November 26, 2014

Stanton A. Glantz, PhD

E-cig enthusiasts should stop assuming that just reducing cigarette consumption is a meaningful clinical outcome

In a comment on another post on this blog Jon Krueger reminded me that in 2010 Rebecca Schane, Pam Ling, and I published "Health Effects of Light and Intermittent Smoking" in Circulation.  It concluded:

As smoking patterns continue to change, there will be a shift in the US smoking population from daily, addicted tobacco users who smoke for the clear physiological and psychological benefits of nicotine to the low-level or occasional smoker who may not experience the same degree of nicotine dependence. Understanding the health effects of light and intermittent smoking is important for healthcare professionals, who are increasingly likely to encounter this type of tobacco use in practice. Although the available literature is not large, it indicates that light and intermittent smoking pose substantial risks; the adverse health outcomes parallel dangers observed among daily smoking, particularly for cardiovascular disease.
...
There is a widespread belief, based in part on truth (ie, the dose-response relationship between smoking intensity and some diseases, including cancer) and in part on successful tobacco industry marketing to “health-conscious smokers,” that light and intermittent smoking are safer than heavier smoking. The fact remains, however, that even stable light smoking carries substantial health risks. Although a reduction in cigarette consumption can be an intermediate stage before a total stop and may increase the motivation of daily, heavier smokers without intention to quit to achieve eventual cessation, chronic light and intermittent smoking should not be presented to patients as a healthy long-term choice. Complete cessation is 1 of the most cost-effective interventions and provides a benefit nearly as large as, if not greater than, other widely used forms of treatment for the secondary prevention of cardiovascular disease. Cessation is the only known primary therapy that can significantly reduce the risk of cancer and obstructive lung disease.

A table summarizing the specific disease risks of light and intermittent smoking from the paper is available here.
 
It would be nice if the e-cigarette advocates, who are using reducing cigarette consumption as a health end point, would seriously engage the evidence summarized in this paper and published since 2010.

Comments

Comment: 

RR for smoking mortality is 3, but it is 1.5 for 1-4 cigs a day.
http://tobaccocontrol.bmj.com/content/14/5/315.full" title="http://tobaccocontrol.bmj.com/content/14/5/315.full";http://tobaccocontr...
 
Dual-users may possibly inhale less smoke as they may be less deprived.

Comment: 

I frequently encounter patients who believe that e cigarettes are a cessation device. Many don't even recognize that they are marketed by tobacco companies. When I point this out, and simply ask, why would big tobacco want you to stop or be suddenly interested in health, many seem shocked. There are physicians who support its use, believing it is less harmful. I think it is irresponsible to make this assertion. We don't know the risks. I would also argue that it is a fad designed to keep people hooked. When you are board with paper cigarettes, you transition to e cigs and vice versa.

Comment: 

The abstract of the paper youi cite says:
 
"Adjusted relative risk (95% confidence interval) in smokers of 1–4 cigarettes per day, with never smokers as reference, of dying from ischaemic heart disease was 2.74 (2.07 to 3.61) in men and 2.94 (1.75 to 4.95) in women."

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