Talk:Electronic cigarette

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The Gateway Effect[edit]

There have been several references to the gateway effect in the article. While there's no doubt teens who tried e-cigarettes are more likely to smoke compared to teens who have abstained from nicotine altogether, both US and UK authorities agree that the evidence does not demonstrate that e-cigarette use causes smoking.

The 2016 US Surgeon General's Report states

The available evidence suggests that e-cigarette use is associated not only with the use of other tobacco products, but also with alcohol and other substance use, such as marijuana. This is consistent with the common liability model for substance use and other risky behaviors (Vanyukov et al. 2012)

The Royal College of Physicians' report states: appears that, to date, concerns over gateway progression into smoking are unfounded. The association between e-cigarette and tobacco cigarette use is therefore more likely to arise from common liability to use of these products, and to use of e-cigarettes as a gateway from, rather than to, smoking.

Zvi Zig (talkcontribs 19:01, 3 July 2017 (UTC)

Sure. Doc James (talk · contribs · email) 02:20, 5 July 2017 (UTC)

Represent consensus on relative safety[edit]

While there is agreement on relative safety, there is an effort to muddle this in the lead. This (1) includes no indication of the magnitude of reduction in risk and (2) displays the level of confidence in the evidence for reduced risk.

A recent systematic review by Truth Initiative --America's largest anti-smoking NGO -- concludes

Studies indicate that ENDS are increasing in use, particularly among current smokers, pose substantially less harm to smokers than cigarettes.

The Framework Convention Alliance on Tobacco Control -- an international umbrella group including more than 500 tobacco control and public health organizations -- reports "widespread agreement" that

E-cigarettes are almost certainly considerably less hazardous for individuals than cigarettes.

FCA Policy briefing: Electronic Nicotine Delivery Systems (a consensus statement), October 2014

Zvi Zig (talkcontribs 12:52, 9 July 2017 (UTC)

There is no agreement on relative safety. A 2015 review concluded "As e-cigarette manufacturing changes, the newer and “hotter” products may expose patients to higher levels of known carcinogens."[1] We can't dismiss this review even when there are newer reviews. A 2014 review found "Electronic cigarettes (e-cigarettes) are advertised as being safer than tobacco cigarettes products as the chemical compounds inhaled from e-cigarettes are believed to be fewer and less toxic than those from tobacco cigarettes."[2] But the same review found "the levels of formaldehyde in vapors from high-voltage devices were almost identical to those in traditional cigarette smoke (1.6–52 μg per cigarette) [18]. Ohta et al. further reported that increasing levels of carbonyl compounds, such as formaldehyde and acetaldehyde, were observed for a voltage over 3 V [13,14]."[3] Again, we can't dismiss this review per WP:MEDDATE. QuackGuru (talk) 13:23, 9 July 2017 (UTC)
QuackGuru - All the papers you cite aboverely on review evidence prior to findings reported in reviews like RCP, PHE and Glasser et al 2016 (PMID 27914771) which show that high levels of formaldehyde are produced under unrealistic conditions. It's not recentism to discredit research which has been shown to be irrelevant based on new studies.Zvi Zig (talkcontribs 20:52, 9 July 2017 (UTC)
Yes there is tentative evidence of short term safety. But overall safety is unclear per many sources. This is why we say "They are likely safer than tobacco cigarettes" follows Doc James (talk · contribs · email) 16:57, 9 July 2017 (UTC)
No, Doc -- not just short-term studies. You're ignoring the chemistry and the toxicology considered in so many reviews.Zvi Zig (talkcontribs 20:57, 9 July 2017 (UTC)
The situation for anything but short-term is not clear, even if there are some studies that support it — there are others that do not. Carl Fredrik talk 14:58, 14 July 2017 (UTC)

Refs that support

  1. "Clear evidence about the safety of e-cigarettes is lacking, and laboratory experiments and case reports suggest these products may be associated with potential adverse health consequences."2015 Mayo Clin Proc
  2. "The USPSTF concludes that the current evidence is insufficient to recommend electronic nicotine delivery systems for tobacco cessation in adults, including pregnant women. The USPSTF recommends that clinicians direct patients who smoke tobacco to other cessation interventions with established effectiveness and safety (previously stated)." USPSTF 2015
  3. "These devices are unregulated, of unknown safety, and of uncertain benefit in quitting smoking."2014 review

