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What does the evidence say: A Rebuttal to Dr Mendelsohn’s blog published on the ATHRA website on 2 December, 2018

Maurice Swanson’s responses are provided below in bold italicised text.

Fact check. Don’t believe everything you hear in the media!
Posted on December 2, 2018

Maurice Swanson, CEO of the Australian Council on Smoking and Health (ACOSH) was interviewed today on radio 6PR about vaping, following an interview with Associate Professor Colin Mendelsohn, whom he repeatedly called ‘Mr Mendelsohn’. ATHRA “fact-checked” some of the statements made by Mr Swanson.

We found that many statements were misleading and did not accurately reflect the best available evidence.

“The evidence so far show that most people who vape to give up don’t quit in large numbers”

Really? Very large numbers of smokers have reported quitting with vaping in large national surveys, such as 6.1 million in the European Union, 3.2 million in the United States and 2.8 million in England.

These cross sectional surveys do not prove that vaping is responsible for declines in prevalence. And they do not account for the tremendous amount of relapse that occurs with e-cigarettes, as with all smoking cessation and that some who quit using e-cigarettes would have quit regardless, using other methods.

On the contrary, there is increasing evidence that e-cigarettes are associated with inhibiting rather than assisting in smoking cessation  

Longitudinal cohort data (12 months) are being published in the USA from the PATH (Population Assessment of Tobacco and Health) study of vapers. These data are more powerful and important than cross-sectional data, which give no account to widespread relapse.

In Coleman et al’s paper looking at nearly 3000 e-cigarette users found for every person vaping at the start of the study who benefited across 12 months by quitting smoking, there are 2.1 who either relapsed back to smoking to or took up smoking.

The net impact of e-cigarettes may well be to hold more people in smoking than it provides an exit ramp out of it. This would be increasing, not reducing harm.

Even smoking fewer than 14 cigarettes a day – previously considered “light smoking” – doubles the risk of dying prematurelythe equivalent of being morbidly obese compared with having a healthy weight.

“Most continue vaping or dual use”

Not true. Research indicates that about HALF of current vapers are not currently smoking (ie are not dual using). For example:

  • United Kingdom: 55% of vaper have quit smoking and the proportion is increasing. In 2014, the figure was 40%
  • United States: 45% of vapers do not smoke
  • Iceland: 60% of vapers do not smoke
  • New Zealand: 77% of vapers do not smoke
  • Greece: 73% of vapers do not smoke
  • Canada: 37% of vapers do not smoke

Furthermore, many vapers have gone on to quit BOTH smoking and vaping. In the UK alone, 770,000 have done so according to Public Health England.

Again, surveys do not account for the tremendous amount of relapse that occurs with e-cigarettes, as with all smoking cessation and that some who quit using e-cigarettes would have quit regardless, using other methods.

“Dual users do not significantly reduce risk”

During dual use, smokers almost always reduce their cigarette intake, often to very low levels.

The available evidence does not support this claim. See below:

 

This is because they get some nicotine from vaping and puff less on cigarettes. As a result, most studies have shown that dual users reduce their intake of toxins and carcinogens (here and here).

As a result, clinical studies have demonstrated improvements in the health of dual users, for example in COPD (emphysema), asthma and blood pressure.

In any case, dual use is a transition stage for many. Long-term dual users are more likely to try to quit smoking and to succeed in quitting. Over a 12 month period Etter found that 46% of 367 dual users had quit smoking. It takes some time to adjust to vaping and gradually let go of the familiar smoking ritual.

The implications of dual use -even smoking fewer than 14 cigarettes a day – previously considered “light smoking” – doubles the risk of dying prematurelythe equivalent of being morbidly obese compared with having a healthy weight.

Again, the implications of dual use – long-term follow-up provides no evidence that heavy smokers who cut down their daily cigarette consumption by >50% reduce their risk of premature death significantly. 

