Vaping: UK experts defend safety in face of US lung injury casesBMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6027 (Published 14 October 2019) Cite this as: BMJ 2019;367:l6027
All rapid responses
To me it seems that it is fine to look at VAPING as a cause of toxicity. But does it also act as a co-factor in promoting toxicity and allergies?
Let us look back. Fifty years ago, “tobacco“ was looked upon as a cause of lung cancer. Now some scientists recognise an association between tobacco smoking and fatty liver (though I have not seen any evidence of tobacco being a cause by itself).
We really ought to be looking at a wider question.
Why have allergies and anaphylaxis become commoner and commoner over the past fifty, sixty years?
What changes have occurred in our diet, in the atmosphere, in the medicines we take?
Have we innocently altered the balance between various intestinal bacteria, between the viruses and bacteria in our respiratory passages, with resulting hypersensitivity to previously harmless chemicals, bacteria, viruses?
Competing interests: No competing interests
In June 2018 San Francisco voters banned sales of flavored tobacco products, menthol cigarettes and flavored vaping liquids; living in the most wealthy district of the US they understood the alarming report from the US National Academies of Sciences, Engineering, and Medicine published in January.(1,2) This report received little attention in Europe in contrast to the recent epidemic of serious lung diseases in the US eliciting responses in both continents, but opposite ones. Michigan became the first US State to ban the sale of flavoured e-cigarettes on Sept 4th. In Europe, there is a tsunami of reassurances for safety.
E.g. in the UK, Alan Boobis, emeritus professor of toxicology at Imperial College London and chair of the UK Committee on Toxicity, just claimed “most of the flavours are already used in food, and at the relatively low temperatures used in e-cigarettes they are not going to give rise to hazardous by-products”.(3)
In France, the secretary of health claimed: "We are not in the same situation as in the US. We do not have a specific health alert, there may be long-term side effects, we do not know today" and stressed “e-cigarette is prohibited for sale under 18 years.”(4) She: a) seems to have relied on spin in lay media (https://www.sovape.fr/presse/); b) seems to have overlooked a recent sting operation from a NGO showing 1/10 of French tobacconists sold tobacco to those aged 12 y and 2/3 to those 17 y, despite the legal age having been legally raised from 16 to 18 in 2009. (https://cnct.fr/wp-content/uploads/2019/10/Pour-consulter-notre-dossier-...). The latter confirmed previous testing and is not a surprise as serial red flags from independent experts highlighted the 2009 law was flawed, lacking concerns for enforcement and compliance checks by the administration. However, there is a huge difference between France and the UK: the UK is ranked top for tobacco control (smoking prevalence <15% and a cross-party group of MPs called this spring for legal smoking age to be raised to 21) while in France, prevalence is 27%.
Nevertheless, the epidemic of lung diseases in the US may be a tree masking the forest. Tang and colleagues, after having shown in mice that electronic-cigarette smoke (ECS) produced DNA damage in the lungs and bladder and inhibits DNA repair in lung tissues, just showed the development of lung adenocarcinomas and bladder urothelial hyperplasia.(5) The former have being confirmed in other species. Accordingly, vaping might soon be classified by the IARC as Group 2A: “The agent is probably carcinogenic to humans (limited evidence of carcinogenicity in humans and sufficient evidence of carcinogenicity in experimental animals)” (https://www.iarc.fr/wp-content/uploads/2018/07/Monographs-QA.pdf)
Certainly the “harm reduction” paradigm is attractive for old or exhausted public health advocates, despite having been previously fooled with filters and then with low-tar or light cigarettes.(6) However, as vaping is not cessation, switching only from a Group I carcinogen to a Group 2A carcinogen lacks ambition! Michelangelo warned “The greater danger for most of us lies not in setting our aim too high and falling short, but in setting our aim too low, and achieving our mark”.
