing of e-cigarettes."

Means:

In conclusion, nurses need to steer smokers to the products and programs that only work temporarily, and support every measure to outlaw sales and use of less hazardous products that can serve as permanent substitutes for smoking. We need to keep smokers whirling around on the Wheel of Misfortune. When they try to quit, they spend money on the proven ineffective smoking cessation products, and some of those profits are funneled back to our institutions by Big Pharma donations. When they relapse, they spend money on cigarettes again, and build up the Master Settlement Agreement funds, some of which is funneled back to us. We win, whether they are trying to quit, or relapse to smoking. Our funding, and our reason for existing will dry up if too many smokers find a permanent way to quit.

 

[dagnagan]

I asked a nurse who has worked in an ER for years if allowing patients to use e-cigarettes would make her job easier. Answer: Lord, YES! Patients who have waited four to six hours just to be seen are not easier to deal with if they're also craving a smoke. The fact that you can't smoke anywhere on the hospital property, not even in your car, makes it likely that some patients are leaving the ER against medical advice just so they can smoke.

The hospital now allows patients to use their e-cigs in their rooms, but I wish all smokers could be given e-cigs when in the hospital instead of those useless patches.

 

[Petrodus]

I asked a nurse who has worked in an ER for years if allowing patients to use e-cigarettes would make her job easier. Answer: Lord, YES! Patients who have waited four to six hours just to be seen are not easier to deal with if they're also craving a smoke. The fact that you can't smoke anywhere on the hospital property, not even in your car, makes it likely that some patients are leaving the ER against medical advice just so they can smoke.

The hospital now allows patients to use their e-cigs in their rooms, but I wish all smokers could be given e-cigs when in the hospital instead of those useless patches.

Even the nurses know the FDA approved Patches and Gums are a joke
and suggest e-cigs for patients who smoke.

There's no question that BP is upset about e-cigs. They don't care if you live or die...However, they do care when they see smokers buying e-cigs and not their "worthless" patches and gums. They are upset that many smokers are not buying Chantix and buying e-cigs. Of course, the odds are Chantix could kill you which is a "non-issue" with BP or our FDA.

Eventually, BP will come out with their own e-cigs and supplies...Of course, the FDA will IMMEDIATELY approve them.

What I find embarassing is how many people watch a commercial like this and then run
to the Doctor's office wanting a script for this POISON

 

[Thulium]

Even the nurses know the FDA approved Patches and Gums are a joke
and suggest e-cigs for patients who smoke.

There's no question that BP is upset about e-cigs. They don't care if you live or die...However, they do care when they see smokers buying e-cigs and not their "worthless" patches and gums. They are upset that many smokers are not buying Chantix and buying e-cigs. Of course, the odds are Chantix could kill you which is a "non-issue" with BP or our FDA.

Eventually, BP will come out with their own e-cigs and supplies...Of course, the FDA will IMMEDIATELY approve them.

What I find embarassing is how many people watch a commercial like this and then run
to the Doctor's office wanting a script for this POISON

"agitation, hostility, depression, or changes in behavior, thinking or mood" are the known effects of varenicline. It's like Auschwitz in a bottle! "Vee have vays of making you talk stop smokink!" Pay no attention to the man behind the black box warning, it's the Nicodemon that runs the Tobacco Companies who wants to kill you! Alright Great and Powerful FDA, we've brought you a de-witched broom and I understand that you're not sure if its completely safe but we did our part, now it's time for you to make with the heart, brains, and courage.

 

[Vocalek]

Very few studies have been conducted on the chemical contents of e-cigarettes and vapor, and these studies tested a limited number of products. Therefore, the chemicals listed in Table 1 do not represent all chemicals contained in e-cigarettes, and concentrations of the chemicals in the cartridges and vapor are not presented.

TRANSLATION: Gee, look at this awful list of ingredients, and be "vewy vewy afwaid" because there might even be more. We are ignoring the first rule of toxicology, and withholding the actual concentrations of the chemicals to make it appear that everything on the list is extremely harmful.

Absurdly, the list starts off with the weight loss drug, Rimonabant, and the erectile dysfunction medication, Amino-tadalafil (......). Perhaps this was intended to give the impression that these drugs are a regular ingredient in most, if not all, e-cigarettes. Some two years ago, ECF members laughed at the web site selling these products. Apparently the FDA monitors this forum, because the next thing we knew, that site was among the five that received warning letters from the FDA. The site hasn't changed one bit--probably because the FDA can't touch them over in China. The FDA does, however, insult the intelligence of US e-cigarette users to imply that we would be flocking to that site to purchase these stupid products. And Riker et al. perpetuate the insult.

The list in Table 1 also includes four chemicals reported by Dr. Murray Laugesen of Health New Zealand. There is a footnote reference "a" next to "(Health New Zealand)" and the citation reads, "a. Industry supported."

