Vaping does not have the benefits its proponents claim, warns Professor Simon Chapman.
Vaping proponents often cite their benefits, promoting the method as a safer alternative to smoking conventional cigarettes. But these claims are dangerous and more grounded in fiction than reality, claims one expert.
Speaking at last weekend’s Annual Women’s and Children’s Health Update conference in Sydney, public health expert Emeritus Professor Simon Chapman tore apart 10 claims frequently made about vaping.
Claim: E-cigarettes are 95% less harmful than smoking
This oft-repeated figure came from a 2014 report built off the expert consensus on the harms of nicotine-containing products such as cigarettes, nicotine replacement therapy, oral tobacco and vaping.
“In the report there is not one calculation of how that figure was conjured,” said Professor Chapman.
Moreover, the report, led by English neuropsychopharmacologist Professor David Nutt, even admitted there was a “lack of evidence” on harms associated with most of these nicotine products.
“I edited a medical journal for the BMJ called Tobacco Control for 17 years,” Professor Chapman said. “I don’t think in that whole time I ever saw a caveat as sweeping as that.”
The paper was “based upon fluff”, he added. “There’s nothing to it. And yet it was published and has become effectually a factoid.”
Claim: We have enough evidence now to call e-cigarettes virtually 100% safe
This claim also misrepresented the nature of scientific research and the timelines needed to make confident calls on the safety of products.
For example, 20 years after the surge in cigarette smoking uptake, surgeons still had not seen much associated lung cancer, yet today it was well established as the leading cause of cancer death worldwide, Professor Chapman said.
That timeline was worth keeping in mind when proponents of vaping pointed to the 10-year period since vaping became popular, Professor Chapman said.
In fact, the evidence is building that vaping does cause harm, he said.
In 2018, the US National Academies of Science, Engineering and Medicine found “substantial evidence” that e-cigarettes could cause acute endothelial cell dysfunction, although they noted that the long-term effects of this exposure wasn’t clear. Moreover, components of e-cigarette aerosols could also promote formation of reactive oxygen species/oxidative stress,” they wrote.
Since then, even more research had been done, Professor Chapman said.
“It is likely to be an area where we’re going to see a lot of morbidity and maybe even mortality,” he told the conference.
Claim: Nicotine is almost harmless – smoke is what causes all the harm
You’ll probably have heard that “people smoke for nicotine, but they die from the tar”, a quote from a 1976 paper by British psychologist and harm reduction advocate Michael Russell..
Nicotine has also been touted as a “wonder drug” for many conditions including pain relief, anxiety, depression, schizophrenia, Tourette’s disease, Parkinson’s disease and ulcerative colitis.
“Yes, there is some evidence for these things,” Professor Chapman said. “But if you go to PubMed and put in the words ‘nicotine angiogenesis’, ‘cell proliferation’ and ‘apoptosis’, you’ll be deluged with a number of scientific papers which present a very, very different view of nicotine as a potentially toxic agent which can be pathological when consumed in high doses.”
What was worrying was the amount of people consuming nicotine at very high doses due to vaping, he said
For example, cigarette smokers inhaled around 104 puffs per day, and vapers inhaled 500-600 puffs daily, he said.
In the four decades since, researchers have also found major safety concerns from nicotine inhalation, certainly from addiction and also likely around cardiovascular disease and reproductive toxicity. There are also suggestions nicotine may impair adolescent brain development and increase the risks of infectious diseases and cancer.
Claim: There’s no reason to worry about thousands of flavouring chemicals
Instead, respiratory physicians have urged caution around inhaling any compound or agent into the lungs that doesn’t need to be inhaled.
Professor Chapman offered the thought experiment of an asthma inhaler manufacturer trying to take a leaf out of the book of e-cigarette companies.
“Why are salbutamol inhalers not flavoured?” Professor Chapman asked. “You would think that manufacturers would bend over backwards to make flavoured salbutamol available, particularly for young kids. They haven’t.”
This was because they would immediately get knocked back by regulators, he said.
Even the US body regulating flavours and extracts said last year that “e-cigarette manufacturers should not represent or suggest that the flavour ingredients used in their products are safe because they have [regulator] status for use in food, because such statements are false and misleading.”
