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Switching to e-cigarettes could prevent millions of premature deaths
Replacing cigarettes with e-cigarettes during a decade-long period resulted in 6.6 million fewer premature deaths, according to findings recently published in Tobacco Control.
“U.S. tobacco control policies to reduce cigarette use have been effective, but their impact has been relatively slow,” David T. Levy, PhD, department of oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, D.C., and colleagues wrote. “This study considers a strategy of switching cigarette smokers to e-cigarette use (‘vaping’) in the U.S.A. to accelerate tobacco control progress.”
According to study background, researchers used a Status Quo Scenario to calculate cigarette smoking rates and health outcomes and compared it with Substitution models in which vaping largely replaced cigarette smoking during a 10-year period. Researchers evaluated an Optimistic and Pessimistic Scenario; these scenarios varied regarding relative harms of e-cigarettes compared with cigarettes, as well as the impact on overall initiation, switching and cessation.
To assess the impact on public health, researchers compared the scenarios to determine projected mortality outcomes by age and sex from 2016 to 2100. Researchers also separated younger (age, 15 years) and older (age, 35 years) cohorts in 2016.
According to results, in the Optimistic Scenario, replacing cigarettes with e-cigarettes resulted in 6.6 million fewer premature deaths and 86.7 million fewer life years lost compared with the Status Quo. In the Pessimistic Scenario, there were 20.8 million fewer life years lost and 1.6 million premature deaths prevented. Levy and colleagues also found the largest life expectancy gains — 0.5 — in the younger cohort.
“Our analysis shows that a strategy of replacing cigarette by e-cigarette use can yield substantial gains, even with conservative assumptions about related risks,” researchers wrote.
Currently, there are mixed opinions on the role of e-cigarettes in weaning smokers off combustible cigarettes. One report presented by Riyad Al-Lehebi, MD, a respirology fellow at the University of Toronto, and colleagues at the 2015 American Thoracic Society International Conference suggested that e-cigarette use may not result in long-term smoking cessation. A survey among physicians about e-cigarettes that was discussed by
Venkatkiran Kanchustambham , MD, of Saint Louis University School of Medicine and colleagues at the 2016 American Academy of Allergy, Asthma & Immunology Annual Meeting revealed that 50% of those physicians asked see a role for e-cigarettes as part of a “harm reduction strategy.” Another report, this one in the Annals of Internal Medicine, suggested that e-cigarettes are safer than combustible cigarettes when used over the long term.
“We conducted estimates of an Optimistic and Pessimistic scenarios to respond to the different views,” Levy told Healio Family Medicine in an interview.
Lynn T. Kozlowski, PhD, professor of community health and health behavior, School of Public Health and Health Professions, University at Buffalo, who was not involved in the study, was also asked about the varying reports.
“The analysis in this paper gives proper weight to the research that should be emphasized, and de-emphasizes the unfounded fears of possible gateway effects and a concern that e-cigarettes are ‘not safe,’ he said in an interview with Healio Family Medicine.
Kozlowski offered suggestions on how primary care physicians can discuss the study’s findings with their patients.
“Physicians should give first priority to getting their patients off cigarettes as soon as possible,” he said. “If FDA-approved cessation approaches have not worked or if the patient is more interested in trying vaping as a substitute for cigarettes, this should be encouraged as a complete substitute for smoking. Once the patient is securely off cigarettes, the physician can explore reduction in vaping.”
Levy provided some tips on how these medical professionals can broach the subject of his study with their patients.
“Primary care physicians can tell their patients that, while the risks for e-cigarette are less well known than for cigarettes, they are certainly much less harmful, and quitting cigarettes is most important,” Levy told Healio Family Medicine. “If e-cigarettes can help them do that, their health is likely to improve.” – by Janel Miller
Disclosures: Kozlowski and Levy report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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E-cigarettes are becoming wildly popular among youth and come in a large variety of fruit and candy flavors. Youth, who may not otherwise be predisposed to smoking cigarettes, are starting with e-cigarettes — and moving on to other tobacco products including cigarettes, cigars and hookah. The evidence shows that youth who start on e-cigarettes are much more likely to progress to combustible tobacco.
Youth who both use e-cigarettes and cigarettes are much less likely to stop their cigarette smoking, and multiple tobacco product use is increasingly common among youth. Evidence from both observations in humans and studies in lab animals show that nicotine serves as a gateway to other drug abuse. E-cigarettes are addicting a whole new generation to tobacco — and the risk for other drug abuse that comes with it.
The findings from Levy et al. suggesting that e-cigarettes will avert deaths appear to be due to a combination of incorrect assumptions and wishful thinking. Although the assumptions of the model are not fully disclosed in the manuscript, it appears to neglect the impact of e-cigarettes on youth smoking initiation, with the use of non-cigarette tobacco products popular with youth — such as cigars and hookah — specifically excluded. It is wishful thinking that adult smokers who do not wish to stop will somehow switch to e-cigarettes, or that cigarette smoking will decrease to 5% simply based on the availability of e-cigarettes without being accompanied by increases in use of other tobacco products.
Modeling harms from e-cigarettes is challenging. There are a wide variety of products available with virtually no regulation on the products, their contents, or even manufacturing standards, and the long-term impact of years from inhaling high concentrations of nicotine, propylene glycol, vegetable glycerin, diverse flavoring agents and metallic nano-particles are not yet known.
The authors claim that the impact of tobacco control policies “has been relatively slow” yet they neglect to discuss how the tobacco industry has fought, sued, bought politicians and de-funded effective tobacco control initiatives. Likewise, the authors neglected to mention evidence that tobacco product use had been steadily decreasing until the rise of the e-cigarette epidemic hit or the gross underfunding of tobacco control programs.
In their zeal to promote a low-nicotine cigarette strategy, the FDA has delayed implementation of premarket review and other regulation of e-cigarettes and (often flavored) cigars. Despite substantial evidence regarding the dangers of flavoring and its impact on youth initiation, the FDA has failed to take action on candy flavored e-cigarettes and cigars or act on menthol flavorings.
E-cigarettes vs. cigarettes is not a real choice. We need to choose whether or not we are serious about tobacco control; we need to decide whether we wish to leave our youth as fodder for the profits of the tobacco industry or whether we have a duty to protect future generations.