Make up your minds, ladies. Were the HNZ findings valid, or do you believe Dr. Laugesen accepted a bribe to falsify the report? If the latter, then the chemicals HNZ reported don't belong in your list. But we can figure out easily why you decided to include them: So that under "Characteristics" you could include the inflammatory description "Many volatile organic compounds can cause health effects."

If Riker et al. wants us to believe that they are providing an objective evaluation of the products, then the following text from the HNZ report should have been included as well: "Several toxicants in headspace of the Ruyan® e-cigarette cartridge have, on some tests, been found, specifically acrolein and acetaldehyde, at very low levels, and at levels below those determined to be harmful, and well below the minimum risk levels accepted by the US Public Health Service and OSHA."

Speaking of non-harmful levels, the comment under "Characteristics" next to the names of the four types of Tobacco-specific Nitrosamines in Table 1 reads, "Tobacco-specific nitrosamines are strong carcinogens present in cigarette smoke" Since Laugesen is cited as one of the references for finding TSNAs, how did the authors happen to miss the Note in the HNA report that reads, "Comment. 1) Tobacco-specific nitrosamines (TSNAs) were found, equal to 8 ng, in the 1g of liquid of the 16 mg cartridge. This amount is extremely small, equal for example, to the amount reported to be present in a nicotine medicinal patch."

An examination of the list of references reveals more about the intentions of the writers.

Included, the press release:

FDA and public health experts warn about electronic cigarettes. U.S. Food and Drug Association Web site. Available at: FDA and Public Health Experts Warn About Electronic Cigarettes. Accessed October 19, 2010.

Missing, the Lab report:

U.S. Food and Drug Administration. Final Report "Evaluation of e-cigarettes". http://www.fda.gov/downloads/Drugs/ScienceResearch/UCM173250.pdf

Included: Several opinion pieces, without making clear that negative statements repeated in the article were conjecture, rather than facts based on research.

Flouris AD, Oikonomou DN. Electronic cigarettes: miracle or menace. Personal view. BMJ 2010;340:215.

Cobb NK, Abrams DB. E-cigarette or drug-delivery device? Regulating novel nicotine products. N Engl J Med 011;365(3):193–5.

Henningfield JE, Zaatari GS. Electronic nicotine delivery systems: Emerging science foundation for policy. Tob Control 2010;19(2):89–90.

E-cigarettes banned on domestic flights, reports ASH. Action on Smoking and Health (ASH) Web site. Available at: E-Cigarettes Banned on Domestic Flights, Reports ASH | PRLog.

Missing, some important clinical research reports:

Darredeau C, Campbell M, Temporale K, et al. Subjective and reinforcing effects of electronic cigarettes in male and female smokers. 12th annual meeting of the Society for Research on Nicotine and Tobacco Europe. Bath, UK, 2010. https://secure2.symphonyem.co.uk/CMS/UserDocuments/899/Cathy Book1-121 .pdf

Miura K, Kikukawa Y, Nakao T, Tokai H, Izumi Y, Fujii H, Hojo, T. Safety Assessment of Electronic Cigarettes in Smokers. SEIKATSU EISEI (Journal of Urban Living and Health Association). Vol. 55 (2011) , No. 1 p.59-64. SEIKATSUEISEI : Vol. 55 (2011) , No. 1 p.59-64

R Polosa, P Caponnetto, J B Morjaria, G Papale, D Campagna, C Russo: Effect of an Electronic Nicotine Delivery Device (e-Cigarette) on Smoking Reduction and Cessation: A Prospective 6-Month Pilot

Vansickel AR, Weaver MF, Eissenberg T. Clinical laboratory assessment of the abuse liability of an electronic cigarette. Addiction. 2012 Jan 9. Clinical laboratory assessment of the abuse liabil... [Addiction. 2012] - PubMed - NCBI
Study. BMC Public Health 2011, 11:786. http://www.biomedcentral.com/content/pdf/1471-2458-11-786.pdf

Also missing: Opinion pieces that are positive

Borland R. Electronic cigarettes as a method of tobacco control. BMJ. 2011 Sep 30;343:d6269. Electronic cigarettes as a method of tobacco control | BMJ

Caponnetto P, Campagna D, Papale G, Russo C, Polosa R. The emerging phenomenon of electronic cigarettes. Expert Rev Respir Med. 2012 Feb;6(1):63-74. The emerging phenomenon of electronic ... [Expert Rev Respir Med. 2012] - PubMed - NCBI

Foulds J, Veldheer S. Commentary on Etter & Bullen (2011): Could E-cigs become the ultimate nicotine maintenance device? Addiction, 106: 2029–2030. Commentary on Etter & Bullen (2011): Could E-cigs become the ultimate nicotine maintenance device? - FOULDS - 2011 - Addiction - Wiley Online Library