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E-quitting

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A five-year, first-in-Canada study, led by McGill cardiologist Dr. Mark Eisenberg, is exploring whether vaping really is the magic ticket to finally breathing free and easy.

By James Martin

Although the holidays may seem like a distant memory, statistically speaking, most of us are still sticking with our New Year’s resolutions. (For now. Let’s not talk about how many of us last until July.) For many, that means quitting smoking — and they’re hoping that electronic cigarettes will help. According to the U.S. Centers for Disease Control and Prevention, nearly half of all American smokers have tried e-cigarettes to help them kick the habit. But Dr. Mark Eisenberg wants to know: Is vaping really the magic ticket to breathing free and easy?

Dr. Eisenberg is passionate about getting people to butt out. He gives a lot of smoking cessation talks — just last month, he spoke at the Jewish General Hospital, where he is staff cardiologist — and has noticed that, invariably, reformed smokers come up to him afterward to sing the praises of e-cigarettes, those increasingly popular handheld battery-operated vaporizers that mimic conventional cigarettes.

“This is just a first step," says Dr. Mark Eisenberg of his five-year study." But the fact is that smoking is still the single most reversible cause of mortality in Canada — so it’s an important first step.”

“They say, ‘I smoked for decades and I’ve tried everything — nicotine gum, patches, Zyban, Champix — and I couldn’t stop. Then I picked up an e-cigarette and I never smoked again,’” recalls Eisenberg, who is also a professor in McGill’s Faculty of Medicine and director of the Joint MD/PhD program. “Anecdotally, we have many, many cases like this.”

What doctors don’t have, however, is hard data to back it up. That’s why, this month Eisenberg will start a five-year clinical trial to look at how effective e-cigarettes are at aiding smoking cessation. It’s not just smokers and physicians who are interested in such clarity — so are lawmakers. Under Canada’s Food and Drug Act, e-cigarettes containing nicotine cannot be imported, advertised or sold without Health Canada’s approval; nicotine-free e-cigarettes are not restricted. Although Health Canada has yet to grant such approval, nicotine-loaded e-cigarettes are nevertheless widely and openly available in Canada.

The study, which is funded by the Canadian Institutes of Health Research (CIHR), will follow 486 outpatient smokers at 19 sites across Canada. The smokers will be randomized into three groups. One group will be given e-cigarettes that contain nicotine and counselling. The second group will receive e-cigarettes that do not contain nicotine, and counselling. The third group will only receive counselling. The researchers will supply the smokers with e-cigarettes for 12 weeks, and then follow up with them after six months and a year, observing whether they graduate to total non-smoking, continue with the e-cigarettes, or return to conventional cigarettes. Although some reformed smokers may fall off the wagon after a smoke-free year, Eisenberg clarifies that “statistically significant results at 12 months would still be important evidence” for the efficacy of e-cigarettes as a cessation aid. All 486 patients will not be enrolled simultaneously, with the study expected to roll out over the course of five years.

“The ultimate goal is to use the e-cigarette as a transitional tool in going from smoking conventional cigarettes to not smoking at all,” says Eisenberg. He notes that, at least in the early stages, e-cigarettes are about “transferring the addiction. You’re getting people onto something else that is giving them their nicotine, so they may never quit. E-cigarettes also provide other physical and social aspects because they feel like a cigarette; a pack-a-day smoker makes that hand-to-mouth motion more than 70,000 times a year, for example. That’s a difficult thing to break away from, and a nicotine patch doesn’t provide it.

“We have great hopes that e-cigarettes will be helpful for people trying to quit smoking,” he adds. “Even if they just switch to smoking e-cigarettes that would be better than continuing to smoke conventional cigarettes for decades. I’m not saying that e-cigarettes are safe, but they’re much safer than conventional cigarettes. They’re not going to give you lung cancer. They’re not going to give you heart disease. They’re not going to give you emphysema.

“But what we’re really hoping for is that e-cigarettes lead people to not smoking altogether.”

