The current context
A similar response occurred during the AIDS crisis in the 1980’s.
The rhetoric at that time was that distributing condoms would encourage youth to become promiscuous28.
Stay current in the credible evidence
Tobacco harm reduction hx
The neo-prohibitionist approach to smoking is “Quit smoking or suffer and die from smoking-related diseases.” All innovative products under this precautionary principle are oppressed which supports the tobacco industry by denying the population safer alternatives and supports the pharmaceutical industry by promoting the incidence of smoking-related diseases. About 95% of unaided smoking cessations attempts end in failure and attempts with nicotine replacement therapies (NRTs) have <10% success rate at six months29.
Snus is an oral tobacco product processed via fermentation which removes the tobacco-specific nitrosamines (the carcinogens found in tobacco). Due to pressure from public health groups, in 1992, the sale of snus was prohibited in the European Union (EU) despite the EU’s acknowledgement that snus is not a carcinogen. Sweden obtained an exemption to allow their smoking citizens a harm reduction option29. As a result, Sweden has the lowest smoking rates and the lowest rates of lung cancer in the EU. It’s notable that 13% of Swedish men are smokers compared to an average 29% of men in the EU. Further, Sweden has the lowest rate of tobacco-related mortality even though Sweden consumes the same amount of tobacco by weight as other countries29.
This is an example of the efficacy and sensibility of tobacco harm reduction (THR). History also illustrates the oppression of tobacco harm reduction by authority29.
nicotine eliquid didn’t cause lung injuries
The recent outbreak of vaping-related lung injuries were a result of illegal THC (cannabis) cartridges used in vaping devices30,31,32. Vitamin E acetate has been identified as the primary causative agent33,34.
During the outbreak, misisnformation was spread by media and health authorities. Click the link below and learn more from a letter released by the Australasian Professional Society on Alcohol and other Drugs35.
Outbreak named EVALI
E-cigarette or Vaping Product Use-Associated Lung Injury
This outbreak of severe lung injuries only occurred in North America, mainly in USA, and over 2800 cases were identified causing 68 deaths30. Smokers have been vaping in the USA for over 10 years without lung injury outbreaks36.
Hx of recent vaping
Age of patients (median 23):
15% under 18 years old
37% 18-24 years old
24% 25-34 years old
24% 35+ years old30
Patients presented with a nonproductive cough, shortness of breath, tachycardia, and fever38.
Investigations
Labs and interviews
58 American EVALI patients were interviewed; 91% reported using illegal THC cartridges39. 51 lung fluid samples of lung injured patients tested positive for fat based substances used in THC cartridges: 48 vitamin E acetate, 1 coconut oil, 1 limonene (a “terpene” found in cannabis)40.
EVALI quickly declined
Law enforcement responded
Commercial nicotine eliquid
Federal regulations
Ingredients in nicotine eliquids have been restricted by Canadian government regulations since May 201844. Lipophilic ingredients are not allowed in commercial nicotine eliquids44. Nicotine eliquid is an aqueous solution and lipids won’t dissolve in it45.
THC cartridges in Canada
Government controlled
THC cartridges were approved for sale in Canada October 19, 2019 during the lung injury outbreak46. Of the 19 Canadian patients with EVALI, 11 reported they only vaped nicotine (many during a time when THC cartridges were illegal)47. Neither toxicology screens nor lung fluid biopsies were performed to confirm patients’ self-reporting47.
Experiment with mice
Vitamin E Acetate aerosols
Wide-spread misinformation
Discouraged harm reduction
Public Health England, March 2020:
“The mistaken belief that e-cigarettes are more harmful than smoking increased rapidly among UK smokers following the US lung injury outbreak in autumn 2019.”49
Listen to the experts
Quotes from those that have done the research
“The burden of proof
demonstrate that the product is unreasonably dangerous for its intended use…electronic cigarette prohibition will do harm to hundreds of thousands
of vapers already using electronic cigarettes in place of tobacco ones – a clear violation of nonmaleficence.”
Electronic cigarettes as a harm reduction strategy for tobacco control: A step forward or past mistakes? (2010) Cahn, & Seigel
“Current state of knowledge
aerosols associated with electronic cigarettes indicates that there is no evidence that vaping produces inhalable
exposures to contaminants of the aerosol that would warrant health concerns by the standards that are used to ensure safety of workplaces.”
Peering through the mist: Systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks. (2014) Burstyn.
