Tobacco Experts blast E-Cig research cited by HK Government

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Ahead of a special meeting on strengthening tobacco control in the Legislative Council (LegCo) on July 6th, public health experts and scientists who are supportive of electronic cigarettes (e-cigs) have spoken against a total ban on the product, and have criticised the Hong Kong Government for citing flawed research. 

Photo: Dr Jed Rose presenting his research findings at the Global Nicotine Forum in Warsaw, Poland. Credit: Global Nicotine Forum 2015

Without success

The co-inventor of nicotine skin patches, Dr Jed Rose, is convinced that e-cigarettes may be the answer to reducing the current 10.7% cigarette smoking prevalence in Hong Kong.

Dr Rose, the Director of the Duke Centre for Smoking Cessation and a Professor at the Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, recently spoke to HT after presenting at the Global Nicotine Forum held in Warsaw, Poland.

“My whole career has been in smoking cessation treatment,” says Dr Rose. “It’s by seeing that the best treatments that we and others have devised are only helping a minority of smokers to permanently quit, has convinced me that there really is the need for these substitutes.”

According to Dr Rose’s research, current cessation methods such as substituting with nicotine gum, nicotine vapour, or his invention, the nicotine patches, do not facilitate rapid absorption of nicotine to activate receptors in the brain like cigarettes do.

“Getting a rapid enough input to activate those receptors seems to be an important element of satisfying the craving for cigarettes,” explains Dr Rose. “E-cigarettes deliver vapour through the lungs, just like tobacco cigarettes, which has a better ability to satisfy what smokers want.”

Varenicline, which is considered the best medication right now for smoking cessation, has a success rate at one year of less than 20%.

Dr Rose believes the fact that it’s something that gives people more pleasure to use, makes it a better substitute to nicotine patch, as smokers will likely stick with the latter for a longer time.

“People think the treatments we have are very effective, but the success rates are very poor,” laments Dr Rose. “So rather than being overly cautious about new things, we should really be very open to innovations because the current situation is so bad.”

Flawed Science

At the forum, Dr Rose and many of his colleagues mention on separate occasions that there is a problem of misinformation about e-cigs in the media and among public health circles. One such instance is the oft touted study published in New England Journal of Medicine (NEJM) in January this year.

Media reports cited the article concluding that e-cigarettes made the cancer risk from formaldehyde “five- to fifteen-times higher than from traditional cigarettes”. Formaldehyde is a known carcinogen, a substance that can cause cancer.

Dr Rose and his colleagues have since dismissed such claims, stating that the methodology was flawed and the results were misinterpreted.

“It’s very unfortunate that the article was interpreted to imply that e-cigarettes might be worse than cigarettes, because the data absolutely do not support that, and there were many serious flaws in that study, many of which have been pointed out,” says Dr Rose.

According to Dr Rose, the authors of the paper conducted their experiment under the “worst and unrealistic overheating of e-liquids”, and concluded there might be a 1 in 230 risk of getting lung cancer from formaldehyde found. The paper then compared that number with their estimates of what the formaldehyde in cigarettes would produce in risk of lung cancer at 1 in 1000, making conventional cigarettes seem less risky. What was left out of the paper, was the fact that the lifetime risk of getting lung cancer for a cigarette smoker is about 1 in 10, much worse than that found in e-cigarettes.

Adding salt to the wounds, the chemical found was not even formaldehyde. “It was the formaldehyde molecule tied up in another molecule without knowing if it would or would not be released,” explains Dr Rose. “It’s possible that there would be no exposure to formaldehyde even in the worse case.”

Dr Konstantinos Farsalinos, a Greek cardiologist who is well known in the vaping community for his research on e-cigarettess, went as far as calling the paper a “scientific disgrace”.

In Dr Farsalinos’ own research, published in the Journal of Addiction in May, high levels of aldehydes were produced, but only at conditions where the users cannot use the e-cigarette. “It generates such an unpleasant taste from the overheating of the liquid, that the smell would be so bad, no one would be able to inhale it,” explains Dr Farsalinos.

“When you put a piece of meat in the oven at 300 degrees celsius for 5 hours, you’re going to create a piece of charred meat. This meat is going to be full of carcinogens, but no one will be able to eat it. You can’t do a study like that and say meat is carcinogenic, because you tested the meat at conditions at which no one would be exposed to,” says Dr Farsalinos. “That’s what they did.”

