African music for beginners 6: Madagascar

 

 

I’ve had a passion for contemporary African music since the early 1980s, when I bought my first LPs by South Africa’s (late) Hugh Masekela and Cameroon’s Manu Dibango, went to my first African gig (the Congolese superstar Sam Mangwana and the African Allstars, at London’s Dominion Theatre near Waterloo). In the years since I’ve collected 1000s of LPs, cassettes, CDs and MP3s.

Before traveling to any city, I look up where its African quarter is and try to get out there to see if there are any music shops and bars.  Music shops are very sadly becoming a thing of the past as people move to digital access. I spent many lunch hours listening to music at Stern’s African Record Centre in Whitfield St just behind Tottenham Court Rd in London when I was studying there between March 1984‑November 1985. They are now an on-line shop and also have a blog.

I subscribe to the monthly email from Alastair Johnston’s invaluable Musikifan record review page, buy lots of books on African music, and maintain an ever-expanding Spotify African page. While for some artists it can be very patchy, Spotify has a delightfully vast range of African music, including a lot of very obscure archival music, sometimes replete with scratchy sounds from the old LPs from where it has been digitised.

I have recently started a Youtube page with live African music concerts.

Over the next months, I’ll post country-by-country blogs with lots of recommendations for those starting out to explore the vast catalogue of African music. I’ll only be including those that I like, with links to the tracks on my Spotify page or to Youtube when they are not available on Spotify. These are just a taste that I hope might infect you in the way I was.

EARLIER SELECTIONS

1.Senegal selections here

2.Zimbabwe selections here

3.Mali selections here

4.Nigeria selections here

5.Ghana (Highlife) here

Madagascar

The Canadian canary in the teenage vaping coalmine

 

canarios11

A recent paper published in the British Medical Journal contains alarming evidence that upswings in vaping by teenagers can see significant parallel rises smoking. The researchers looked at large samples of 16-19 year olds in the USA, Canada and England, and reported changes in vaping and smoking between the years 2017 and 2018.

They summarized their findings this way:

The prevalence of vaping in the past 30 days, in the past week, and on 15 days or more in the past month increased in Canada and the US between 2017 and 2018 (P<0.001 for all), including among non-smokers and experimental smokers, with no changes in England. Smoking prevalence increased in Canada (P<0.001 for all measures), with modest increases in England, and no changes in the US. The percentage of ever vapers who reported more frequent vaping increased in Canada and the US (P<0.01 for all), but not in England. The use of JUUL increased in all countries, particularly the US and Canada—for example, the proportion of current vapers in the US citing JUUL as their usual brand increased threefold between 2017 and 2018.

The Canadian data were particularly alarming. There has not been an increase recorded in teenage smoking in Canada in 30 years. The data on vaping and smoking on 15+ days a month saw a 71% increase from 2.1% to 3.6% for vaping, and a 54% increase in smoking from 4.8% to 7.4%. This was no mere rise in casual experimental vaping or smoking.

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The four invoilable articles of faith that form the vaping advocacy creed are that

  • nicotine is all but benign
  • inhaling micro-particles of propylene glycol, nicotine, flavouring chemicals approved for ingestion but not inhalation, and metals an average of 200 times a day deep into the lungs (73,000 times a year) is all but inconsequential
  • ecigarettes are highly effective at getting smoker to quit and preventing relapse and
  • vaping by non-smokers (especially kids) will not be followed by any uptake of smoking by the previously nicotine naïve (often called the “gateway” hypothesis).

I’ve taken a skeptical look at several of these before (see the links above), as have at least 45 major health and medical agencies around the world whose policies urge precaution.

Ecig apostles will rush to point out that the US — also awash with large increases in vaping (a 46% increase in past month and a 66% increase in past week) — did not see any increase in teenage smoking, and that the increase in smoking in England was only “modest”. These differences are interesting and deserve greater analysis. But they cannot paper over what has happened in Canada nor provide any assurance that as ecigarette manufacturers salivate over the massive potential of the teenage market becoming addicted to nicotine and play their Piped Piper marketing tunes to ensure this, that the Canadian results won’t consolidate and appear elsewhere.

Gateway concerns  were strengthened with the publication of a meta-analysis of longitudinal studies showing that e-cigarettes can serve as a gateway to later cigarette smoking among some nicotine naïve youth and by the 2018 report of the National Academies of Sciences, Engineering, and Medicine. Public health consequences of e-cigarettes, which concluded that such studies provided “strong evidence of plausibility and specificity of a possible causal effect of e-cigarette use on smoking…” with the Committee “consider[ing] the overall body of evidence of a causal effect of e-cigarette use on risk of transition from never to ever smoking to be substantial” [p16-32].

Gateway hypothesis critics have relied on several arguments in their dismissals. I coauthored a critique of these in Nicotine & Tobacco Research in 2018. Here’s an edited version of what we wrote.

Are downward trends in adolescent smoking are incompatible with a gateway effect for e-cigarettes?

Several prominent harm reduction proponents have argued that the gateway hypothesis is incompatible with population trends in the USA and UK of declining adolescent smoking. Their argument here runs that vaping has been rising while smoking continues to fall, so vaping cannot be causing smoking to any significant degree among adolescents.

In both nations, declining trends of smoking among youth were apparent well before the introduction of e-cigarettes. Moreover, associations in population trends are known to be prone to the ecological fallacy; i.e. what is true at the population level may not be true at the individual level, especially when other population-level attributes are not considered (e.g. effective tobacco control policies).  Specifically, the ecological argument relies on an assumption that the population net impact of any putative gateway effect of e-cigarette use would be larger than the combined net impact of all other policies, programs and factors which are responsible for reducing adolescent smoking prevalence (e.g. tobacco tax and retail price, measures of the denormalisation of smoking, exposure of children to adult-targeted quit campaigns, retail display bans, health warnings and plain packaging). This is an extremely high bar that gateway critics demand that anyone suggesting gateway effects needs to jump over. The combined impact of such factors in preventing uptake could, thereby, easily mask considerable smoking uptake that might not have occurred in the absence of e-cigarettes.

With smoking prevalence at record lows in the US, England and Australia, only adequately powered longitudinal studies, which control for factors known to be associated with smoking uptake are vital to examining potential gateway effects. Nine such studies were included in the 2017 meta-analysis. Adjusting for demographic, psychosocial, and behavioral risk factors for cigarette smoking, the odds of subsequent cigarette smoking by non-smokers who had any experience of vaping more than tripled among e-cigarette users compared to those with no vaping experience.

Common liability rather than gateway?

One of the main criticisms of the gateway hypothesis lies in the difficulty in excluding other mechanisms for the observed relationship between vaping and later cigarette smoking. The most commonly proposed alternative explanation is based on the “common liability theory”, which emphasizes shared predisposing characteristics among multi-drug users. According to this hypothesis, a “propensity” for drug use predicts multi-drug use. Interestingly, however, several longitudinal studies have reported the strongest association between e-cigarette use and smoking initiation among youth with the lowest risk of smoking. Moreover, recent evidence using national data from the US shows that a third of youth who start with e-cigarettes have risk profiles that make them unlikely to start with cigarettes.

Rather than being mutually exclusive, the gateway and common liability hypotheses are likely to be complementary. Common factors will explain the use of drugs in general, and specific factors will explain why young people use specific drugs and in what contexts. This dynamic perception is in line with contemporary models of behavioral change being dependent on the balance between intention and ability. Intention implies individual factors including any propensity for drug use. However, such factors are contingent on environmental conditions, such as access and feasibility of drug use for intentions to be materialized.

Indeed, most tobacco control successes were the result of targeting those potentiating environmental factors rather than some innate propensity to use drugs. The salience of these environmental factors is also evident from societal trends of smoking propagation in response to tobacco industry marketing and obstruction of tobacco control policies, as well as declines in smoking in response to successful implementation of effective population-based policies.

The wide availability and intense marketing of e-cigarettes, and their putative low-risk appeal may coalesce to increasingly make e-cigarette delivered nicotine the likely first drug on a multi-drug cascade. But, rather than be alarmed, e-cigarettes proponents use this to argue against a specific temporal sequence needed to establish causality. For example, Etter argues that “The temporal sequence argument would not hold if the ordering of product use was explained solely by the ordering of opportunities to use the products, rather than by some inherent capacity of vaping to cause smoking”.  In reality, things are far more complicated, and relationships between risks (causes) and outcomes are complex, nonlinear and multi-directional. For example, obesity leads to joint stress, and joint problems also potentiate obesity through reduced movement. Which of these comes first and how they interact at different stages, ages, and contexts is dynamic rather than static relationship.  A recent study applying a prospective design and causal analytical framework found a bi-directional association between e-cigarette use and cigarette smoking among 11-18-year-olds in Great Britain, yet the association was stronger from ever e-cigarettes use to cigarettes initiation. So if e-cigarettes are a gateway into or away from other drugs/tobacco in different situations that does not constitute a basis to refute causality in both directions.