However, the present date of affairs in Europe is exciting. Doll and Peto illuminated epidemiological research for all time with their landmark article about smoking.(7) France is looking for revenge: as early as 2016 the High Council of Public Health began its recommendation that e-cigarettes are an aid for stopping or reducing smoking and concluded by proposing the creation of a “medicalized’ e-cigarette” (https://www.hcsp.fr/explore.cgi/avisrapportsdomaine?clefr=541), seeming to overlook the 2015 warning from the WHO against such claims. Further, in January 2019 the Official Bulletin of the French Republic published a report from the Economic, Social and Environmental Council, the third French assembly, recommending in #15: "Position the electronic cigarette with or without nicotine among the other smoking cessation devices: integrate it into the addiction prevention discourse …” (https://www.lecese.fr/sites/default/files/pdf/Avis/2019/2019_02_addictio...) However, John Newton, director of Health Improvement at Public Health England, just stimulated the English team “surely to pursue the epidemiological investigation” and “accept that e-cigarettes have an important part to play in tobacco control” as, in contrast to France, there are hesitations in the UK.(8)
Proctor created the term “agnotology” to point the finger of blame at Big Tobacco for misrepresenting the evidence about tobacco. He may have ignored Voltaire’s warning: “Lord, protect me from my friends; I can take care of my enemies.”
1 Braillon A. San Francisco Voters End the Sale of Flavored Tobacco Products. Ann Intern Med 2019;170:907.
2 National Academies of Sciences, Engineering, and Medicine. Public health consequences of E-cigarettes. January 2018. Available at https://www.nap.edu/resource/24952/012318ecigaretteConclusionsbyEvidence... Accessed 25 October 2019.
3 Hawkes NG. Vaping: UK experts defend safety in face of US lung injury cases. BMJ 2019;367:l6027.
4 Sportouch B, Haddad MP. Vaping: No additional restrictions for electronic cigarettes, announces Buzyn. RTL 22 September 2019. Available at https://www.rtl.fr/actu/politique/vapotage-pas-de-restriction-supplement... Accessed 15 Oct 2019.
5 Tang MS, Wu XR, Lee HW et al. Electronic-cigarette smoke induces lung adenocarcinoma and bladder urothelial hyperplasia in mice. Proc Natl Acad Sci U S A 2019. Online Oct 7. doi: 10.1073/pnas.1911321116.
6 Braillon A. Electronic Cigarettes and Insanity. Am J Prev Med 2016;50:e27.
7 Doll R, Peto R. Mortality in relation to smoking: 20 years' observations on male British doctors. Br Med J. 1976;2:1525-36.
8 Newton JN. Time for The Lancet to realign with the evidence on e-cigarettes? Lancet. 2019. Online 10.1016/S0140-6736(19)32486-9.
Competing interests: AB is an unpaid member of the High Council of Public Health, the expert body of the Ministry of Health for the French government (in France, blowing the whistle when being a civil servant is a specific criminal offence).
In response  first, I wish to bring to your attention certain inaccuracies in Public Health England’s (PHE) report entitled Vaping in England: an evidence update February 2019. It states: “The common features remain that they [e-cigarettes or ECs] contain a battery-powered heating element designed to aerosolise a solution of propylene glycol and/or glycerol, water and frequently flavouring and nicotine (freebase or nicotine salts)”.
What is known is that given ECs rapid development, such products contain many more compounds, including the following: cannabis, synthetic cannabinoids, methamphetamine, MDMA, synthetic cathinones, cocaine, heroin, fentanyl and derivatives, blue lotus flower e-liquids and resins, tryptamines, ketamine, and any combinations that user may add to their ECs tanks. Only some ECs are uniquely nicotine delivery systems. Therefore, when referring to ECs, one ought to specify those which contain nicotine as opposed to others which may contain numerous other compounds.
Many devices contain flavouring products: “The number of available e-liquid flavors exceeded 7500 in 2014 and is still increasing”, all can be easily added to the 4th generation of ECs (mods) at variable concentrations and variable temperatures, enabling users to combine any substance which they can design
An earlier report publish by PHE entitled “E-cigarettes: an evidence update: A report commissioned by Public Health England (2015) stated: “best estimates show e-cigarettes are 95% less harmful to your health than normal cigarettes, and when supported by a smoking cessation service, help most smokers to quit tobacco altogether.” That same report also stated that “There is a need to publicize the current best estimate that using EC is around 95% safer than smoking.”