Official endorsement

Back home in Hong Kong, the paper was first cited in a literature review by Dr Ho Sai Yin, a Public Health Professor at the University of Hong Kong. The findings were presented at a press conference with the Hong Kong Council on Smoking and Health (COSH) in April this year.

The paper was then the sole scientific paper cited in a briefing provided to legislators in May, stating, “in a recent study, it was demonstrated that formaldehyde-releasing agents could be formed during vapourisation of e-cigarette liquid. Formaldehyde is a known cancer-causing agent.”

Both Dr Rose and Dr Farsalinos blame the inclusion of the flawed paper by academics and officials alike on their inexperience with the product. “A lot of people who don’t have the specific expertise to analyse the details rely on the fact that a journal has a good reputation,” says Dr Rose. “In this case there were many requests for the New England Journal of Medicine to retract the paper, but sometimes things slip through the review process and it leads to a lot of confusion in the public.”

However, the argument does not stop there. A spokesperson from COSH insists the NEJM is a well respected academic journal and believes it has gone through the proper scrutiny before the paper was published. The spokesperson also pointed out that the paper in question is not the only research that has found significant amounts of formaldehyde in e-cig vapour.

COSH has since provided HT with several research papers. One such study from 2013 concluded, “E-cigarettes incidentally generate carbonyl compounds [including formaldehyde] in the E-cigarette smoke mist”. Another paper provided claims, “The amounts of formaldehyde and acetaldehyde in vapors from lower voltage [e-cigs] were on average 13- and 807-fold lower than in tobacco smoke, respectively”, but “[the] levels of formaldehyde in vapors from high-voltage device were in the range of levels reported in tobacco smoke.”

Interestingly, in a 2014 paper provided by COSH that was conducted by the same authors as the 2013 paper, the conclusion writes, “studies have shown that e-cigarettes emit toxic carbonyl compounds, generated from thermal decomposition … in most cases, the levels are lower than those in tobacco cigarette smoke.”

Despite claims that e-cigs may have less carcinogens than tobacco cigarettes, COSH believes e-cigarettes should still be banned. “It’s not a matter of whether there are large or small amounts of carcinogens,” says the spokesperson. “It is the fact that these harmful chemicals are present. We therefore stand by our recommendation to the Government to impose a total ban on e-cigarettes.”

It should come to no surprise that the Food and Health Bureau (FHB) holds the same views. In a reply to HT regarding criticism around the NEJM paper, the FHB states the World Health Organisation (WHO) has also reported on the existence of carcinogens in electronic nicotine delivery systems.

The FHB reiterated their proposal for a strict ban on e-cigs, citing “the apparent health effect and hazards, […] the wider long-term impact to students and youngsters (e.g. inducing them to smoke), […] and the recommendation of the WHO.”

The LegCo battle

Earlier in May, the Food and Health Bureau (FHB) proposed to the Panel on Health Services a number of measures to strengthen tobacco control in Hong Kong, including the enlargement of graphic health warnings on tobacco products from 50% to 85%, the designation of eight tunnel bus interchange facilities (BIs) as non-smoking areas (NSAs), and a complete ban on e-cigarettes.

After legislators expressed outrage at the FHB’s lack of communication with the industries, the Bureau agreed to hold a special meeting regarding all three measures, and invited submissions from interested parties. The special meeting will be held on July 6th, and the deadline for submissions was on 23rd June.

A complete ban on e-cigarettes would entail the “prohibition of sales, advertising, promotion and sponsorship, distribution, importation and manufacturing” of the product.

Ahead of the meeting, the Federation of Trade Unions’ Aron Kwok Wai-Keung believes the Government lacks its own research, and so it relies on foreign research or media reports. “The Government must do its own research to back up its claims,” says Mr Kwok,

“I think whether we impose regulations or a ban really depends on whether the Government can prove if e-cigs are toxic. If they can prove that e-cigs are in fact less harmful than cigarettes, then perhaps we should regulate to allow smokers to switch to them. That being said, I agree with the Government’s stance that e-cigs could become a gateway for teenagers to cigarette smoking.”

Democratic Party legislator Helena Wong Pik-wan also feels the Administration has not provided the necessary information to make a well-grounded decision and thinks there is a need for democratic consultation.

“The Government needs to show us the research that prove which products are poisonous, and which are not. It would not be appropriate for the Government to hastily implement a complete ban, based solely on ideology without scientific evidence to back it up.” says Ms Wong. The Democratic Party will have representatives present at the special meeting.