(This particular study, Eisenberg notes, is not designed to investigate safety concerns, such as whether e-cigarette vapour contains trace elements of harmful substances. Other than their smoking habits, the trial’s participants are healthy, he explains, “so the chances that they’d have adverse effects over a short time like the course of one year are quite low.” The researchers will, however, track whether the smokers are hospitalized for any cardiopulmonary issues. They will also gather data about benign side effects, such as throat irritation.)

E-cigarettes are already big business, ringing up an estimated $500-plus million in sales in the U.S. alone — and that’s without being able to make any claims about helping smokers kick their habits. Eisenberg says that the e-cigarette industry itself isn’t clamouring to make such claims: “They don’t want to be regulated by the Food and Drug Administration [in the U.S.] and Health Canada, so they don’t want to support clinical trials,” he says. “And they don’t need to: Smokers are voting with their feet by buying e-cigarettes to help them quit smoking.” Governments, however, want more than anecdotal evidence.

“This study alone would not be enough for Health Canada to allow companies to market e-cigarettes as smoking cessation aids,” explains Eisenberg. “That said, if this trial shows that there is a substantial reduction in smoking traditional cigarettes, then Health Canada will have to rethink their policy.

“This is just a first step. Then we would need multiple big trials in multiple populations. We would need to use tapering [of nicotine levels] studies, and we would need to use interventions that are longer than 12 weeks. But the fact is that smoking is still the single most reversible cause of mortality in Canada — so it’s an important first step.”

Posted on Wednesday, February 3, 2016

Do e-cigarettes make it harder to stop smoking?

File picture taken on May 25, 2009 in Beiijng shows the inventor of the electronic cigarette, Hon Lik

People trying to give up smoking often use e-cigarettes to help wean themselves off tobacco. Most experts think they are safer than cigarettes but a surprising paper was published recently – it suggests that people who use e-cigarettes are less successful at giving up smoking than those who don’t.

“E-cigarettes WON’T help you quit,” reported the Daily Mail. “Smokers using vapers are ‘28% less likely to ditch traditional cigarettes,'” read the paper’s headline.

The story was reported on many other websites around the world, including CBS: “Study: E-cigarettes don’t help smokers quit,” it said.

The study causing the fuss was written by researchers at the Center for Tobacco Control Research and Education at the University of California, and published in one of the Lancet’s sister journals, Lancet Respiratory Medicine.

It is a meta-analysis, which means the authors reviewed the academic literature already available on the topic. They sifted out the weaker papers – ones that didn’t have control groups, for example – and were left with 20.

E-cigarettesImage copyrightiStock

The conclusion? Smokers who use e-cigarettes have a 28% lower chance of quitting than smokers who don’t use them, according to Prof Stanton Glantz, one of the authors.

But while the conclusion is surprising, so is the number of academics who have criticised the paper.

One was Ann McNeill, professor of tobacco addiction at Kings College London, whose own research is included in Glantz’s analysis.

“This review is not scientific,” she wrote on theScience Media Centre website.

“The information… about two studies that I co-authored is either inaccurate or misleading… I believe the findings should therefore be dismissed.

“I am concerned at the huge damage this publication may have – many more smokers may continue smoking and die if they take from this piece of work that all evidence suggests e-cigarettes do not help you quit smoking; that is not the case.”

Prof Peter Hajek, director of the Tobacco Dependence Research Unit at the Wolfson Institute also called the findings “grossly misleading”.

e-cigarettesImage copyrightiStock

The critics are making three main points. First, the definition of e-cigarettes is a bit loose. There are many different types – some look like cigarettes, others have tanks for the vaping liquid, some are disposable and other are multi-use. They all deliver different doses of nicotine. Many of the papers included in the analysis don’t specify which type people are using, according to Linda Bauld, professor of health policy at the University of Stirling.

Another point is that the studies vary in the way they measure how often people use e-cigarettes. “Some only assessed whether a person had ever tried an e-cigarette or if they had tried one recently, not whether they were using it regularly or frequently,” Bauld says.

Even the paper’s author admits it’s possible that in some of the studies e-cigarettes may only have been used once, which he says would not be a good predictor of whether they had affected people’s ability to stop smoking.

And there is another problem. You might expect, if you were going to draw conclusions about how useful e-cigarettes are in helping people quit, to focus on studies looking at people who are trying to give up.