“Vaping is likely to be less risky than smoking”

This statement is very misleading and does not reflect the huge risk differential between smoking and vaping. All credible scientists are very clear that long-term vaping is highly likely to be far less harmful than smoking. For example:

UK Royal College of Physicians

‘the hazard to health arising from long-term vapour inhalation from the e-cigarettes available today is unlikely to exceed 5% of the harm from smoking tobacco’

Public Health England

The English government health agency agrees with the 95% safer figure, based on the following analysis:

‘the constituents of cigarette smoke that harm health – including carcinogens – are either absent in e-cigarette vapour or, if present, they are mostly at levels much below 5% of smoking doses (mostly below 1% and far below safety limits for occupational exposure)’

Public Health England’s “95% safer figure” has been extensively criticised.

The history of tobacco control is littered with examples of purported reduced harm products including filters, asbestos filters, reduced carcinogen cigarettes, “low” tar, “lights and milds” and tobacco substitutes.

“I suspect many people will be surprised to learn that the entire concept of light (or lite) as applied to foods, beer and virtually everything else was a tobacco industry invention, a vehicle to sell cigarettes.” (Proctor NR, Golden Holocaust: Origins of the cigarette catastrophe and the case for abolition. University of California Press. 2011. (p. 406))

Many of these products have been promoted by false prophets, commercially driven with little evidence, and none of these have been able to demonstrate reduced harm in those who used them.

In areas where risks and harms for new tobacco products need to be considered as well as potential benefits, adherence to the evidence is critical – evidence that can only be collected, reviewed and reported through a rigorous framework, which considers overall population health.

The factoid that e-cigarettes are “95% safer” than cigarettes has been promoted by Public Health England and derives from the guesstimates of 12 hand-picked panellists (the Nutt report).

Public Heath England’s lead officer on smoking told an Australian House of Representatives Enquiry “There’s a lot of nonsense talked about-this 95 per cent figure. It’s getting beyond a joke really. We are very clear that this is just one of the figures that we have used, and there are plenty more. We say what really matters is that evidence underlying this figure came from the Nutt report.”

However, the Nutt report stated: “A limitation of this study is the lack of hard evidence for the harms of most products on most of the criteria.”

Director of the US FDA, Dr Scott Gottlieb

On 15 November 2018 USA FDA Director Dr Scott Gottlieb said:

“Today, the FDA and the Centers for Disease Control and Prevention are publishing data from the 2018 National Youth Tobacco Survey (NYTS). The data from this nationally representative survey, conducted of middle and high school students, show astonishing increases in kids’ use of e-cigarettes and other ENDS, reversing years of favorable trends in our nation’s fight to prevent youth addiction to tobacco products. These data shock my conscience: from 2017 to 2018, there was a 78 percent increase in current e-cigarette use among high school students and a 48 percent increase among middle school students. The total number of middle and high school students currently using e-cigarettes rose to 3.6 million — that’s 1.5 million more students using these products than the previous year. Additionally, more than a quarter (27.7 percent) of high school current e-cigarette users are using the product regularly (on 20 or more days in the past month). More than two-thirds (67.8 percent) are using flavored e-cigarettes. Both these numbers have risen significantly since 2017. 


These increases must stop. And the bottom line is this: I will not allow a generation of children to become addicted to nicotine through e-cigarettes. We won’t let this pool of kids, a pool of future potential smokers, of future disease and death, to continue to build. We’ll take whatever action is necessary to stop these trends from continuing.

‘If we can migrate every adult smoker completely on to an e-cigarette, it will have a profound public health impact. E-cigarettes are not risk free, but they are certainly safer than combustion. I think we can all accept that.’

The overall cancer risk from long-term vaping has been estimated at less than 0.5% of the risk from smoking. There is also a dramatic reduction in exposure to carcinogens and toxins (biomarkers) measured in the blood and urine of vapers compared to tobacco smokers.

The small health risks from vaping should be compared to the substantial risks from smoking. Two out of three long-term smokers will die from a smoking-related disease.

Over 8 million people die globally from smoking each year. There has been only one recorded death ever from vaping, due to a battery malfunction.