The first statement failed to quantify as to whether "all" "most" or "some" ECs are 95% safer than cigarettes. Barring a logical quantifier, and give the variety and content of ECs, one would interpret that, most or all ECs are 95% safer than smoking cigarettes. The second statement, states that there was a need to publicize the stated hypothesis.
PHE messages were transmitted worldwide. For those of us living North American that meant that if a reputed institution, such as PHE claims the above to be the case, then there must be some empirical data to corroborate such assertions. A closer look at the evidence now appears meagre and inclusive.[8, 9]
Ironically, publicizing that ECs are 95% safer than cigarettes is similar to Big Tobacco adopting a marketing claim that vaping is healthier and safer. A visit to Philip Morris advertising campaign to Unsmoke the world uses similar language in introducing its line of heat not burn and their newly acquired major hold of JUUL, the number one seller of ECs used in this part of the world and now arriving to England‘s shores. 
Such messaging can lead to adolescents and young adults not only stopping smoking cigarettes but also initiating non-smokers to begin vaping, in the belief that ECs are healthier, safer and non-addictive compared to smoking.
The 2019 update report by PHE recognizes that advertisement ought to be based on more robust evidence and that “marketers can only do so about specific products and not ECs in general”, but PHE does refer to ECs safety in general.
The other component of the statement in PHE 2015 was “…and when supported by a smoking cessation service, help most smokers to quit tobacco altogether“. The logical quantifier in this statement is “most”, which means more than 50% of those who use ECs will eventually quit smoking. Based on current available evidence, that is clearly false. To the best of my understanding several studies show that the rate of cessation using ECs coupled with intensive counselling to be at best 18% one year abstinence.[12, 13] This is certainly short of 51% purported abstinence to help most to quit. Moreover, 18% cessation using ECs compares favorably to the usage of nicotine replacement therapy (NRT) or bupropion coupled with effective intensive counselling, but without the negative known risks associated with vaping. 
But there is another form of harm, possibly even greater than was previously mentioned and as yet not entered into the harm equation. Once a person continues to vape, the vast majority are unwilling or unable to stop vaping.  One reason is that their motivational system is attenuated due to the belief that vaping is safer and, therefore, there is no reason to quit. Another reason is that even if vapers do want to quit there are no guidelines regarding vaping cessation.
We thus have the potential that those who presently vape will become long term users, and inadvertently through the messaging that ECs are safer products helped create new addictions. I say addictions because there are numerous addictive substances that can now be vaped using ECs. And we know that all addictions entail harm, some of which we are beginning to see in the real world, but was overlooked by PHE in its since effort at reducing smoking cigarettes. [16, 17] In its haste at promoting ECs as a smoking cessation tool, it may have inadvertently aided in advancing a new addiction - vaping - which, as yet, there are no known evidence based vaping cessation guidelines.
Yet PHE maintains that compared to smoking cigarettes ECS are less harmful. That remains to be seen, given their recent introduction into the marketplace. But PHE ought to, as well, compare ECs to counselling coupled with NRT or bupropion to determine which are the safest way to help smokers quit, if they wish to maximally reduce the harm associated with smoking cigarettes. This is not to say the ECs have no role in assisting cigarette smokers quit, but as of today there ought to be greater quality assurance as to their safety. Barring such assurance, ECs ought to be the last option smokers should consider using if they are unwilling or unable to quit, not the first. That, I belief, is the ethical approach we ought to be currently pursuing concerning integrating ECs as aides for smoking cessation.
1. Hawkes, N., Vaping: UK experts defend safety in face of US lung injury cases. BMJ, 2019:367: 16027.
2. McNeil, A., Brose, S.L., Calder, R., Bauld, L., Vaping in England: An evidence update February 2019 A report commissioned by Public Health England: 2019. Public Health England: London.
3. Ibid. p.15.
4. Breitbarth, A. K., Morgan, M., Jones, A.L., E-Cigarettes - An unintended illicit drug delivery system. Drug and Alcohol Dependence, 2018. 192: p.98-111.
5. Krüsemann, E.J.Z., Boesveldt, S., de Graaf. K., Talhout, R. An E-Liquid Flavor Wheel: A Shared Vocabulary Based on Systematically Reviewing E-Liquid Flavor Classifications in Literature. Nicotine & Tobacco Research, 2018, 1–10.