Doc James (talk · contribs · email) 17:26, 9 July 2017 (UTC)

These reviews, - and certainly the more recent ones like PMID 27914771 - do not support the overemphasized redundant uncertainty in the lead in relation to relative safety compared to combustible tobacco cigarettes.Zvi Zig (talkcontribs 21:06, 9 July 2017 (UTC)
It is citation overkill to continue to add more and more sources for the same claim. A 2017 review found "Electronic cigarettes (e-cigarettes) are a growing public health concern because of a dramatic increase in use by adolescents and the uncertainty of potential health impacts."[4] Reviews like this one do support it is "uncertain". QuackGuru (talk) 21:13, 9 July 2017 (UTC)
2016 Cochrane review states "People who do not wish to quit can be helped to cut down the number of cigarettes they smoke and to quit smoking in the long term, using NRT, despite original intentions not to do so. However, we rated the evidence contributing to the cessation outcome for NRT as 'low' by GRADE standards. There is a lack of evidence to support the use of other harm reduction aids to reduce the harm caused by continued tobacco smoking."2016 Cochrane review
So Cochrane is saying e cigs are unclear in reducing harm from continued tobacco use. This is aside from the population effect of continued nicotine addition for those not yet using tobacco. Doc James (talk · contribs · email) 17:29, 9 July 2017 (UTC)
Zvi Zig, which review says we know the health risks for certain? The sources indicate it is still uncertain. That's why the sources use words such as "may". For example, see "E-cigarettes that deliver nicotine in water vapor may be safer than tobacco smoking."[5] QuackGuru (talk) 17:35, 9 July 2017 (UTC)
And well almost certainly safer than cigarettes, this does not mean the health risks of e-cigs at either a individual or population level is known. Doc James (talk · contribs · email) 17:39, 9 July 2017 (UTC)
Doc James, the precise health effects of eating carrots remain uncertain. There are statistical envelopes of uncertainty around everything in epidemiology, and the etiology of diseases are complex. However, opening a page on bananas saying "the health effects of carrots are uncertain" would be highly misleading. There are people addicted to the world's most deadly legal product reading this page every day, we cannot afford this level of ambiguity when reviews assess the chemical, in vivo, in vitro and clinical toxicology in relation to smoking.Zvi Zig (talkcontribs 21:14, 9 July 2017 (UTC)
There are also people reading this page not currently addicted to nicotine. The last thing we want to say is that this is without risk when evidence does not say it is without risk. Doc James (talk · contribs · email) 22:48, 9 July 2017 (UTC)
There are virtually no never-smokers who become regular users of e-cigarettes, as the Royal College of Physicians' report notes. In any case, no one is saying that there's no risk.Zvi Zig (talkcontribs 01:05, 10 July 2017 (UTC)
A 2015 review found "e-cig use by nonsmokers and especially by youth may result in a new generation of nicotine addicts and may become a gateway to smoking."[6]
Another review found "E-cigs are used by some smokers as an aid for quitting or smoking reduction, and by never smokers (e.g., adolescents and young adults)."[7] QuackGuru (talk) 01:29, 10 July 2017 (UTC)
Do you read the reviews that you quote? Or are you simply harvesting them for words that you want to use? The first review (by Farsalinos&Le Houezec (2017)) does not "find" what you quoted - they cite this as one of 4 "arguments" used to support applying the precautionary principle towards e-cigarettes. In fact in the examination section for this argument (yes, there is a whole section of the paper dedicated to this argument), the conclusion is: Thus, although e-cig experimentation is increasing, there is no evidence of regular e-cig use by youth and never-smokers, while the gateway to smoking argument is largely hypothetical and not supported by current evidence. - in fact much the opposite of what you claim the paper said! --Kim D. Petersen 14:46, 14 July 2017 (UTC)
This seems to be more cherry-picking than the other way around, and isn't entirely truthful. None of the papers condemn ecigs, but QG and Doc James are closer to the money. Carl Fredrik talk 14:58, 14 July 2017 (UTC)
I hope that you aren't indicating that i cherry-picked the above - because your comment could be read that way. The reason i verified QG's quote, is because both Farsalinos and Le Houesec are known for a no nonsense approach towards the data, and thus it would be extremely surprising if they had supported a claim of non-smokers taking up e-cigarettes.