The overall risks and benefits of e-cigarettes have been examined in comprehensive reviews of the published evidence by the NHMRC , the TGA , the US National Academy of Sciences, Engineering and Medicine, the European Respiratory Society and Australia’s CSIRO, the findings of which support a precautionary approach to e-cigarettes.

On 1 December 2018, the Lancet Oncology medical journal published a scathing editorial on e-cigarettes: ‘E-cigarettes—new product, old tricks.’

“At the heart of the debate over the utility of e-cigarettes is concern about the extent to which the potential benefits of making a likely-less harmful alternative to tobacco widely available to smokers might be outweighed by several potential risks. Risks identified to date include uptake by non-smokers, gateway effects, dangers associated with dual use, discouragement from cessation, renormalising smoking, and allowing the tobacco industry to influence decision-making in public health” (Tobacco Facts and Issues).

“The ATHRA website has only 4 so-called medical organisations that support vaping”

Actually, there are 33 Australian and international health and medical organisations listed on the ATHRA website here that support vaping.

There are only 3 Australian Health or Medical Organisations listed on the ATHRA website as supporting ATHRA’s current position on e-cigarettes.

In contrast, the following national and international health and medical organisations, support a precautionary approach to e-cigarettes:

  • National Health and Medical Research Council
  • Australian Medical Association
  • Cancer Council Australia
  • National Heart Foundation of Australia
  • Public Health Association of Australia
  • Royal Australasian College of Physicians
  • Royal Australian College of General Practitioners
  • Lung Foundation of Australia
  • Australian Association of Smoking Cessation Professionals
  • Australian Competition & Consumer Commission
  • All Australian government Health Departments
  • World Health Organization
  • World Medical Association
  • World Heart Foundation
  • World Federation of Public Health Associations
  • Forum of International Respiratory Societies
  • International Union Against Tuberculosis and Lung Disease
  • British Medical Association
  • Royal Pharmaceutical Society
  • New Zealand Cancer Society
  • Heart and Stroke Foundation, Canada
  • American Association for Cancer Research
  • American Society of Clinical Oncology
  • US Surgeon General
  • American Lung Association
  • American Thoracic Society
  • National Association of Attorneys General (USA)
  • American College of Preventive Medicine
  • American Medical Association
  • American Society of Addiction Medicine
  • American Osteopathic Association
  • American Association of Clinical Endocrinologists
  • American College of Cardiology
  • American Academy of Family Physicians
  • American Academy of Pediatrics
  • Society of Thoracic Surgeons
  • American College of Chest Physicians

“The latest results from the FDA is a catastrophe”

On 31 October 2018, Dr Scott Gottlieb said:

…”At the FDA, we’re considering the data and proposals shared by the companies, in addition to the disturbing data in youth use trends that has come to light over the past months as we continue to re-examine the FDA’s regulatory approach. We are committed to taking the necessary steps to fully confront the epidemic of e-cigarette use that has gripped the nation’s youth and set in motion an accelerating epidemic. 

… “But, as I’ve said before, the current trends in youth use are not tolerable. We have warned for more than a year that the availability of e-cigarettes cannot come at the expense of addicting a generation of youth on nicotine through these products. We gave ample warnings of the worrisome trends we were observing with respect to rising youth popularity of these products. Now we have hard data to support that public health tragedy that is now underway.”

Mr Swanson refers to the fact that there has been a reported 78% increase in vaping by high school students (14-18 years old) in the US from 2017-2018, which he says is ‘a public health tragedy’.

The National Youth Tobacco Survey (NYTS) did find a 78% increase in past 30-day vaping from 11.7% in 2017 to 20.6% in 2018. However, most of this increase was experimental and occasional vaping which presents little risk to health.

Only 5.8% of high school students in 2018 were regular vapers (≥20days per month). The vast majority of regular vapers are already smokers, so any additional risk to health from vaping is likely to be minimal.

Most importantly however, smoking rates in adolescents are plummeting in the US. Since 2014 when vaping became widespread, smoking rates in adolescents have fallen three times faster than the long-term trend prior to that.

