Monday, February 25, 2019

Can vaping be the answer for cancer prevention?

Emirates also has lifted the ban on the sale of vaping products

Earlier this week, the Emirates Authority for Standardisation and Metrology (ESMA) announced the lifting of a ban on the sale of e-cigarettes.  For the first time now, e-cigarettes and vaping devices will be legally sold in the UAE under new regulations, known as UAE.S 5030, which allow the sale of electronic cigarettes, electronic pipes, electronic shisha devices plus the liquid refills.

Under the new standards, Esma will regulate all nicotine components used in e-cigarettes including other details such as technical specifications, weight, list of ingredients, import, packaging, and labeling, among others.

Manufacturers will be allowed to sell the battery-powered products as long as they meet new standards and carry health warnings. E-cigarettes are expected to be available in stores from mid-April this year.

This carefully considered decision was made with the sole aim of protecting public health.

Until now it has been against the law for retailers to sell e-cigarette products, although it is not an offence to own or use one and they are widely available online. Legalizing these businesses will allow the relevant authorities to oversee the quality of products they sell and to enforce the prominent display of appropriate health warnings.

In recent years, there has been a significant cultural shift from traditional cigarettes to vaping. In some countries, electronic cigarettes are promoted as an effective way to quit smoking.

Is vaping safer than smoking?

Use of e-cigarettes or “vaping” has always been looked upon with suspicion. This is despite accumulating evidence, which shows them to be safer than the conventional combustible cigarettes.

Although generally perceived to be considerably similar, vaping and smoking are not alike. It therefore becomes important to understand the distinction between vaping and smoking.

Smoking is a practice in which a substance (tobacco) is burned and smoke is produced, which is inhaled into the lungs and is absorbed into the blood. When combustion occurs, new chemicals are formed via the process of oxidation. Hence, smoke contains thousands of new chemicals different from those initially burned.

E-cigarettes do not produce tobacco smoke, but an aerosol, which is commonly termed as “vapor”. Vaping is the act of inhaling and exhaling a vapor or an aerosol. Unlike smoke, when vapor is produced, no new chemicals are formed. The chemicals that are in vapor are the same as those found in the vaporized substance.

Therefore, the major and the most important difference between smoke and vapor is the presence of toxic tar and carbon monoxide in smoke. “People smoke for the nicotine, but they die from the tar” (BMJ. 1976) as it is the tar, which contains most of the mutagenic and carcinogenic agents in tobacco smoke.

An evidence review of e-cigarettes and heated tobacco products published in 2018 by the Public Health England has said “vaping is at least 95% less harmful than smoking.” “An advantage of e-cigarettes is that particular constituents can be removed or minimised in a way that is not feasible with tobacco cigarettes.”

As vaping does not involve combustion, no tar is produced and the resultant vapor has no carcinogens that are normally found in the cigarette smoke.

Long-term NRT-only and e-cigarette–only use, but not dual use of NRTs or e-cigarettes with combustible cigarettes, is associated with substantially reduced levels of measured carcinogens and toxins relative to smoking only combustible cigarettes, concluded a study reported in Annals of Internal Medicine in 2017.

According to a study published in Tobacco Control in 2017. “e-cigarette emissions have much less carcinogenic potency than tobacco smoke”.

In a report by its Tobacco Advisory Group titled “Nicotine without smoke. Tobacco harm reduction” and published in April 2016, the Royal College of Physicians has said, “Although it is not possible to precisely quantify the long-term health risks associated with e-cigarettes, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure.”

Do e-cigarettes help smokers to quit?

A key observation of the Public Health England report (2018) was that “in the first half of 2017, quit success rates in England were at their highest rates so far observed and for the first time, parity across different socio-economic groups was observed. It is plausible that e-cigarettes have contributed to this.”

The RCP further says, “Large-scale substitution of e-cigarettes, or other non-tobacco nicotine products, for tobacco smoking has the potential to prevent almost all the harm from smoking in society. Promoting e-cigarettes, NRT and other non-tobacco nicotine products as widely as possible, as a substitute for smoking, is therefore likely to generate significant health gains in the UK.”

A study reported as recently as January 2019 in the New England Journal of Medicine found that e-cigarettes were nearly twice as effective as conventional nicotine replacement products, like patches and gum, for quitting smoking. The success rate was 18% among the e-cigarette group as compared to 9.9% among those using traditional nicotine replacement therapy. 

