Fact Check: Too soon to know if e-cigarettes help people quit smoking

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Fact Check: Too soon to know if e-cigarettes help people quit smoking

E-cigarettes are increasingly popular with smokers and people who are trying to quit smoking.

Dr Tarun Weeramanthri is the Executive Director of Public Health at the Western Australian Department of Health. He told ABC Radio on June 3, 2014, that the evidence doesn’t support the idea that e-cigarettes help people stop smoking. 

“Some people will say, you know, and it may be true on the individual basis, these devices helped me quit. But when we look at the evidence, many more people keep smoking both normal cigarettes and e-cigarettes,” he said.

“So the long term trials haven’t been that conclusive about the effectiveness of e-cigarettes to help people actually stop smoking.”

ABC Fact Check investigates.

What are e-cigarettes?

E-cigarettes are battery-powered devices. Some closely resemble conventional cigarettes, but others don’t. The device includes a refillable cartridge containing “e-liquid” or “e-juice”.

The liquid usually contains nicotine, as well as flavours and chemicals which are converted into a vapour and absorbed into the bloodstream. Flavours range from menthol through to pina colada and banana split. 

The vapour is exhaled as an odourless mist. Smoking an e-cigarette is often called vaping.

Why are people using e-cigarettes?

Research shows that people often use e-cigarettes in the hope that they will help them quit smoking.

E-cigarettes provide the nicotine hit found in conventional cigarettes but do not contain tobacco. Because vaping mimics smoking, it is thought to help with the behavioural aspect of cravings.

People also think that e-cigarettes are less dangerous than conventional cigarettes. Recent studies show between 80 and 84 per cent of users thought they were less harmful.

Surveys show that in 2012, seven per cent of adults in the European Union and the United States had tried e-cigarettes, according to a recent scientific review by researchers from the Center for Tobacco Control Research and Education at the University of California, San Francisco. 

The researchers said all the population-based studies they reviewed showed that people still smoking tobacco were the main users followed by former smokers, with non-smokers the least common users.

What are the risks?

E-cigarettes can contain nicotine, which is highly addictive and can have harmful effects on the developing foetus in pregnant women.

The level of nicotine in the e-liquid is high enough to raise concerns and there have been reports of nicotine poisoning if the liquid is spilled on the skin or ingested.

E-cigarette vapour is not simply water vapour. It contains small particles, similar in size and number to those found in tobacco smoke, that reach deep into the lungs. While it includes toxic substances, these are at much lower levels than in conventional cigarettes.

The safe lower limit for exposure to these toxicants is unknown. The long-term effects of some of the ingredients in the vapour like propylene glycol in inhaled form, as opposed to its more widespread use as a topical or ingested agent, are unknown. 

Australia’s Quitline says “there is a lack of evidence that e-cigarettes are safe to use, or that they help people to quit smoking”.

What are the current controls on e-cigarettes in Australia?

E-cigarettes are not currently approved for use as a quitting device in Australia, as they have not yet been assessed by the Therapeutic Goods Administration, whose website says the Australian Government is concerned about the use of e-cigarettes, and the impact of wide scale use is unknown.

A spokesman for the Department of Health told Fact Check that so far no e-cigarette manufacturers have applied for approval or provided any safety or efficacy data to the TGA. 

Without TGA approval, e-cigarettes cannot be imported as quitting devices, or sold as such.

Importing the devices is not prohibited as long as the packaging does not make a claim about any form of therapeutic benefit. 

But selling the device within Australia may be illegal under state and territory legislation because most states prohibit the sale of goods resembling tobacco products, even those without nicotine.

Western Australia recently prosecuted Vincent Van Heerden, whose company Heavenly Vapours was selling nicotine-free e-cigarette devices over the internet. He was fined $1750 and ordered to pay court costs of over $14,000 for breaching the WA Tobacco Products Control Act 2006.

Nicotine is classified as a ‘Schedule 7 Dangerous Poison’ and it is illegal to sell it unless a permit has been granted.

Users in Australia get around the ban on sale by importing small personal supplies of the liquid refills from overseas.

The evidence for e-cigarettes as a quitting device 

When asked why he thought e-cigarettes did not help people quit, Dr Weeramanthri referred Fact Check to a 2012 scientific review by the University of California, San Francisco. It found more people end up using both e-cigarettes and conventional cigarettes, instead of quitting tobacco completely.

The review pooled the results of five population-based studies and found e-cigarette users were less likely to quit tobacco cigarettes than people who smoked tobacco but not e-cigarettes. 