“Even if there are longterm
Dr Jean-François Etter
“None of the toxicological
A fresh look at tobacco harm reduction: The case for the electronic cigarette. (2013) Polosa, Rodu, Caponnetto, Maglia, & Racitti
“The burden of proof
Electronic cigarettes as a harm reduction strategy for tobacco control: A step forward or past mistakes? (2010) Cahn, & Seigel
“Even if there are longterm
Dr Jean-François Etter
“Current state of knowledge
Peering through the mist: Systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks. (2014) Burstyn.
“None of the toxicological
A fresh look at tobacco harm reduction: The case for the electronic cigarette. (2013) Polosa, Rodu, Caponnetto, Maglia, & Racitti
Facilitate informed decision making
Your patients’ lives depend on it
In the next section we look at the current false narratives about nicotine vaping and offer evidence to help you make informed decisions.
28. Sellers, D., McGraw, S., & McKinlay, J. (1994). Does the promotion and distribution of condoms increase teen sexual activity? Evidence from an HIV prevention program for Latino youth.
29. Institute of Economic Affairs. (2013). Free market solutions in health: The case of nicotine.
30. Centers for Disease Control and prevention. (2020). Outbreak of lung injury associated with the use of e-cigarette, or vaping, products. Updated February 25, 2020.
31. FDA. (2019). Vaping Illness Update: FDA warns public to stop using tetrahydrocannabinol (THC)-containing vaping products and any vaping products obtained off the street.
32. Utah Department of Health. (2019). Vaping-related lung injury, Utah, 2019: Investigation to date updated September 30, 2019.
33. Duffy, B.; Li, L.; Lu, S.; Durocher, L.; Dittmar, M.; Delaney-Baldwin, E.; Panawennage, D.; LeMaster, D.; Navarette, K.; Spink, D. (2019). Analysis of cannabinoid-containing fluids in illicit vaping cartridges recovered from pulmonary injury patients: Identification of vitamin E acetate as a major diluent.
34. Blount, B., Karwowski, M., Shields, P., Morel-Espinosa, M., Valentin-Blasini, L., Gardner, M., Braselton, M., Brosius, C., Caron, K., Chambers, D., Corstvet, J., Cowan, E., et al., (2019). Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI.
35. Australasian Professional Society on Alcohol and other Drugs. (2020). Miscommunication about the causes of the US outbreak of lung diseases in vapers by public health authorities and the media.
36. Public Health England. (2019). Vaping and lung disease in the US: PHE’s advice.
37. M. Perrine CG, Pickens CM, Boehmer TK, et al. Characteristics of a Multistate Outbreak of Lung Injury Associated with E-cigarette Use, or Vaping — United States, 2019. MMWR Morb Mortal Wkly Rep 2019;68:860–864.
38. J. Schier JG, Meiman JG, Layden J, et al. Severe Pulmonary Disease Associated with Electronic-Cigarette–Product Use — Interim Guidance. September 6, 2019 MMWR Morb Mortal Wkly Rep 2019;68:787–790
39. A. Taylor J, Wiens T, Peterson J, et al. Characteristics of E-cigarette, or Vaping, Products Used by Patients with Associated Lung Injury and Products Seized by Law Enforcement — Minnesota, 2018 and 2019. MMWR Morb Mortal Wkly Rep 2019;68:1096-1100.
40. B. Blount, B.C., Karwowski, M.P., Shields, P.G. et al. (2020). Vitamin E acetate in bronchoalveolar-lavage fluid associated with EVALI.
41. C. US Food and Drug Administration. (2019). FDA, DEA seize 44 websites advertising sale of elicit THC cartridges to US consumers as part of Operation Vapor Lock.
42. D. ABC News. (2019). Sheriff details charges against brothers accused of running THC vape ring.
43. E. ABC News. (2019). Minnesota police seize over 75,000 THC vaping cartridges in record bust.
44. Government of Canada. (2018). Tobacco and Vaping Products Act.
45. F. Campagna, D., Amaradio, M.D., Sands, M., & Polosa, R. (2016). Respiratory infections and pneumonia: potential benefits of switching from smoking to vaping.
46. Government of Canada. (2019). Backgrounder: Final regulations on new cannabis products.
47. H. Government of Canada. (2019). Vaping-associated lung illness.
48. K. Bhat, T.A., Kalathil, S.G., Bogner, P.N., Blount, B.C., Goniewicz, M. L., & Thanavala, Y.M. (2020). An animal model of inhaled vitamin E acetate and EVALI-like lung injury.
49. L. Public Health England. (2020.) False fears preventing smokers from using e-cigarettes to quit.