Prof Robert West, who heads a team at University College London researching ways to help people stop smoking, says this analysis mashed together some very different studies – only some of which include people using e-cigarettes to help them quit.

Vape Lab employee uses an e-Cigarette while workingImage copyrightGetty Images

“To mix them in with studies where you’ve got people using an e-cigarette and are not particularly trying to stop smoking is mixing apples and oranges,” he says.

Some of the studies track smokers who use e-cigarettes for other reasons – perhaps because smoking a cigarette in a bar or an office is illegal and they want a nicotine hit.

“With the studies where people are using electronic cigarettes specifically in a quit attempt the evidence is consistent,” says West, referring to two randomised control trials.

Both are quite small and one was funded by the e-cigarette industry. They took two groups of smokers, and gave one real e-cigarettes, and the other a placebo. The studies reach a broadly similar conclusion to a large, real-world study called the Smoking Toolkit run by West.

West’s investigation follows people in their daily lives and assesses how successful various methods of giving up smoking are – this includes nicotine patches, medicines and going cold turkey.

These studies suggest that people using e-cigarettes to help them quit are 50% to 100% more successful than those who use no aids at all.

In his paper, Glantz acknowledges there are limitations to the research that he analysed. He agrees there are problems with the way the use of e-cigarettes is measured and accepts it’s not clear which devices people are using. But he is sticking by his analysis because he believes he has taken these factors into account.

The editor of Lancet Respiratory Medicine, Emma Grainger, defends the article too. She says she does not see a problem with the paper and that it has been through the normal peer-review process.

Smoke e-cigarettes? The laws are changing…

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This year could ring in big changes for those of you who smoke e-cigarettes.

From May, laws will be standardised across the EU restricting how large their liquid containers can be and how much nicotine they can contain.

Restrictions on advertising will also come in.

Politicians have been grappling for ages about how to deal with e-cigarettes, and whether they could serve as a ‘gateway’ to smoking actual cigarettes.

Opponents say they are a helpful tool for people quitting smoking and should be promoted.

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In the UK, the new laws mean there will be tighter rules on what products you can buy but in other countries the laws will actually be loosened.

For example, they are currently banned in Belgium but from May will be permitted again.

Refill containers will have to be no larger than 10ml while cartridges will have a maximum size of 2ml.

The strongest permissible nicotine strength will be set at 20mg (similar to a strong cigarette).

If three or more EU countries decide e-cigarettes are harmful, they could potentially be banned outright.

Some new laws have already been passed in the UK, such as a ban on selling e-cigarettes or e-liquids to anyone under the age of 18 which came into force in October last year.

One in four e-cigs will be banned in Britain next year after being branded too strong in European Court ruling

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POSTED ON DECEMBER 24, 2015BY IN HEADLINE NEWS, INTERNATIONAL NEWSWITH 116 VIEWS

One in four e-cigs will be banned in Britain next year after being branded too strong in European Court ruling

  • Experts are concerned that e-cigs are gateway for teens to smoke tobacco

  • Under new EU directive e-cigs will have to carry a health warning on them

  • New rules, in May, could also see cigarettes only sold in packets of 20

  • Around 2.6 million adults in UK have used e-cigs in the past decade

By Ben Spencer – December 23, 2015

A quarter of e-cigarettes are set to be banned in Britain next year after Europe’s highest court paved the way for tough new regulations.

Juliane Kokott, advocate general to the European Court of Justice, warned that e-cigarettes may act as a ‘gateway’ for teenagers to go on to smoke tobacco.

Dr Kokott, the EU’s most senior legal officer, said regulation is needed because of ‘possible risks to human health’.

Her intervention will have huge implications for the debate currently raging between health experts in Britain, some of whom insist that e-cigarettes will save thousands of lives, and others who are concerned that they have not yet been proven to be safe.

Dr Kokott said an industry challenge against the new rules – which are due to be introduced in May as part of a new EU directive – should be dismissed.

Judges at the court will have the final say when they deliver a ruling in March.