There are a handful of overseas studies that suggest e-cigarettes could be effective for quitting smoking, but all have significant limitations..

“A survey of almost 6000 adults in the UK found 20 per cent of e-cigarette users had quit tobacco cigarettes in the previous 12 months. Only 10 per cent of respondents who had used over-the-counter nicotine replacement therapy (like patches) and 15 per cent of those using no quitting agent at all had managed to quit tobacco cigarettes.

While this suggests e-cigarette users were the most successful quitters, there are several limitations to the study. It relied on self-reporting which can affect recall and lead to over- or under-reporting depending on method used.

Long-term quitting and relapse rates are unclear. The longest quit attempt of those surveyed was 12 months.

The study also shows a much higher number of participants continued to smoke tobacco cigarettes compared to those who quit. Eighty per cent of e-cigarette users had not stopped smoking tobacco cigarettes at the time they were surveyed. 

A randomised controlled trial in New Zealand looked at smokers who attempted to quit using nicotine e-cigarettes, nicotine patches, or nicotine-free e-cigarettes. It found that while slightly more people in the nicotine e-cigarettes group quit, so few people in any of the three groups stopped smoking that the differences were not statistically significant. Its authors said: “Uncertainty exists about the place of e-cigarettes in tobacco control, and more research is urgently needed”.

A review of published data included an analysis of nine studies looking at e-cigarettes and quitting. It found the data was “ultimately inconclusive” and that e-cigarettes are “of uncertain benefit in quitting smoking”. 

What the experts say

The director of advocacy at Cancer Council Australia, Paul Grogan, says there is a lack of convincing evidence that e-cigarettes help people quit, and the Cancer Council has concerns over the widespread introduction of e-cigarettes because they could reduce Australia’s quitting rates and increase the acceptability of smoking again.

The latest data from the Australian Bureau of Statistics on smoking shows that in 2012, just over 16 per cent of the population aged 18 and over, or 2.8 million Australians, smoked tobacco.

More recent findings released in July by the Australian Institute of Health and Welfare show the number of daily smokers aged 14 and over has dropped from about 15 per cent in 2010 to 12.8 per cent in 2013.

OECD data from 2010 showed Australia, with 15 per cent of the population smoking daily, had the sixth lowest rate among 40 surveyed countries. The OECD average is 21 per cent, with Russia and Greece the heaviest smokers at nearly 34 per cent and 32 per cent respectively.

Mr Grogan said the research on e-cigarettes so far has limited relevance for Australian smokers, because most were overseas studies and do not compare to the Australian context of low smoking rates and a ready availability of effective quitting therapies.

Professor Wayne Hall, Director of the University of Queensland Centre for Youth Substance Abuse Research, said people on both sides of the debate are making firm statements despite flimsy observational evidence and often with a selective approach to the literature.

Professor Hall, a signatory to an open letter to the World Health Organisation asking for e-cigarettes to be considered as part of a wider harm reduction strategy, believes current bans in Australia should be reconsidered.

“We’ve been trying to run a randomised controlled trial… but we can’t do our study in certain states because it is a criminal offence to distribute the nicotine,” he said.

Professor Stephen Leeder, Emeritus Professor of Public Health and Community Medicine at the University of Sydney, says e-cigarettes exist in an “evidence-free zone” and caution is necessary.

Professor Leeder, a signatory to a second open letter to the WHO urging a strict regulatory framework for e-cigarettes, says the current scientific literature is problematic because of the short duration of the studies. 

“You’ve got to have studies that will look at a duration that’s biologically meaningful – it’s not much use quitting for six months,” he told Fact Check. 

Professor Mike Daube, from Curtin University in Perth and also a signatory to the second letter, told Fact Check that on the basis of the currently available evidence it was correct to say e-cigarettes were more likely to result in people both vaping and smoking. 
But he said it was very difficult to make “any sensible assessments about e-cigarette-type products” due to a lack of quality control and good information about them. 

“We are still in the very early stages, and we don’t actually know very much – from what’s actually in them, to their longer-term health impacts,” he said.

The verdict

Dr Weeramanthri can say that recent evidence has shown e-cigarettes more often result in people continuing to use both e-cigarettes and conventional cigarettes instead of quitting smoking.

But current research is generally of poor quality and experts contacted by Fact Check said there was not enough reliable scientific evidence to sure about the effectiveness or otherwise of e-cigarettes as a quitting agent.   

It’s too soon to know.

Sources