A recent NEJM review of the molecular basis of nicotine as a gateway drug by the founder the gateway hypothesis (Denise Kandel) and her husband (Eric Kandel, 2000 Nobel Prize winner in Medicine for neurophysiology) concluded that “nicotine acts as a gateway drug on the brain, and this effect is likely to occur whether the exposure is from smoking tobacco, passive tobacco smoke, or e-cigarettes”. Although the biological basis of nicotine’s gateway effect on the brain is likely to be consistent across different delivery means, the manifestation of nicotine dependence can vary according to different nicotine delivery methods (e.g. sensory cues in e-cigarettes can be different from those of traditional cigarettes).

A gateway out of smoking, but not into it?

E-cigarette proponents often assert that vaping is demonstrably a reverse gateway out of smoking for those who quit, while being scathing about suggestions that it could ever be a gateway into smoking  have been repeatedly used as debate enders. Any cessation researcher offering the equally trite “smokers who will quit, will quit” as a serious contribution to understanding the complexity of transitioning out of smoking, would be rightly pilloried for their primitive understanding of the complex processes that can culminate with permanent smoking cessation  Yet, with e-cigarettes, all that is apparently required to be said about anyone who smokes regularly is that that they had a propensity to do so. If this hard determinism was all that was needed to be invoked in understanding smoking uptake, how then do we explain the dramatic falls in uptake that have been seen in nations which have robust, comprehensive tobacco control programs? What eroded the “propensity” of all those who never took up smoking? Nicotine liability may well be a predisposing factor, but what of the known tractable reinforcing and enabling factors that tobacco control has so successfully identified and addressed over decades?

The implausibility of experimental vaping transitioning to smoking?

Another salient argument used by e-cigarette proponents is that studies showing a gateway effect do not differentiate adolescent experimental vaping from more regular use, so “any vaping” is treated the same when the association between vaping and later cigarette smoking is assessed. Etter argued that it is “hardly plausible that a simple puff or a few puffs on an e-cigarette can cause subsequent regular smoking”. But of course every regular smoker started with a “simple puff”, nearly always in adolescence. They then typically progress through more regular use to daily smoking. Birge et al recently reported that over two-thirds of smokers who tried as little as a single puff became, for a time, regular smokers.

Moreover, the assertion about the implausibility of experimental e-cigarette use leading to regular smoking in youth contrasts with an important body of evidence regarding the high susceptibility of children and adolescents to the psychotropic and addictive effects of nicotine. For example, Fidler et al and others have highlighted that children only require a very minimal exposure to develop an important and identified “sleeper effect”: a vulnerability to smoking after trying just a single cigarette, that can lie dormant for three years, or more: “From a neurobiological viewpoint, neural reward pathways might be changed as a consequence of a single exposure to nicotine, thus potentially increasing vulnerability to later smoking uptake”. Others have referred to an established body of evidence relating to youth nicotine exposure; “Importantly, several studies support that a single drug exposure can lead to changes in synaptic strength that are associated with learning and memory. The high susceptibility of children and youth to the “neurobiological insult” of nicotine was recently been highlighted in the US Surgeon General’s report on the potential risks of nicotine and electronic cigarettes to youth. Ultimately, these cellular changes could underlie the long-lasting effects of drugs”.

McNeill, who has been persistently critical of gateway effects  co-authored two heavily cited papers one of which noted that “The first symptoms of nicotine dependence can appear within days to weeks of the onset of occasional use, often before the onset of daily smoking”. Moreover, in a 30-month follow-up of the same subjects, it was noted that “Symptoms of tobacco dependence commonly develop rapidly after the onset of intermittent smoking, although individuals differ widely in this regard. There does not appear to be a minimum nicotine dose or duration of use as a prerequisite for symptoms to appear. The development of a single symptom strongly predicted continued use, supporting the theory that the loss of autonomy over tobacco use begins with the first symptom of dependence”. The clear contrast between the well-established understanding of cigarette smokers’ rapid onset of symptoms of nicotine dependence with efforts to trivialise concerns about initial infrequent use of e-cigarettes is therefore noteworthy.

The NASEM report  emphasizes that  because the e-cigarette phenomenon is relatively recent, “the majority of studies … lack sufficient duration of follow-up to study the naturalistic cigarette smoking progression sequence, which can involve a lengthy period between ever use and reaching daily smoking.”  Emerging longitudinal data should provide greater clarity on the extent to which “ever” smoking after e-cigarette uptake converts to daily smoking.

African music for beginners 5: Ghana highlife

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I’ve had a passion for contemporary African music since the early 1980s, when I bought my first LPs by South Africa’s (late) Hugh Masekela and Cameroon’s Manu Dibango, went to my first African gig (the Congolese superstar Sam Mangwana and the African Allstars, at London’s Dominion Theatre near Waterloo). In the years since I’ve collected 1000s of LPs, cassettes, CDs and MP3s.

Before traveling to any city, I look up where its African quarter is and try to get out there to see if there are any music shops and bars.  Music shops are very sadly becoming a thing of the past as people move to digital access. I spent many lunch hours listening to music at Stern’s African Record Centre in Whitfield St just behind Tottenham Court Rd in London when I was studying there between March 1984‑November 1985. They are now an on-line shop and also have a blog.

I subscribe to the monthly email from Alastair Johnston’s invaluable Musikifan record review page, buy lots of books on African music, and maintain an ever-expanding Spotify African page. While for some artists it can be very patchy, Spotify has a delightfully vast range of African music, including a lot of very obscure archival music, sometimes replete with scratchy sounds from the old LPs from where it has been digitised.

I have recently started a Youtube page with live African music concerts.

Over the next months, I’ll post country-by-country blogs with lots of recommendations for those starting out to explore the vast catalogue of African music. I’ll only be including those that I like, with links to the tracks on my Spotify page or to Youtube when they are not available on Spotify. These are just a taste that I hope might infect you in the way I was.

EARLIER SELECTIONS

1.Senegal selections here

2.Zimbabwe selections here

3.Mali selections here

4.Nigeria selections here

GHANA (Highlife)

Eric Agyemang

AB Crentsil

CK Mann

Adomako Nyamekye

African Connexion

Amakye Dede

Kuntum 13 Band

Bassa Bassa Soundz

George Darko

Sweet Talks

Pat Thomas

West African Highlife Band

ET Mensah

African music for beginners 4: Nigeria

fela-kuti-documentary-music-is-the-weapon

Fela Kuti

I’ve had a passion for contemporary African music since the early 1980s, when I bought my first LPs by South Africa’s (late) Hugh Masekela and Cameroon’s Manu Dibango, went to my first African gig (the Congolese superstar Sam Mangwana and the African Allstars, at London’s Dominion Theatre near Waterloo). In the years since I’ve collected 1000s of LPs, cassettes, CDs and MP3s.

Before traveling to any city, I look up where its African quarter is and try to get out there to see if there are any music shops and bars.  Music shops are very sadly becoming a thing of the past as people move to digital access. I spent many lunch hours listening to music at Stern’s African Record Centre in Whitfield St just behind Tottenham Court Rd in London when I was studying there between March 1984‑November 1985. They are now an on-line shop and also have a blog.

I subscribe to the monthly email from Alastair Johnston’s invaluable Musikifan record review page, buy lots of books on African music, and maintain an ever-expanding Spotify African page. While for some artists it can be very patchy, Spotify has a delightfully vast range of African music, including a lot of very obscure archival music, sometimes replete with scratchy sounds from the old LPs from where it has been digitised.

I have recently started a Youtube page with live African music concerts.

Over the next months, I’ll post country-by-country blogs with lots of recommendations for those starting out to explore the vast catalogue of African music. I’ll only be including those that I like, with links to the tracks on my Spotify page or to Youtube when they are not available on Spotify. These are just a taste that I hope might infect you in the way I was.

Senegal selections here  Zimbabwe selections here Mali selections here

Nigeria

Chief Ebenezer Obey

Femi Kuti

Fela Kuti

Seun Kuti & Egypt 80

King Sunny Adé

Lagbaja

Onyeka Onwenu

Tony Allen

African music for beginners 3: Mali

 

I’ve had a passion for contemporary African music since the early 1980s, when I bought my first LPs by South Africa’s (late) Hugh Masekela and Cameroon’s Manu Dibango, went to my first African gig (the Congolese superstar Sam Mangwana and the African Allstars, at London’s Dominion Theatre near Waterloo). In the years since I’ve collected 1000s of LPs, cassettes, CDs and MP3s.

Before traveling to any city, I look up where its African quarter is and try to get out there to see if there are any music shops and bars.  Music shops are very sadly becoming a thing of the past as people move to digital access. I spent many lunch hours listening to music at Stern’s African Record Centre in Whitfield St just behind Tottenham Court Rd in London when I was studying there between March 1984‑November 1985. They are now an on-line shop and also have a blog.

I subscribe to the monthly email from Alastair Johnston’s invaluable Musikifan record review page, buy lots of books on African music, and maintain an ever-expanding Spotify African page. While for some artists it can be very patchy, Spotify has a delightfully vast range of African music, including a lot of very obscure archival music, sometimes replete with scratchy sounds from the old LPs from where it has been digitised.