The most plausible explanation for this unprecedented drop in smoking rates is substitution by vaping.

The following graph of NYTS data shows the rise in vaping in US youth (blue) coinciding with a dramatic decline in smoking (orange).

The primary concern of public health is the youth and adult SMOKING rates.

A rise in youth vaping is not desirable, but is a far safer alternative to smoking. This is a public health success story!

These last two sentences do not even warrant a rebuttal.

The use of alcohol and cannabis among youth in the US is MUCH higher than vaping rates.

Mr Swanson may like to read Clive Bates excellent analysis of this here.

“The role of Big Tobacco”

Mr Swanson used the Big Tobacco bogey to reject vaping on the basis that anything that Big Tobacco does must be evil and therefore rejected. Big Tobacco has a wicked and dishonest past. But what if Big Tobacco switched from making lethal combustible tobacco products to safer nicotine products like vapes, surely that is a win for public health?

Juul, one of the largest manufacturers of e-cigarettes, is in discussion with the Altria Group (Philip Morris) to buy a stake in the Juul Company estimated to be worth US$15 Billion. Why would Philip Morris want to buy a stake in Juul if there was real evidence that e-cigarettes help large numbers of smokers quit? They would be sending themselves out of business! 

This is simply an example of product diversification to grow profits in a business that delivers nicotine to addicted smokers and vapers. So, in low-income countries it is full speed ahead with their traditionally lethal and toxic cigarettes, but for high-income countries they want to promote and market traditional cigarettes as well e-cigarettes, which they know are an effective on- ramp for kids to smoking.

“ATHRA takes funding from Big Tobacco”

The Sydney Morning Herald recently reported that: “Australian Tobacco Harm Reduction Association (ATHRA), the doctor-led charity that has driven much of the debate in the past year, says it does not accept donations from tobacco companies or their subsidiaries.

However, it accepted a “one-off, unconditional” donation of $8000 from UK harm reduction organisation Knowledge-Action-Change (KAC), which supports vaping and has accepted money that originated from tobacco companies.”

What all else fails, some vaping opponents play the man in an attempt to discredit the opposition. This criticism was answered in this recent ATHRA blog, by Dr Joe Kosterich.

The Cancer Council receives funding from Coles which is Australia’s largest tobacco retailer. Is the Cancer Council therefore compromised?

“Just an anecdote”

Vapers hate this one. Sharon called in to tell her story on air. After 45 years of smoking, she finally quit by vaping and is slowly weaning herself off vaping. She described how she felt fantastic, has phenomenal cost savings, a reduced cough, no more smell, no stress about where she can smoke, happy it is 95% safer than smoking etc.

Mr Swanson’s response: This is the experience of just one person and cannot be used by governments for policy change.

Anecdotes may be true for individuals but are the lowest level of evidence when it comes to developing policy on “what works”.

It is true that policy cannot be based on one story, but millions of stories should have some influence. How long can we continue to dismiss the lived experience of real people?

In the meanwhile, sorry Sharon, but you will need to go back to smoking. You and the many millions of other vapers have quit the WRONG way.

Please see above the strength of cohort data on vaping and dual use. 

Invitation to Mr Swanson

All of this leads to the pertinent question – what drives this strident opposition to a far less harmful substitute for combustible tobacco? ATHRA and ACOSH share the same objective of reducing smoking-related death and disease as soon as possible and are in 99% agreement on how to do this.

It is important to note that there is no reference on the ATHRA website supporting the evidence-based strategies that have reduced smoking in Australia: TV-led public education campaigns, sustained tax increases, smoke-free workplaces and public places, product regulation, curbs on industry promotion and lobbying etc. And there is no mention of the cynical marketing and promotional activities of the tobacco industry in low-income countries. In contrast, ACOSH has made a major contribution to the adoption of all these strategies since 1971.

We invite Mr Swanson to meet members of the ATHRA Board to discuss the evidence and work together towards our common goal.

This rebuttal was posted by Mr Maurice Swanson, Executive Director, ACOSH.

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