If they take Dr Kokott’s advice, and dismiss industry objections, vaping devices will no longer be allowed to contain more than 20 mg of nicotine per ml of liquid.

Analysis by London Economics, a policy consultancy, suggests that 25 per cent of the gadgets currently on sale use liquid stronger than this threshold.

The EU Tobacco Products Directive will also mean adverts have to be much more strictly regulated so that teenagers are not targeted.

E-cigarettes will have to carry health warnings telling people they contain a ‘highly addictive substance’.

And the size of refills and of the ‘tanks’ on the gadgets will also be limited for the first time.

Dr Kokott also said that a separate challenge from big tobacco firms over plain packaging for cigarette boxes should be dismissed, paving the way for rules to be brought in from May.

If that change goes through, cigarette packets will only be sold in boxes of 20, the packets will only allowed to be brown or green, and will carry a health warning covering 65 per cent of the box.

E-cigarettes contain a liquid form of nicotine that is heated into vapour to be inhaled, avoiding the harm caused by tobacco smoke.

Industry figures yesterday warned that the new rules will mean vapers are ‘outlawed’ and may go back to smoking if they cannot get the strongest e-cigarettes – but health charities say it is right that emerging industry is properly regulated.

Health experts agree that the devices are much safer than smoking tobacco – but some are concerned about unresolved safety concerns.

The World Health Organisation has warned that they may be toxic to bystanders, many rail companies have banned people from vaping on trains or in stations, and the Welsh Government is planning to prohibit the practice in restaurants, pubs and offices from 2017.

Yet Public Health England claimed in a report earlier this year that vaping was ‘95 per cent safe’ – a claim that was widely criticised when it emerged that it originated with scientists in the pay of the e-cigarette industry.

Dr Kokott said in a written ‘opinion’ presented to the court yesterday: ‘It is not manifestly wrong or unreasonable to accept that e-cigarettes possibly cause risks to human health and that that product could — above all in the case of adolescents and young adults — develop into a gateway to nicotine addiction and, ultimately, traditional tobacco consumption.’

Around 2.6 million adults in Britain have used e-cigarettes in the decade or so that they have been on the market.

Public health experts are keen to promote the gadgets as a smoking-cessation tool.

But they are concerned that the devices are being advertised as a lifestyle accessory – in much the same way that tobacco was in the past.

Ian Gregory, who runs the 100K group of e-cigarette companies, threatened that vapers would feel ‘outlawed’ – and would vote to leave the EU in a bid to rid themselves of the regulation.

He said: ‘Britain’s vapers are determined to save the devices which they believe save their lives.

‘They will now start playing a game of Brexit Poker with the Commission – threatening to vote for Britain to leave the EU in the referendum unless the Commission insists on Britain having an opt-out.

‘There is little awareness yet among politicians as to just how damaging the EU Tobacco Products Directive could be for the e-cigarette industry.’

He claimed that the ban on stronger e-liquid would drive so many vapers back to smoking that it would cost 105,000 lives every year across Europe.

But Alison Cox, director of prevention at Cancer Research UK, said regulation is needed.

‘We believe e-cigarettes need light touch regulations which will help guarantee products are safe and effective, and prevent them being promoted to non-smokers and children,’ she said.

‘But the implementation of these regulations needs to be monitored to ensure that they don’t prevent smokers who want to use e-cigarettes from doing so. It’ s important that people who want to, are able to move away from tobacco cigarettes, which are responsible for one in four cancer deaths.’

Deborah Arnott, chief executive of health charity Action on Smoking and Health, added: ‘Growing numbers of governments around the world are banning the sale of electronic cigarettes.

‘The EU, by regulating them as consumer products, and allowing their sale and use, is recognising the value of these products as alternatives to smoking.’

Totally Wicked, the Blackburn-based e-cigarette company which headed the legal objection, last night played down the significance of the document.

Fraser Cropper, Totally Wicked’s managing director, said: ‘This is not a formal decision, nor a legal judgement on the questions we raised in our challenge.

‘It is a legal opinion prepared to assist the judges in making their decision and will be considered alongside the written and oral submissions. It is not binding.’

One in four e-cigs will be banned in Britain next year after being branded too strong in European Court ruling