I have recently started a Youtube page with live African music concerts.

Over the next months, I’ll post country-by-country blogs with lots of recommendations for those starting out to explore the vast catalogue of African music. I’ll only be including those that I like, with links to the tracks on my Spotify page or to Youtube when they are not available on Spotify. These are just a taste that I hope might infect you in the way I was.

Senegal selections here

Zimbabwe selection here

 

Mali

 

Ali Farka Touré

Amadou et Mariam

Boubacar Traoré

Cheikh Tidane Seck with Hank Jones

Djelimady Tounkara

Fatimata Diawara

Habib Koité

Issa Bagayago

Kasse Mady

Mama Sissoko

Rail Band de Bamako

Rokia Traoré

Salif Keita

Tinariwen

Vieux Farka Touré

African music for beginners 2: Zimbabwe

 

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I’ve had a passion for contemporary African music since the early 1980s, when I bought my first LPs by South Africa’s (late) Hugh Masekela and Cameroon’s Manu Dibango, went to my first African gig (the Congolese superstar Sam Mangwana and the African Allstars, at London’s Dominion Theatre near Waterloo). In the years since I’ve collected 1000s of LPs, cassettes, CDs and MP3s.

Before traveling to any city, I look up where its African quarter is and try to get out there to see if there are any music shops and bars.  Music shops are very sadly becoming a thing of the past as people move to digital access. I spent many lunch hours listening to music at Stern’s African Record Centre in Whitfield St just behind Tottenham Court Rd in London when I was studying there between March 1984‑November 1985. They are now an on-line shop and also have a blog.

I subscribe to the monthly email from Alastair Johnston’s invaluable Musikifan record review page, buy lots of books on African music, and maintain an ever-expanding Spotify African page. While for some artists it can be very patchy, Spotify has a delightfully vast range of African music, including a lot of very obscure archival music, sometimes replete with scratchy sounds from the old LPs from where it has been digitised.

I have recently started a Youtube page with live African music concerts.

Over the next months, I’ll post country-by-country blogs with lots of recommendations for those starting out to explore the vast catalogue of African music. I’ll only be including those that I like, with links to the tracks on my Spotify page or to Youtube when they are not available on Spotify. These are just a taste that I hope might infect you in the way I was.

See Senegal selections here

Zimbabwe

Bhundu Boys

Four Brothers

James Chimombe & the Ocean City Band

Jonah Sithole

Lovemore Majaivana

Machanic Manyeruke & the Puritans (gospel)

Oliver Mtukudzi

Real Sounds

Thomas Mapfumo & Blacks Unlimited

 

African music for beginners 1: Senegal

 

350px-Orchestra_Baobab

Orchestra Baobab

I’ve had a passion for contemporary African music since the early 1980s, when I bought my first LPs by South Africa’s (late) Hugh Masekela and Cameroon’s Manu Dibango, went to my first African gig (the Congolese superstar Sam Mangwana and the African Allstars, at London’s The Venue near Waterloo station on May 17, 1984). In the years since I’ve collected 1000s of LPs, cassettes, CDs and MP3s. In 1985-6 I ran a late night African music program on Adelaide’s 5MMM radio and more recently, I’ve played African selections three times on Simon Marnie’s Sonic Journey on ABC Sydney.

Before traveling to any city, I look up the location of its  African quarter and try to get out there to see if there are any music shops and bars.  Music shops are very sadly becoming a thing of the past as people move to digital access. I spent many lunch hours listening to music at Stern’s African Record Centre in Whitfield St just behind Tottenham Court Rd in London when I was studying there between March 1984‑November 1985. They are now an on-line shop and also have a blog.

I subscribe to the monthly email from Alastair Johnston’s invaluable Musikifan record review page, buy lots of books on African music, and maintain an ever-expanding Spotify African page. While for some artists it can be very patchy,  Spotify has a delightfully vast range of African music, including a lot of very obscure archival music, sometimes replete with scratchy sounds from the old LPs from where it has been digitised.

I have recently started a Youtube page with live African music concerts.

Over the next months, I’ll post country-by-country blogs with lots of recommendations for those starting out to explore the vast and intimidating catalogue of African music. I’ll only be including examples of those that I like, with links to the tracks on my Spotify page. These are just a taste that I hope might infect you in the way I was.

Senegal

Africando (and Africando Allstars) – African salsa

Baaba Maal

Cheikh Lô

Dexter Johnson & Super Stars de Dakar (old time jazz)

Ismaël Lô

Mansour Seck

Orchestra Baobab

Thione Seck

Toure Kunda

Wasis Diop

Youssou N’Dour

Xalam

Highlights and lowlights of World No Tobacco Day, Australia 2019

Highlights

May 31 is World No Tobacco Day. Australia has much to celebrate, no better captured in two sets of killer facts.

First, Sir Richard Peto’s Oxford University research group has produced estimates of  the changes in total and tobacco-caused mortality for a large number of countries across the 65 years 1950-2015.  Australia is one country which has seen huge falls (see figure below). In 1970, the risk of a 35 year old man dying by age 69 was 42%. 16% of those deaths would have been caused by smoking.

Forty five years later, the all-cause risk of early death had dropped by two thirds to 15%, while smoking-caused deaths had fallen by four fifths to just 3%. Australia began introducing the first baby steps in the suite of comprehensive tobacco control policies and campaigns in 1973 when the first timidly tepid warnings appeared on cigarette packs.

This is harm reduction writ very large indeed.

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Second, as more and more tobacco control policies were legislated and implemented in Australia, and campaign funding became serious, allowing mass-reach of don’t start and quit motivating messages into the whole population, the proportion of people who smoked continued falling, occasionally plateauing as political feet were sometimes removed from the accelerator, but resuming their downward spiral when tobacco control became bipartisan.

Australia has long been at or near the very front of the international pack in reducing smoking. Here are the latest available data for five nations often compared with Australia. The Australian data are from the 2017-18 ABS National Health Survey (see table 9 here)

  • Australia (2017-18 ages 18+): 15.1% (includes cigarette smokers plus all exclusive users of other combustible tobacco products)
  • USA: (2017 ages 18+) 16.7% (all combustible tobacco product users)
  • Canada (2017 ages 12+): 16.2% (cigarettes & Roll Your Own tobacco only)
  • New Zealand (2016 ages 15+) 15.7%. (Māori adults 35.3%) (cigarettes & RYO only)
  • UK (2017 ages 18+): 15.1% (cigarettes and RYO only)

In summary, of these five nations, only Australia and the USA include all combustible tobacco products in their data on “smoking” prevalence, while other nations only include cigarettes (factory made and hand-rolled). Their “smoking” prevalence figures thus underestimate the true prevalence of “smoking”. Australia and the UK have the same (lowest) smoking prevalence of these nations, although the UK data do not include combustibles other than cigarettes (for example pipes, cigars, shisha and hookah). It is therefore likely that today Australia has the lowest smoking prevalence of these nations in the vanguard of reducing ,smoking.

But wait, there’s more. This week, the Cancer Council Victoria released data on changes in smoking prevalence in Victoria, our second most populous state, between 2015-2018. The main take home findings are that  in that state we now have the lowest daily smoking prevalence ever recorded: 10.7% (down from 13.5% in 2015)  with falls in the most disadvantaged group down from 16.8% to 13%.

The same study found that less than 2% of smokers & 1% of ex-smokers vape daily. We know from large longitudinal cohort studies that sustained quitting from smoking among people who vape compares unfavourably with other ways of quitting (eg: see table below). The Victorian report concluded that “There was no evidence to suggest an increase in the use of e-cigarettes to aid cessation by Victorians who were attempting to quit across the study period”.

blog table

Tobacco control is widely regarded as the poster child of chronic disease control.  These data, on radical falls in both smoking and smoking caused deaths , show why.

Lowlights

On the day before WNTD, a triumvirate of three e-cigarette advocacy groups launched “Aussie Vape Day” in a brazen attempt to gatecrash and rain on the parade of WNTD. On April Fools day, 2019 one of these groups, launched a Go Fund Me fundraiser, setting a target of $15,000 to pay for “a dedicated website, a launch event, professionally produced videos, testimonials, social media infographics and mainstream media promotion, a flyer for beginners on how to switch and a handout on the common questions people ask.”

ATHRA’s chairman Colin Mendelsohn, opened the donations with $500 and 30 days later, another $1345 was donated by just 37 others, with 679 sharing the Go Fund Me link, apparently with very little effect. Their $1845 fell  88% short of their modest target.

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By 8pm at the end of the big day, the Twitter hashtag #AussieVapeDay had a whole 9 tweets, with collectively 4 comments, 16 retweets and 25 likes, not exactly the stuff of a national Twitter trend.

The launch event, held on a cold, windy Thursday in a Sydney suburban park looked like Groundhog Day of recent poorly attended ecig seminars held in rooms in the Victorian and NSW parliament buildings.  (see photos below).

Aussie Vape Day

Aussie Vape Day launch

(2019) VapeDay Money shot

Next year will be bigger … !!