Can vaping be the answer for lung cancer

Lung cancer is number one cancer in males in urban India and is linked to tobacco smoking. In one of the harm reduction conference organised by us it was concluded that there is no evidence that nicotine causes lung cancer. In a country like India amongst smokers to prevent lung cancer either they should quit or shift to less harmful non-tobacco inhalation products.  

e-cigarettes cut exposure to carcinogens (HT)

A recent study sponsored by JUUL Labs and conducted by Deletion Labs, and independent global research facility found that electronic cigarettes reduce harmful exposure to addictive nicotine and chemicals known to cause cancer and present a safe alternative to smoking. The study presented before the Society for Research on Nicotine & Tobacco 2019 annual meeting in San Francisco on Saturday has found that some advanced e-cigarettes reduce the exposure to carcinogens.
The study found that electronic nicotine delivery systems reduce harmful exposure to chemicals known to cause cancer and present a safe alternative to smoking. The study was based on a clinical analysis of biomarkers of smokers, non-smokers and people who vaped (used electronic cigarettes) using a closed nicotine-salt pod system (NSPS).
The study ‘e-cigarettes cut exposure to carcinogens (HT) Changes in Biomarkers of Exposure Associated with Switching for 5 Days from Combusted Cigarettes to Nicotine Salt Pod System’ by Joanna Jay et all explored whether switching from cigarettes to ENDS may potentially reduce exposure to key toxicants. 
Data was presented from a randomized, open-label, parallel-group, inpatient study of adult smokers that examined changes in primary urine and blood biomarkers of exposure (BOEs), relative to baseline, following a 5-day exclusive use period of the nicotine salt pod system (“NSPS”, JUUL Labs, Inc.) with one of four flavors at 5% nicotine strength (Virginia Tobacco, Mint, Mango, Crème), abstinence, or continued use of usual brand combustible cigarettes.
In the study ninety subjects were randomized into one of six cohorts: use of JUUL system (n=15 for each of the four flavors), use of usual cigarette (n=15), or abstinence (n=15).  Total nicotine equivalents, and the following biomarkers were measured in 24-hour urine collections: NNN, NNAL, 3-HPMA, MHBMA, S-PMA, HMPMA, CEMA, and 1-OHP. COHb was measured in blood. 
All subjects randomized to the use of NSPS (n=60 ITT) and usual cigarettes (n=15) completed the study; four subjects from the abstinence arm terminated early (n=11; 73% completion rate in-arm). Over the course of 5 days, mean total nicotine equivalents increased by 9% in the pooled NSPS group vs. 26% in the usual cigarette group (p>0.05).
Decreases in the mean levels of all non-nicotine BOEs were observed in the abstinence group and all four NSPS groups at Day 5 compared to baseline (Day -1); the cigarette group demonstrated increases in all BOEs except for 1-OHP and HPMA. The eight non-nicotine urine BOEs were reduced by an aggregate 85.3% in the abstinence group and 85.0% in the pooled NSPS group (99.6% relative reduction in aggregate biomarkers; p>0.05).
Similar reductions were seen in the pooled NSPS and abstinence groups for each individual BOE (p>0.05 for each analyte). In the usual cigarette group, these BOEs increased by an aggregate of 14.4% (pooled NSPS vs. usual cigarette; p<0.001 for each analyte). COHb was likewise reduced by 71.8% in the pooled switching group vs. 69.1% in the abstinence group (p>0.05), while increasing by 13.3% in the usual cigarette group (p<0.001).
These results support the hypothesis that complete switching from cigarettes to the NSPS may lead to meaningful reductions in multiple key, short-term biomarkers of exposure observed with combustible use. 
Incomplete switching from cigarettes to NSPS (dual-use) was not studied.
Main points
1.      The urine biomarkers for adult smokers who used NSPS for five days and those who didn’t smoke were almost at par, with the NSPS group reporting an aggregate mean reduction of 99.6% relative to the reduction associated with five days of abstention.
2.       The subjects were all healthy smokers between the ages of 22 and 62 years, with a minimum 12-month history of smoking 10 or more king-size manufactured, combustible cigarettes each day.
3.       The study found equivalent reductions in select short-term biomarkers of exposure between adult smokers who exclusively switched to JUUL products and those who abstained from smoking over a five-day period. (Source Hindustan Times)

Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA

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