Claim: People who both smoke and vape use significantly fewer cigarettes per day: a no-brainer for harm reduction
This simply wasn’t borne out in the evidence, which showed that most vapers were both smoking and vaping, said Professor Chapman.
Moreover, the benefits of reducing cigarette use pale in contrast to the benefits of quitting altogether.
One US prospective cohort study looked at data between 1992 and 2011 for more than 500,000 adults to determine dose responses to smoking levels. Researchers looked at mortality and morbidity data among daily and nondaily smokers, by cigarettes per month, years after cutting down their smoking, and years since quitting. They concluded that “although reducing smoking from daily to nondaily was associated with decreased mortality risk, cessation was associated with far greater benefit.”
Researchers found lifelong nondaily smokers were more likely to die early compared to those who never smoked, even if the number of cigarettes was as low as six to 10 per month.
“Thus, all smokers should quit, regardless of how infrequently they smoke,” they concluded.
“You need to get patients to stop, not to cut down,” said Professor Chapman.
Claim: Many smokers can’t quit. E-cigarettes are therefore needed
This claim is also known as the “hardening hypothesis”.
The argument was that the people who have already quit smoking were the low hanging fruit, and the ones who haven’t yet were in need of extra help, Professor Chapman said.
But a 2020 qualitative review of 26 studies found that was not the case. “Results convincingly indicate hardening is not occurring in the general population of smokers,” the authors said.
Professor Chapman pointed out that the number of cigarettes smoked by people who smoke today continued to decline every time it was measured. “That is an argument for the softening of the smoking population,” he said. “It doesn’t sit well with the argument that people who smoke today can’t quit. People are still quitting every year.”
Claim: E-cigarettes are effective for smoking cessation
This one also doesn’t hold up to scrutiny. A 2020 Cochrane review found that only 10 out of every 100 people who used nicotine e-cigarettes to stop smoking were successful.
“Do you prescribe any drug that routinely has a 90% failure rate?” Professor Chapman asked. “There’s nothing in medicine that uses the word ‘success’ when the failure rates are this high.”
In the general population, there were many more ex-smokers than smokers, and most of those quit without help, Professor Chapman said.
“They heard it was bad, they didn’t like doing it, they regretted starting, their families nagged them and people at work and their peers stopped smoking, so they started quitting,” he said.
That combination of factors often accumulated and was a strong driver of the growth in quitting rates, he added.
To illustrate their lack of value as a quit aid, he pointed to a 2020 US cohort study that found smokers who used both traditional cigarettes and vapes had no higher quit rates than those who didn’t vape.
Claim: Nations with high vaping rates are seeing faster declines in smoking
Australia has done a good job of reducing smoking rates when compared to countries that have higher rates of vaping, said Professor Chapman. Data from 2020 showed that only 11.8% of Australians currently smoked, the second-lowest rate just behind New Zealand.
“The typical cigarettes smoked per day in current cigarette users, ex-vapers, and people who have tried to quit but didn’t continue, are approximately the same,” said Professor Chapman, pointing to UK figures from the Office for National Statistics.
The “conversation showstopper” was the fact that in 2013 there was a massive increase in e-cigarette uptake in England, but there was no dramatic effect on number of cigarette smokers, he said.
What did change smoking numbers was the rise in cost of cigarettes.
Claim: Vaping is not a gateway to smoking
Many cohort studies show that young people who use e-cigarettes have a higher uptake of cigarettes than their counterparts who don’t vape, Professor Chapman told the audience. One study of more than 10,000 children tracked from birth, years 11, 14 and 17, found that of those who weren’t already smokers at age 14 but vaped, were five times more likely to start smoking by age 17 than the non-vapers.
“It looks like it’s very much a gateway for some kids,” he said.
Claim: Big Tobacco really wants to get out of smoking
“Really? Why are they still opening new factories? Why are they opposing effective tobacco control in New Zealand,” Professor Chapman asked. “They’ve just introduced a bunch of other budget priced tobacco products.”
“They’re not trying to get people to use vaping instead of smoking, but as well as smoking.”