 

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Melbourne and Sydney seminars, 2019

The health communications company, Palin Communications, issued a press release on the big day. A cover letter to recipients stated:

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Australian health and medical which have expressed scepticism and regulatory caution about ecigarettes are in lockstep with a very long list of global and international expert agencies (see here). And as for “Smoking rates fall in countries that embrace vaping and they are sure not falling here in Australia”, here was my response (the link was to the Victorian report above).

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Philip Morris International

Some bright spark at PMI decided it would be just so apposite and witty to rename World No Tobacco Day as World No Smoking Day. I’ve written several long pieces on this blog here, here and here and elsewhere about awkward questions that we all need to ask about that company’s publicly stated ambition to move all its smokers over to its heat-not-burn product. Critically, while it’s been running its global “unsmoke” campaign, its cigarettes have continued to sell well, with sales of brands like Marlboro recently increasing.

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Global, regional and national agencies concerned about e-cigarettes: statements you are unlikely to hear from vaping advocates

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Vaping advocates like to point to lists of agencies which support the proliferation of vaping as a way of helping smokers quit and reducing harm. They hope that uninformed readers will take from such lists that there is now virtual consensus that nicotine vaping products are established to be safe and effective, and that many august bodies have now concluded that the jury has returned with a resounding global verdict.

These lists rarely include statements from agencies who remain far from  convinced that vaping products indeed live up to the hype that their commercial and often financially supported consumer interest groups wish to see dominate public and political narratives.

Some of these interest groups have very deep pockets which enable them to pay for lavish advertising, promotional, and public relations campaigns and to fund third party groups and individuals to proselytise on their behalf, with their financial connections are often either buried deep in links within links in the fine print of websites or undeclared.

This blog post provides a list of international and national agencies and collections of researchers and public health agencies which have expressed significant concerns about e-cigarettes and other heat-not-burn nicotine delivery products.

I have provided indicative examples of cautious and sceptical statements, with links to their full reports or statements. I will update it regularly with those I have missed and as more statements are published or revised.

I’d be grateful for notification of any such additions via the comment facility on this page. [updated 30 May 2019; 3 Jun 2019]

International Agencies

Forum of International Respiratory Societies (including American College of Chest Physicians, the American Thoracic Society, the Asian Pacific Society of Respirology, Asociación Latinoamericana del Tórax, the European Respiratory Society, the International Union Against Tuberculosis and Lung Disease, the Pan African Thoracic Society, the Global Initiative for Asthma, and the Global Initiative for Chronic Obstructive Lung Disease) (2014 and 2018)

The Forum of International Respiratory Societies is composed of professional organisations and experts in respiratory disease. Member societies include Asociacio´n Latinoamericana del To´rax, the American College of Chest Physicians, the American Thoracic Society, the Asian Pacific Society of Respirology, the European Respiratory Society, the International Union Against Tuberculosis and Lung Disease and the Pan African Thoracic Society.

  • The health risk of electronic cigarettes has not been adequately studied.  (2014)
  • Potential benefits to an individual smoker should be weighed against harm to the population of increased social acceptability of smoking and use of nicotine.  (2014)
  • Electronic nicotine delivery devices should be restricted or banned, at least until more information about their safety is available. (2014)
  • There can be no argument for harm reduction in children. To protect this vulnerable population from electronic cigarettes and other nicotine delivery devices, we recommend that electronic cigarettes be regulated as tobacco products and included in smoke-free policies. Sale of electronic cigarettes should be barred to youths worldwide. Flavouring should be prohibited in electronic cigarettes, and advertising accessible by youths and young adults be banned. (2018)

International Union Against Tuberculosis and Lung Disease  (2013 and 2014)

Key messages of the 2014 statement include:

  • The safety of electronic cigarettes (ECs) or electronic nicotine delivery systems (ENDS) has not been scientifically demonstrated.
  • Adverse health effects for third parties exposed (second-hand exposure) cannot be excluded because the use of ECs leads to the emission of fine and ultrafine inhalable liquid particles, nicotine and cancer-causing substances into indoor air.
  • The benefits of ECs have not been scientifically proven. To date, few studies have assessed ECs/ENDS as a harm reduction and cessation aid; those that do exist have conflicting findings.
  • The tobacco transnationals have increasingly entered the EC/ENDS marketplace with a strong presence.
  • ENDS could undermine the implementation of the WHO Framework Convention on Tobacco Control (FCTC) Article 12 (de-normalisation of tobacco use); use of ENDS could also hamper the implementation of Article 8 (protection from exposure to tobacco smoke), as ENDS users in public places may claim that their electronic cigarette does not contain tobacco and/or does not produce second-hand tobacco smoke.
  • The Union strongly supports regulating the manufacturing, marketing and sale of ECs or ENDS, preferably as medicines.

World Federation of Public Health Associations  (2018)

The World Federation of Public Health Associations has 123 member organisations. It supports recommendations provided by the WHO in their 2014 report.

World Medical Association (2012)

The World Medical Association is a federation of 111 national medical associations, including the Australian Medical Association. In their 2012 statement Electronic igarettes and other electronic nicotine delivery systems, the WMA recommended:

  • That the manufacture and sale of e-cigarettes and other electronic nicotine delivery systems be subject to national regulatory bodies prior approval based on testing and research as either a new form of tobacco product or as a drug delivery device.
  • That the marketing of e-cigarettes and other electronic nicotine delivery systems as a valid method for smoking cessation must be based on evidence and must be approved by appropriate regulatory bodies based on safety and efficacy data.
  • That e-cigarettes and other electronic nicotine delivery systems be included in smoke free laws.
  • Physicians should inform their patients of the risks of using e-cigarettes even if regulatory authorities have not taken a position on the efficacy and safety of these products.

World Health Organization and the Framework Convention on Tobacco Control  (FCTC)

In October 2014, the WHO presented its report Electronic nicotine delivery systems to the Sixth Session of the FCTC Conference of the Parties in Moscow. The report included the following clauses:

General considerations (clauses 33–38)

  1. Smokers will obtain the maximum health benefit if they completely quit both tobacco and nicotine use. In fact, Article 5.2(b) of the Convention commits Parties not only to preventing and reducing tobacco consumption and exposure to tobacco smoke but also to preventing and reducing nicotine addiction independently from its source. Therefore, while medicinal use of nicotine is a public health option under the treaty, recreational use is not.
  2. The rapid growth of ENDS use globally can neither be dismissed nor accepted without efforts to appropriately regulate these products, so as to minimize consequences that may contribute to the tobacco epidemic and to optimize the potential benefits to public health. Thus it is important to identify public health concerns and to consider these concerns when undertaking regulation and surveillance.
  3. Regulation of ENDS is a necessary precondition for establishing a scientific basis on which to judge the effects of their use, and for ensuring that adequate research is conducted, that the public has current, reliable information as to the potential risks and benefits of ENDS, and that the health of the public is protected. Public health authorities need to prioritize research and invest adequately to elucidate evidentiary uncertainties as soon as possible. However, the greater responsibility to prove claims about ENDS scientifically should remain with the industry.
  4. When designing a regulatory strategy for ENDS, governments should bear in mind the following general regulatory objectives:

(a) impede ENDS promotion to and uptake by non-smokers, pregnant women and youth;

(b) minimize potential health risks to ENDS users and non-users;

(c) prohibit unproven health claims from being made about ENDS; and

(d) protect existing tobacco-control efforts from commercial and other vested interests of the tobacco industry.

  1. Because the product, the market and the associated scientific evidence surrounding ENDS are all evolving rapidly, all legislation and regulations related to ENDS should be adaptable in response to new scientific evidence, including evaluation of different models for ENDS regulation, as evidence accumulates.

The decision following the report:

Invites Parties to consider applying regulatory measures such as those referred to in document FCTC/COP/7/11 to prohibit or restrict the manufacture, importation, distribution, presentation, sale and use of ENDS/ENNDS, as appropriate to their national laws and public health objectives.

Australian Agencies

Australian Competition & Consumer Commission (Product Safety Australia)

“No assessment of the safety and quality of electronic cigarettes has been undertaken. If liquid nicotine is imported for uses other than therapeutic, it is considered a substance that may cause harm and requires special precautions in manufacture, handling or use.”

Australian Council on Smoking and Health (March 2019)

“there is insufficient evidence to recommend e-cigarettes as a safe and efficacious method to give up smoking. It is also important to note that we are now seeing increasing evidence of harms attributable to their use. It is also important to emphasise that there is now also convincing evidence that the use of e-cigarettes by children and young people is an on-ramp for the use of traditional cigarettes. In recent months, the US Surgeon General, Secretary for Health and Commissioner of the Food and Drug Administration have sounded an alarm about the “epidemic” of vaping there by adolescents.”