6. McNeill A, Brose, L.S., Calder, R., Hitchman, S.C., Hajek, P., McRobbie, H. E-cigarettes: an evidence update A report commissioned by Public Health England. 2015. Public Health England: London.
7. Ibid. p13.
8. Nutt, D.J., Phillips, L.D., Bellfour, D., Curran, H.V., Dockrell, M., Foulds, J., Fagerstrom, K., Letlape,K., Milton, A., Polosa, R., Ramsey, J., Sweanor, D. Estimating the harms of nicotine-containing products using the MCDA approach. European Addiction Research, 2014. 20(5): p. 218-225.
9. West, R., Hajek, P., McNeill, A., Arnott, D.., Electronic cigarettes: what we know so far. Briefing report to UK All-Party Parliamentary Group on Pharmacy. 2014.
10. Philip Morris International, Unsmoke Your World. https://www.unsmokeyourworld.com/ (accessed October 21, 2019)
11. Cooper, M., Loukas, A., Case,K.R., Marti, N. C., Perry, C.L. A longitudinal study of risk perceptions and e-cigarette initiation among college students: Interactions with smoking status. Drug Alcohol Depend. 2018: 186: 257–263.
12. Hajek, P., Phillips-Waller, A., Przulj, D., Pesola, F., Myers Smith,K., Bisal, N., Jinshuo Li, J., Parrott, S., Sasieni, P., Dawkins, L., Ross,L. Goniewicz, M., et al. A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy. N Engl J Med 2019: 380:629-637.
13. Hartmann‐Boyce,J., McRobbie, H., Bullen, C., Begh, R., Stead, L.F., Hajek, P. Electronic cigarettes for smoking cessation. Cochrane Systematic Review. 2016. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010216.pub3/... (accessed October 20, 2019).
14.McEwen, A., Hajek, P., McRobbie, H., West, R., Manual of smoking cessation. Blackwell. 2006: p.66.
15. Simmons, V.N, Quinn, G.P., Harrell, P.T., Meltzer, L.R., Correa, J.B., Unrod, M., Brandon, T.H. E-cigarette use in adults: a qualitative study of users’ perceptions and future use intentions. Addiction Research & Theory. 2016: Addiction Research & Theory: 24,:313-321.
16. Centers for Disease Control, Outbreak of lung injury associated with e-cigarette use, or vaping. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-d... (accessed October 21, 2019.
17. Stubley, P., Vaping ‘linked to 200 health problems in UK including pneumonia’ Independent. September 29, 2019. https://www.independent.co.uk/news/health/vaping-uk-pneumonia-lung-disea... (accessed October 20, 2019.
Competing interests: No competing interests
The article defending the UK position on the (relative) safety of vaping is scientifically flawed . The quote from Alan Boobis, chair of the UK committee on toxicology that “most of the flavours (in vaping) are used in food and are not going to give rise to hazardous byproducts” implies that these substances are safe when inhaled. The reverse is true.
The commonest cause of occupational asthma in most of Europe is from inhaled flour in bakers, who are mostly able to eat cooked bread without problems (2). We have also shown that thiamine when inhaled (in the production of breakfast cereals) is able to cause asthma despite its requirement as an essential element in food , and that most vitamins have the chemical structure of respiratory allergens .
The “safety” of vaping is based on theoretical grounds, rather than observational science. It would help if those promoting vaping took account of the differences between inhalation and oral toxicology.
1 Hawkes N. Experts defend vaping safety after US deaths. BMJ 2019;367:16027
2 Stocks SJ, McNamee R, Turner S, Carder M, Agius RM, Assessing the impact of national level interventions on workplace respiratory disease in the UK: part 2—regulatory activity by the Health and Safety Executive, Occup Environ Med, 2013;70:483-490
3 Drought VJ, Francis HC, McL Niven R, Burge PS, Occupational asthma induced by thiamine in a vitamin supplement for breakfast cereals, Allergy, 2005;60:1213-1214
4 Vellore AD, Madathil S, Heinink RA, Moore VC, Manney S, Burge CBSG, Burge PS, Vitamins as asthmagens in the workplace, Eur Respir J, 2008;32:819-820
Competing interests: No competing interests