Australian Dental Association (July 2017)

“The ADA’s review of the research literature finds that much more research must occur to confirm whether the use of ecigarettes/PV/ENDS assists people to quit smoking and does not cause further health impacts… many of these devices are being presented to the market as the ‘healthy’ alternative to smoking or claim to help people quit smoking. However, ENDS, of which e-cigarettes are one example, have not been rigorously assessed for efficiency and safety by the Therapeutic Goods Administration (TGA) and therefore the quality and safety is unknown. … The model taken to regulate the marketing of e-cigarettes and personal vaporisers should mirror those that pertain to the smoking of tobacco products. With the body of scientific and clinical research about the health impacts of e-cigarettes/personal vaporisers still in their early stages of infancy, the Australian Government should draw from lessons pertaining to public policy debates regarding the health impacts of tobacco products in the 20th century.The ADA urges the Australian Government to adopt in the precautionary principle and adopt the same regulations that underpin the use, manufacturing and marketing of tobacco products; applying them to e-cigarettes and personal vaporisers and ENDS.”

Australian Medical Association (2015)

“The evidence supporting the role of e-cigarettes in cessation is mixed and low level, and e-cigarettes are not currently recognised as cessation aids by the National Health and Medical Research Council, the Therapeutic Goods Administration or the World Health Organisation. In fact, using an e-cigarette may significantly delay the decision to quit smoking.  In addition, there is uncertainty about the longer term health implications of inhaling the vapours produced by the illegally imported (and unregulated) solutions.”

Cancer Council Australia, Heart Foundation and Cancer Australia (Feb 2018 joint policy)

“Based on current evidence, the potential benefit of e-cigarettes on smoking cessation is not established, and there is increasing evidence of health harms.”

CSIRO (Commonwealth Scientific and Industrial Research Organisation) (Jun 2018)

  • The evidence available suggests that regular use of e-cigarettes is likely to have adverse health consequences.
  • The evidence is consistent in suggesting that use of e-cigarettes by non-smoking youth predicts future smoking.
  • While many smokers and former smokers state a preference for e-cigarettes as a smoking cessation method, the effectiveness of this method compared with other smoking cessation methods is not known.
  • Based on the current evidence it is not possible to ascertain whether e-cigarettes have a positive or a negative effect on health in countries where they are permitted.
  • On present evidence, it is not possible to determine whether less restrictive access to e-cigarettes would reduce rates of smoking in Australia.

Lung Foundation Australia  (2014)

“There is currently not enough evidence to suggest the use of e-cigarettes as an effective smoking cessation tool over current recommended strategies including pharmacotherapy and clinical counselling. This could change as more research is published on this subject.

While the number of toxins in an e-cigarette is fewer than those in traditional cigarettes, there are no long-term studies on the safety of e-cigarettes and concern has been expressed about the small particles inhaled when “vaping” and their health impact, particularly on youth.

Members noted that the current evidence base in relation to e-cigarettes supports maintaining and, where appropriate, strengthening the current controls that apply to the marketing and use of these products in Australia. Members agreed to national guiding principles which reflect a precautionary approach to e-cigarettes and affirmed the current national regulatory framework remains appropriate.” 

National Health & Medical Research Council (2017)

E-cigarettes may expose users to fewer toxic chemicals than conventional tobacco cigarettes; however the extent to which this reduces harm to the user has not been determined; There is currently insufficient evidence to conclude whether e-cigarettes can assist smokers to quit; There is some evidence from longitudinal studies to suggest that e-cigarette use in non-smokers is associated with future uptake of tobacco cigarette smoking.

Ministerial Drug and Alcohol Forum (27 Nov 2017)

Parliament of Australia. House of Representatives. Report on the Inquiry into the Use and Marketing of Electronic Cigarettes and Personal Vaporisers in Australia

The Committee recommends that the Therapeutic Goods Administration continues to oversee the classification of nicotine and relevant exemptions, and the assessment of any electronic cigarette product as a therapeutic good.

The Committee recommends that the Australian Government establish a regulatory process for assessing and, if necessary, restricting colourings and flavourings used in electronic cigarettes.

Public Health Association of Australia (2018)

Based on current evidence, and in line with recommendations from the WHO, the World Federation of Public Health Associations, the Cancer Council, Heart Foundation, Cancer Australia and other leading evidence-based organisations, the PHAA strongly supports a precautionary approach to the use, promotion and availability of e-cigarettes in Australia

Royal Australian College of General Practitioners (July 2014)

“Concerns about e-cigarettes include a lack of evidence for short-term efficacy and short-and long-term safety, particularly in patients with current chronic disease. Rather than cessation, concurrent use with smoking may continue. There are also concerns that e-cigarettes may potentially act as a gateway to smoking.163 However it is reasonable to conclude that if used as a substitute rather than an addition, e-cigarettes are much less harmful than continuing to smoke.”

Royal Australasian College of Physicians (May 2018)

“The RACP is concerned there remains a lack of clear and robust evidence to inform policy makers, clinicians and the public about e-cigarettes. While there is some evidence that e-cigarettes mayreduce the number of tobacco cigarettes smokers consume and that they are likely to be less harmful than tobacco cigarettes (due to lower level of potentially toxic substances in e-cigarettes compared with tobacco cigarettes), the evidence on their efficacy as aids in smoking cessation and their long-term health effects is either mixed or limited. There is also evidence indicating that their use affects the likelihood of youth initiating use of tobacco cigarettes. Based on the current evidence, at this point in time the net public health effect of e-cigarettes cannot be clarified with any degree of confidence. The RACP acknowledges that e-cigarettes may have a potential role in tobacco harm reduction and smoking cessation for smokers unable or unwilling to quit. However, due to lack of long-term data and large population studies, e-cigarettes should be treated with caution. Users should be aware when using a nicotine-containing e-liquid that nicotine is highly addictive and a poison. Any e-cigarette that claims therapeutic benefit (including smoking cessation) must undergo the appropriate regulatory approval pathway in order to be allowed to make such claims, by either the Australian Therapeutic Goods Administration or in New Zealand, Medsafe.

The RACP is of the view that e-cigarettes present no benefits and only potential harms to those who do not smoke, be they never smokers or former smokers. We are concerned that the use of e-cigarettes may increase the likelihood of tobacco smoking initiation, in particular among adolescents and young people, as indicated in some evidence. In view of this, the sale, supply, promotion and useof e-cigarettes must be effectively regulated and they should not be available to minors. E-cigarettes should be included within smoke-free environment legislation, primarily due to the potential harms from re-normalising smoking and the exposure to second-hand e-cigarette aerosol.”

Therapeutic Goods Administration (2015)

“Unlike Nicotine Replacement Therapy (NRT) products, which have been rigorously assessed for efficacy and safety and, therefore, approved by the Therapeutic Goods Administration for use as aids in withdrawal from smoking, no assessment of electronic cigarettes has been undertaken and, therefore, the quality and safety of electronic cigarettes is not known.

The Australian Government is concerned about the use of electronic cigarettes in Australia. The impact of wide-scale use of these devices on tobacco use is not known, and the outcome in the community could be harmful.”

Thoracic Society of Australia and New Zealand (2017 joint statement with Lung Foundation Australia)

{There is no good public health claim for an unregulated approach to e-cigarettes and personal vaporisers. There is a strong case for a total ban on these products as they are currently available. Currently, e-cigarettes and personal vaporisers are being marketed as a harmless life choice, without any cautionary labels or health warnings. The use of these devices causes injury to the lung. There is no reason to support an approach to regulating a product which causes ill health, contains known carcinogens and other toxic compounds. The most compelling argument for these devices, and it is an argument based on anecdotal and personal experiences rather than an evidence base, is for use in smoking cessation. It is likely that these devices are less harmful than smoking cigarettes, however they are not harmless. If they are to be used as cessation aids, then this is a therapeutic device and must be regulated as such by the Therapeutic Good Administration.”

VicHealth (July 2017)

  • ECPVs should only be made available as a smoking cessation aid if they are approved by the Therapeutic Goods Administration (TGA).
  • ECPVuse should be subject to the same restrictions as tobacco smoking,and therefore should not be permitted in existing smoke-free areas.
  • ECPVs should only be marketed as a therapeutic good if approved by the TGA.

US Agencies

American Academy of Family Physicians (April 2019)

“There are concerns about the lack of any regulatory oversight by the Food and Drug Administration’s Center for Tobacco Products on the manufacture, distribution and safety of e-cigarettes. Therefore, the AAFP calls for rigorous research in the form of randomized controlled trials of e-cigarettes to assess their safety, quality, and efficacy as a potential cessation device. The AAFP also recommends that the marketing and advertising of e-cigarettes, especially to children and youth, should cease immediately until e-cigarette’s safety, toxicity, and efficacy are established.”

American Academy of Pediatrics (2018) 

“Electronic cigarettes (e-cigarettes) are the most commonly used tobacco product among youth. The 2016 US Surgeon General’s Report on e-cigarette use among youth and young adults concluded that e-cigarettes are unsafe for children and adolescents. Furthermore, strong and consistent evidence finds that children and adolescents who use e-cigarettes are significantly more likely to go on to use traditional cigarettes—a product that kills half its long-term users. E-cigarette manufacturers target children with enticing candy and fruit flavors and use marketing strategies that have been previously successful with traditional cigarettes to attract youth to these products. Numerous toxicants and carcinogens have been found in e-cigarette solutions. Nonusers are involuntarily exposed to the emissions of these devices with secondhand and thirdhand aerosol. To prevent children, adolescents, and young adults from transitioning from e-cigarettes to traditional cigarettes and minimize the potential public health harm from e-cigarette use, there is a critical need for e-cigarette regulation, legislative action, and counterpromotion to protect youth.”

American Association for Cancer Research & American Society of Clinical Oncology (joint statement Jan 2015)

“ENDS may be beneficial if they reduce smoking rates or prevent or reduce the known adverse health effects of smoking. However, ENDS may also be harmful, particularly to youth, if they increase the likelihood that nonsmokers or formers smokers will use combustible tobacco products or if they discourage smokers from quitting. The American Association for Cancer Research (AACR) and the American Society of Clinical Oncology (ASCO) recognize the potential ENDS have to alter patterns of tobacco use and affect the public’s health; however, definitive data are lacking. AACR and ASCO recommend additional research on these devices, including assessing the health impacts of ENDS, understanding patterns of ENDS use, and determining what role ENDS have in cessation. Key policy recommendations include supporting federal, state, and local regulation of ENDS; requiring manufacturers to register with the FDA and report all product ingredients, requiring childproof caps on ENDS liquids, and including warning labels on products and their advertisements; prohibiting youth-oriented marketing and sales; prohibiting child-friendly ENDS flavors; and prohibiting ENDS use in places where cigarette smoking is prohibited.”

American Cancer Society Cancer Action Network (Feb 2018) 

“The ACS strongly recommends that every effort be made to prevent the initiation of e-cigarettes by youth.  The use of products containing nicotine in any form among youth is unsafe and can harm brain development. Furthermore, evidence indicates that young e-cigarette users are at increased risk for both starting to smoke and becoming long-term users of combustible tobacco products.

The ACS encourages the FDA to regulate all tobacco products, including e-cigarettes, to the full extent of its authority, and to determine the absolute and relative harms of each product.  The FDA should assess whether e-cigarettes help to reduce tobacco-related morbidity and mortality, and the impact of marketing of e-cigarettes on consumer perceptions and behavior.  Any related regulatory regime should include post-marketing surveillance to monitor the long-term effects of these products and ensure the FDA’s actions have the intended health outcome of significantly reducing disease and death.  Furthermore, the FDA should use its authorities to reduce the toxicity, addictiveness and appeal of tobacco products currently on the market.  The ACS also applauds the FDA for recognizing its significant role as a science-based agency in helping to address the addictiveness of nicotine in cigarettes.  Reducing nicotine in all combustible tobacco products to below addictive levels holds the potential to significantly accelerate reductions in the use of combustible tobacco products, which remain by far the leading preventable cause of cancer and preventable death in the United States.” 

American College of Cardiology (Nov 2018)

“Traditional cigarettes are an often-lifelong habit with major health implications that usually begins in adolescence. According to the CDC, youth who use e-cigarettes may be more likely to smoke in the future. When the latest e-cigarettes are designed to almost mimic a flash drive and feature flavors like strawberry and chocolate, it’s not hard to see why they’re on the rise among American youth. It is the responsibility of the health community—public organizations, medical societies and even individual clinicians—to make it less likely American children become smokers. Furthermore, we have concerns about the widespread use of a product for which, frankly, the medical and scientific community has yet to clearly establish the long-term health implications ”

American College of Physicians (Dec 2018)

“ACP’s 2015 policy paper, Electronic Nicotine Delivery Systems, highlighted the dangers that ENDS products, including e-cigarettes, present to individuals, particularly minors, and called for a ban on flavored tobacco products, which often attract minors. ACP is especially concerned about the increase in ENDS use among young people, as evidence suggests that adolescents who start using ENDS also use, or intend to use, combustible tobacco products later in life.

ACP is committed to supporting regulations that will reduce the use of all forms of tobacco products, including e-cigarettes. ACP looks forward to continuing to work with regulators and health care stakeholders to implement meaningful policy that will not only improve public health, but will take concrete steps towards combating the epidemic of ENDS use among young people.”

American College of Preventive Medicine (Jan 2019)

“The evidence behind the safety and efficacy of ENDS has not caught up with the rapid increase in widespread use of these products. Limited evidence supports the short-term efficacy of exclusive use of nicotine-containing ENDS in adults desiring to quit, with several RCTs demonstrating positive results compared with observational studies that often do not show benefit. These studies compared ENDS with no treatment, non-nicotine ENDS, or, in rare cases, NRT. There is insufficient evidence comparing the efficacy of ENDS to established evidence-based treatments.

The evidence on the benefits versus harms of e-cigarettes is still emerging. There are significant population health concerns, and it is unclear if the potential benefit to the individual adult smoker interested in quitting outweighs the potential harms of attractiveness to youth, including a gateway to cigarette smoking and changing norms around vaping and smoking.

On an individual level, limited evidence suggests that ENDS may be effective at reducing cigarette use among adult smokers intending to quit. There is insufficient evidence addressing potential long-term harms of ENDS, and limited evidence is available about short-term harms of ENDS and the impact of secondhand exposure. Although ENDS appear safer than combustible cigarettes, they are not without risk. Among youth there is no known benefit and significant concern for harm. On a population level, there may be significant harms associated with ENDS, particularly among youth nonsmokers. The long-term balance of potential benefits versus harms from the individual and population perspectives are unclear.”

American Lung Association (Feb 2019)

“The American Lung Association is very concerned that we are at risk of losing another generation to tobacco-caused diseases as the result of e-cigarettes. The Lung Association remains extremely troubled about the rapid increase of youth using these products and has repeatedly called upon the Food and Drug Administration (FDA) to increase their oversight and scrutiny of these products to protect kids.”

American Heart Association (March 2019)

Policy positions:
All marketing and advertising of tobacco products, including e-cigarettes and other non-combustible products, should be restricted. This includes online, social, television, radio, and print ads, celebrity endorsements, movie placements, price promotions, event sponsorships and branding of non-tobacco merchandise.

The FDA’s Center for Drug Evaluation and Research should collaborate with the FDA’s Center for Tobacco Products on the research and legal analysis needed to facilitate e-cigarettes being regulated and sold only as FDA-approved cessation products.

American Medical Association (2018)

“Our AMA:

(1) recognizes the use of e-cigarettes and vaping as an urgent public health epidemic and will actively work with the Food and Drug Administration and other relevant stakeholders to counteract the marketing and use of addictive e-cigarette and vaping devices, including but not limited to bans and strict restrictions on marketing to minors under the age of 21;

(2) encourages the passage of laws, ordinances and regulations that would set the minimum age for purchasing tobacco products, including electronic nicotine delivery systems (ENDS) and e-cigarettes, at 21 years, and urges strict enforcement of laws prohibiting the sale of tobacco products to minors…” 

American Public Health Association (Nov 2018)

“The safety of ENDS and their efficacy in smoking cessation programs have not been demonstrated, and scientific evidence exists to the contrary. In the United States, ENDS use has increased among all demographic groups, including young people, vulnerable populations, and minorities. Studies suggest that ENDS use increases use of combustible tobacco, and chemicals are harmful to both users and those exposed to secondhand vapor. … APHA supports efforts to regulate ENDS, urges restriction of ENDS advertising and promotion, encourages prohibition of ENDS use in public places and workplaces, calls for evidence-based research regarding ENDS efficacy in smoking cessation, and recommends prohibiting the sale of ENDS to people 21 years and younger.”

American Society of Addiction Medicine (April 2018)

“The concern with the current situation is that e-cigarettes have largely not been tested or standardized, and products offered on the market are rapidly changing, making it difficult to assess true potential benefit for cessation or harm to the user in the long term. Available evidence suggests that harm from e-cigarettes is expected to be much lower than from combustible cigarettes, which are estimated to contain roughly one hundred times the amount of toxins.  However, there are other risks associated with e-cigarettes, as there are reports of these devices spontaneously exploding, causing burns and other injuries to users. They are banned from airline flights for this reason. Finally, other modifiable forms or “mods” that rely the on use of refillable liquid nicotine solutions are at risk for contamination with other substances since the production and manufacturing of these products are not tested or regulated by any government agency or held to any standard. …

An additional concern is the still-unknown risk to young people who are currently major consumers of electronic cigarettes in the US.  Although cigarette smoking continues to decrease among American teens, use of electronic cigarettes has been escalating and surpassed use of other forms of tobacco.  A study of middle and high school students found that, among those who were current users of tobacco products, an estimated 70.0% (3.26 million) had used at least one flavored tobacco product in the past 30 days.  The long-term effects of this are unknown. There are concerns that, as prevention efforts to educate children on the harms of tobacco in cigarettes had a positive impact on teen cigarette use, the tobacco industry has promoted alternative ways to attract teens to smoking by adding flavoring and engaging in direct advertising. These strategies coincide with the rise in e-cigarette use among youth, thereby increasing exposure and the potential for the development of addiction involving the use of nicotine. Lastly, there is a potential risk that e-cigarette use will be a gateway to subsequent combustible tobacco and other drug use, including marijuana; however, research findings on such long-term effects will not be available for some time.”

American Society of Clinical Oncology Joint Statement with American Association for Cancer Research (Jan 2015)

“ENDS may be beneficial if they reduce smoking rates or prevent or reduce the known adverse health effects of smoking. However, ENDS may also be harmful, particularly to youth, if they increase the likelihood that nonsmokers or formers smokers will use combustible tobacco products or if they discourage smokers from quitting. The American Association for Cancer Research (AACR) and the American Society of Clinical Oncology (ASCO) recognize the potential ENDS have to alter patterns of tobacco use and affect the public’s health; however, definitive data are lacking. AACR and ASCO recommend additional research on these devices, including assessing the health impacts of ENDS, understanding patterns of ENDS use, and determining what role ENDS have in cessation. Key policy recommendations include supporting federal, state, and local regulation of ENDS; requiring manufacturers to register with the FDA and report all product ingredients, requiring childproof caps on ENDS liquids, and including warning labels on products and their advertisements; prohibiting youth-oriented marketing and sales; prohibiting child-friendly ENDS flavors; and prohibiting ENDS use in places where cigarette smoking is prohibited.”

American College of Obstetricians and Gynecologists (May 2017)

  • Exhaled ENDS vapor is not harmless water vapor—it has been shown to contain chemicals that cause cancer, can cause harm to unborn babies, and is a source of indoor air pollution. ENDS are promoted as a way to smoke where smoking is prohibited. However, state and local officials are incorporating ENDS use into existing smoke-free air regulations to protect health.
  • Some people use ENDS as a way to quit smoking combustible cigarettes, but current evidence is insufficient to recommend ENDS for tobacco cessation in adults, and some people use both devices due to the addictive nature of nicotine.

ENDS are a health hazard

  • ENDS companies can legally promote these products by using techniques that cigarette companies have not been able to use since the 1998 Master Settlement Agreement, including television and radio ads, billboards, outdoor signage, and sponsorships.
  • ENDS and ENDS solutions are available in many flavors (bubble gum, chocolate, peppermint, etc.) that appeal to youth. Flavors, design, and marketing renormalize and glamorize smoking

National Academies of Science, Engineering and Medicine (Jan 2018)

Selected conclusions:

Conclusion 3-1. There is conclusive evidence that e-cigarette use increases airborne concentrations of particulate matter and nicotine in indoor environments compared with background levels.

Conclusion 4-1. There is conclusive evidence that exposure to nicotine from e-cigarettes is highly variable and depends on product characteristics (including device and e-liquid characteristics) and how the device is operated.

Conclusion 4-2. There is substantial evidence that nicotine intake from e-cigarette devices among experienced adult e-cigarette users can be comparable to that from combustible tobacco cigarettes.

Conclusion 5-1. There is conclusive evidence that in addition to nicotine, most e-cigarette products contain and emit numerous potentially toxic substances.

Conclusion 5-2. There is conclusive evidence that, other than nicotine, the number, quantity, and characteristics of potentially toxic substances emitted from e-cigarettes are highly variable and depend on product characteristics (including device and e-liquid characteristics) and how the device is operated.

Conclusion 7-1. There is substantial evidence that e-cigarette aerosols can induce acute endothelial cell dysfunction, although the long-term consequences and outcomes on these parameters with long-term exposure to e-cigarette aerosol are uncertain.

Conclusion 7-2. There is substantial evidence that components of e-cigarette aerosols can promote formation of reactive oxygen species/oxidative stress. Although this supports the biological plausibility of tissue injury and disease from long-term exposure to e-cigarette aerosols, generation of reactive oxygen species and oxidative stress induction is generally lower from e-cigarettes than from combustible tobacco cigarette smoke.

Conclusion 8-1. There is substantial evidence that e-cigarette use results in symptoms of dependence on e-cigarettes.

Conclusion 10-1. There is no available evidence whether or not e-cigarette use is associated with intermediate cancer endpoints in humans. This holds true for e-cigarette use compared with use of combustible tobacco cigarettes and e-cigarette use compared with no use of tobacco products.

Conclusion 10-2. There is limited evidence from in vivo animal studies using intermediate biomarkers of cancer to support the hypothesis that long-term e-cigarette use could increase the risk of cancer; there is no available evidence from adequate long-term animal bioassays of e-cigarette aerosol exposures to inform cancer risk.

Conclusion 10-4. There is substantial evidence that some chemicals present in e-cigarette aerosols (e.g., formaldehyde, acrolein) are capable of causing DNA damage and mutagenesis. This supports the biological plausibility that long-term exposure to e-cigarette aerosols could increase risk of cancer and adverse reproductive outcomes. Whether or not the levels of exposure are high enough to contribute to human carcinogenesis remains to be determined.

Conclusion 11-1. There is no available evidence whether or not e-cigarettes cause respiratory diseases in humans.

Conclusion 16-1. There is substantial evidence that e-cigarette use increases risk of ever using combustible tobacco cigarettes among youth and young adults.

Conclusion 17-1. Overall, there is limited evidence that e-cigarettes may be effective aids to promote smoking cessation.

National Alliance for Hispanic Health (April 2019)

“E-cigarettes are addicting a new generation of smokers and online retail sales are a driving force. We applaud the bipartisan introduction today of the Preventing Online Sales of E-Cigarettes to Children Act to close the online door to underage sales and protect the health of our children … E-cigarette sales are driving a youth tobacco tipping point.  It is time for us to protect youth and give parents the tools they need to ensure their children cannot easily evade age restrictions on purchase of e-cigarettes”

Prevention Institute (Aug 2016)

“Big Tobacco and its allies have been trying to obscure the emerging science on the dangers e-cigarettes pose to public health. But claims that “vaping” is a healthier alternative to cigarettes, instead of a gateway, were disproven by a recent American Journal of Public Health study that found smokers who have used e-cigarettes are less likely to cut back on cigarettes in the future than smokers who haven’t used them.”

U.S. Preventative Services Task Force (Sept 2015)

“The evidence on the benefits versus harms of e-cigarettes is still emerging. There are significant population health concerns, and it is unclear if the potential benefit to the individual adult smoker interested in quitting outweighs the potential harms of attractiveness to youth, including a gateway to cigarette smoking and changing norms around vaping and smoking
The USPSTF concludes that the current evidence is insufficient to recommend electronic nicotine delivery systems (ENDS) for tobacco cessation in adults, including pregnant women.”

US Surgeon General (2016)

“The use of products containing nicotine poses dangers to youth, pregnant women, and fetuses. The use of products containing nicotine in any form among youth, including in e-cigarettes, is unsafe.. E-cigarette aerosol is not harmless. It can contain harmful and potentially harmful constituents, including nicotine. Nicotine exposure during adolescence can cause addiction and can harm the developing adolescent brain. 

U.S. Food and Drug Administration

Statement from FDA Commissioner Scott Gottlieb, M.D., on proposed new steps to protect youth by preventing access to flavored tobacco products and banning menthol in cigarettes

“Today, I’m pursuing actions aimed at addressing the disturbing trend of youth nicotine use and continuing to advance the historic declines we’ve achieved in recent years in the rates of combustible cigarette use among kids.”

“Today, I’m announcing proposals to help reverse these trends, with the unwavering support of HHS Secretary Alex Azar, who shares my deep commitment to protecting the health of our nation’s children. Today, we advance our efforts to combat youth access and appeal with a policy framework that firmly and directly addresses the core of the epidemic – flavors.

The data show that kids using e-cigarettes are going to be more likely to try combustible cigarettes later. This is a large pool of future risk.”

“These increases must stop. And the bottom line is this: I will not allow a generation of children to become addicted to nicotine through e-cigarettes. We won’t let this pool of kids, a pool of future potential smokers, of future disease and death, to continue to build. We’ll take whatever action is necessary to stop these trends from continuing.”

Understanding the Health Impact and Dangers of Smoke and ‘Vapor’

“While we’re still learning about the long-term potential benefits and health risks of e-cigarettes and related products, existing scientific research offers some clear evidence that several of the dangerous chemicals in tobacco smoke are also present in the aerosol of some e-cigarette products. And this is concerning because of the very technology that distinguishes e-cigarettes — their delivery system that feeds aerosol into the body. We know that aerosol exposure is a major health concern due to the ability of aerosol particles to penetrate deeply into the respiratory system. E-cigarette aerosols can enter the lungs and small airways in various ways, which may depend on a number of factors, including nicotine content and the type of e-cigarette. That means some of the toxic chemicals and other substances contained in e-cig aerosols have the potential to go deep into the lungs and may pose risk for diseases not usually seen in smokers.

This is why we’ve been so concerned about youth use of these products. It’s not just the addiction to nicotine, and the potential for kids who become addicted to nicotine from e-cigarettes to eventually transition to regular combustible cigarettes. It’s also the direct risks posed by the e-cigarettes themselves.

This isn’t idle speculation. We know the aerosol produced by some e-cigarettes can contain high amounts of some toxic substances.”

“Still another potential danger from certain types of e-cigarette designs can relate to the metal coil elements that heat and cool the product.”

“The mounting research on the physical impacts of aerosol produced by e-cigarettes provides a strong basis for concern. This is especially true when it comes to use of these products by children. But there remains a great deal to learn.”

“We’re especially concerned by evidence from animal studies that the vapor in e-cigarettes can cause changes to tissue in the airways that can induce cancer or be a precursor to cancer. We have initiated a comprehensive research plan to fully evaluate these risks, and we will report our results publicly.”

“The FDA has made a strong commitment and taken a number of actions to address the addictiveness posed by nicotine in cigarettes. However, there are now new concerns about the dangers from aerosols inhaled by users of e-cigarettes. We see potential opportunity from the ENDS products for currently addicted adult smokers to help them quit smoking. But we also see risk, especially when it comes to youth use of these products.”

“…we also must consider the risks of use by youth and others not already addicted to cigarettes. Whether it’s traditional cigarettes or e-cigarettes, the FDA will remain especially firm in preventing kids from using and becoming addicted to tobacco products.”

US National Institute on Drug Abuse (2015)

“Some people believe e-cigarettes may help lower nicotine cravings in those who are trying to quit smoking. However, e-cigarettes are not an FDA-approved quit aid, and there is no conclusive scientific evidence on the effectiveness of e-cigarettes for long-term smoking cessation… E-cigarettes haven’t been thoroughly evaluated in scientific studies. For now, not enough data exists on the safety of e-cigarettes, how the health effects compare to traditional cigarettes, and if they are helpful for people trying to quit smoking. “

Europe

European Public Health Association (2018)

The health risks associated with e-cigarettes remain uncertain but they cannot be considered safe. What is certain is that statements that they are some percentage safer than conventional cigarettes are so far unjustified… Overall, e-cigarettes may help some smokers quit but, for most, e-cigarettes depress quitting…. The net effect of making e-cigarettes widely available, at population level, seems likely to be an increase in sole and dual use of e-cigarettes and sole smoking unless there is very stringent regulation.”

European Respiratory Society: Task Force report  (2018)

“ECIG aerosol contains potentially toxic chemicals. As compared to conventional cigarettes, these are fewer and generally in lower concentrations. Second-hand exposures to ECIG chemicals may represent a potential risk, especially to vulnerable populations. There is not enough scientific evidence to support ECIGs as an aid to smoking cessation due to a lack of controlled trials, including those that compare ECIGs with licenced stop-smoking treatments. So far, there are conflicting data that use of ECIGs results in a renormalisation of smoking behaviour or for the gateway hypothesis. Experiments in cell cultures and animal studies show that ECIGs can have multiple negative effects. The long-term effects of ECIG use are unknown, and there is therefore no evidence that ECIGs are safer than tobacco in the long term. Based on current knowledge, negative health effects cannot be ruled out.”

plus statement in May 2019 “”There is also a lack of evidence to support the claims that e-cigarettes are more effective than established smoking cessation medications or nicotine replacement therapies, but the few independent studies that have been published indicate that e-cig and heated tobacco device use undermines quit attempts outside of a clinical setting, and show that most people use alternative nicotine delivery products alongside conventional cigarettes, rather than as a replacement.”

OTHER NATIONS

Indian Council on Medical Research (2019)

“Based on the currently available scientific data from multiple streams of research, the Council recommends complete prohibition on ENDS or e-cigarettes in India in the greater interest of protecting public health, in accordance with the precautionary principle preventing public harm from a noxious agent, considering the following facts and circumstances:

• ENDS or e-cigarettes contain nicotine solution, which is highly addictive, and also contain other ingredients as flavouring agents and vapourizers, which are also harmful for health.

• Use of ENDS or e-cigarettes has documented adverse effects on humans which include DNA damage; carcinogenesis; cellular, molecular and immunological toxicity; respiratory, cardiovascular and neurological disorders and adverse impact on foetal development and pregnancy.

• The magnitude of potential short-term and long-term health risks to the users still remains undetermined at the population level since the products are recent and come in diverse forms.

• Whereas, the degree to which, if at all, the ENDS or e-cigarettes benefit as tobacco cessation aides is not firmly established, evidence suggests that there is a risk of dual use to some extent and initiation to tobacco addiction to non-smokers. Hence, on the balance these products have a net negative impact on public health.

• Use of ENDS can open a gateway for new tobacco addiction which is a potential threat to the country’s tobacco control laws and on-going tobacco control programmes.

• The rapidly increasing trend of use of ENDS or e-cigarettes by young persons, in countries where it was introduced, underscores a potential threat to public health.”

Acknowledgements: Quit Victoria and Campaign for Tobacco Free Kids, Washington DC.

 

 

The non-disease now on life-support: wind farm complaints in Australia are way down

The third annual report of Australia’s National Wind Farm Commissioner is about to be released. Commissioner Andrew Dyer’s recent appearance before Senate estimates and various presentations to the energy sector show that the report will cover all complaints received during 2018, and also contain all data from the very first complaint received since November 2015 when the Commission office opened. It has also now taken responsibility for investigating complaints about solar farms (5mw or more) and energy storage facilities (major batteries of 1mw or more).

The Commission combines all complaints made from a single household as one complaint, so the data is effectively best understood as a count of complaining households across Australia.

During 2018, 123 complaints were received:

  • 8 (7% of total) about four operational wind farms (there are 78 operational wind farms across Australia, meaning some 95% of Australian wind farms had  no residents who ever complained in 2018)
  • 95 (77%) about 34 proposed wind farms
  • 3 (2%) about 3 proposed solar farms
  • 17 (14%) which did not specify any existing or proposed farm

In total, across the 37 months that the office has been open for complaints, it has received 286 complaints:

  • 65 (23%) about 11 operational wind farms
  • 191 (about 51 proposed wind farms
  • 3 about 3 proposed solar farms
  • 27 which did not specify any existing or proposed farm

Of the 286 complaints, 268  (94%) have been closed by the office with the remainder still being processed.

Many complainants mention more than one issue. The Commissioner’s statement to Senate Estimates noted that “Over the three calendar years of our operations, cited issues in complaints received that have dropped considerably include health, from 46 instances to 18; noise, from 55 to 38; and vibration, from 19 to zero. Cited issues that have increased over this time include visual amenity, from 24 instances to 57; lack of community engagement, from 15 to 41; construction, from seven to 14; and planning processes, from 26 to 42.” Most of these concern farm that were not even operating when the complaints were made.

The phenomenon of complaints about wind farms is by no means the first time we have seen communities expressing anxiety about new technology, with small minorities of those who are anxious, expressing that anxiety through complaints and sometimes somaticizing it in symptoms.

Perhaps the most recent and pertinent comparison here is with mobile phone towers and the phones themselves. The heyday of anxiety about these was in the mid-1990s, when cell phone use began to accelerate rapidly. Within a few years, a large and quickly a very large proportion of the population was using cell phones. The resulting service demands required that transmission towers mushroom across all countries.

Mobile phones and towers rapidly moved from being exotic technologies to being near-ubiquitous in every nation on earth. While outbreaks of health concerns were quite common in the early years of phone use, today they have long been a phenomenon of the past. It is now around 25 years since reports of protests about mobile phone towers regularly featured in Australian news media.

While there are still die-hard enclaves of passionate crusaders against mobile phones and Wi-Fi, these are tiny. Their dire warnings in the face of no evidence of any increase in the diseases they have constantly warned us all about have rendered them as marginal and eccentric as the occasional person we have all encountered who tells us they would never have a microwave oven, a computer or a television in their home because ‘those things are deadly’. Here, there is probably no rival for heroic predictions gone badly wrong than that made in 2006 by two researchers who predicted that by 2017, half of all the world’s population would have developed electrosensitivity.

The ever-diminishing number of complaints — including health complaints – documented in  the forthcoming third report of the Commissioner, shows that the sub-culture of complaint about wind farms is almost now on life support. This was entirely predictable for any student of the history non-diseases attributed to new technologies when they first appear.

Own goal from wind farm loathing senators?

The cabal of former wind farm loathing senators (Madigan, Leyonhjelm, Xenophon, Day) whose infamous 2015 report gave birth to the national wind farm commissioner via the appeasing Abbott government can be seen today to have kicked a massive own goal.  In their fevered imaginations, they would have hoped that a government sponsored complaints office would be deluged with complaints about these evil industrial artifices blighting bucolic landscapes, decimating local birds, and ruining the health of oppressed local residents.

But just the opposite occurred. The transparency of the Commissioner’s investigative processes circumvented the populist rhetoric of indifferent, corrupt and secretive wind energy companies trampling on the concerns of powerless locals. I’ve had a Google alert set for Australia’s anti- wind farm advocates, the Waubra Foundation. I’ve had nothing since in my inbox since about August 2015.

Historians of the renewable energy revolution will bookmark that there was a period of complaining about wind farms in Australia that started up in 2009 and then died away a decade later. May it rest in peace and we all learn about how predictable the rise and fall of these psychogenic “communicated diseases” are, and what we might to avoid them in the future. The final chapter in our free book and the detailed descriptions and recommendations of the National Wind Farm Commissioner’s previous reports are good places to guide how to go about this.

own goal