And when you say that QG is closer to the money, what sources are you using to support that stand? --Kim D. Petersen 11:18, 15 July 2017 (UTC)
A 2015 review found that there is an argument to apply the precautionary approach, stating that one of the arguments is that "e-cig use by nonsmokers and especially by youth may result in a new generation of nicotine addicts and may become a gateway to smoking."[8] The precautionary approach like NPOV policy can also be used with this article rather than push it is safer than smoking. Read below where it says "But there is also evidence...". QuackGuru (talk) 15:58, 15 July 2017 (UTC)
No QuackGuru. You are misrepresenting the source. They state that there is an argument in the debate about vaping ("by those supporting strict regulations and/or bans") that is getting used... but find that this argument, via a review of the scientific evidence, is unfounded. It would be helpful if you actually tried to read and understand the source. Using a paper to argue the exact opposite of its findings is unacceptable. --Kim D. Petersen 17:35, 15 July 2017 (UTC)
The source did say state that one of the arguments others are making is to apply the precautionary approach. That means others do apply this method. That is a statement of fact. They acknowledged what others are saying. What are other saying? For example, a review found "The tobacco crisis justifies the current application of the PP to e-cigarette use. E-cigarettes are devices that deliver nicotine to the body with vaporized delivery mechanisms that were introduced to the US market in 2004. Currently, although e-cigarettes are regulated by the Food and Drug Administration (FDA), research on risks and benefits of their use is scant."[9] QuackGuru (talk) 20:18, 15 July 2017 (UTC)
If the Farsalinos paper had said that the argument was common amongst scientific sources, then you may have had an argument - but they do not. What they say is that it is an argument used by "by those supporting strict regulations and/or bans", and people/debates that argue for policy is not usually in the scientific realm, but in the political one. The review you refer to in the above is in a non-MEDLINE journal and thus (according to precedence on this article) not usable. But if you wanted to argue for this - then you should use such a review, and not a paper that argues the exact opposite of what you are stating. The former is acceptable, the latter is not. --Kim D. Petersen 23:25, 15 July 2017 (UTC)
You say "If the Farsalinos paper had said that the argument was common amongst scientific sources, then you may have had an argument - but they do not." The Farsalinos paper made even a stronger argument than being common. The main arguments can be found here. The word "main" is much strong than just being "common". The main arguments are likely the most common arguments. QuackGuru (talk) 02:17, 16 July 2017 (UTC)
I'm sorry? Can you point me at the place in your particular dictionary, where "main" is a synonym for "scientific"? Also how do you interpret the evidence section of that table to be supportive of your claims? You are grasping for straws now, trying to get us to forget that, you in this case, as in others, have misused this source to support something that is diametrically opposite of the conclusions of the paper! Just as before: Not acceptable. --Kim D. Petersen 11:53, 16 July 2017 (UTC)
The word "main" is a different argument than being scientific. They acknowledged what are the primary arguments for using the precautionary approach. The main arguments are very clear. This means they are the most relevant. QuackGuru (talk) 15:18, 16 July 2017 (UTC)
It matters where the argument is used QG... is it in the scientific sphere (ie. in peer-review) or is it in the public policy debate. As you should know. (and from context it is strongly indicative that the paper is referring to the public policy debate) --Kim D. Petersen 18:02, 16 July 2017 (UTC)
The main arguments are sourced to a review. They did not indicate who made the main arguments. If they are not specific then we can't be specific. QuackGuru (talk) 18:06, 16 July 2017 (UTC)
So what you are saying that every sentence in a review can be quoted, no matter what the context, and no matter whether it completely contradicts the conclusions of the paper? Because the only place that those arguments are sourced, is to this particular review, which gives no indication as to whether these are medical or public health policy arguments. I find it interesting that you, as an experienced editor, can even contemplate such nonsense. --Kim D. Petersen 01:15, 17 July 2017 (UTC)
You say "Because the only place that those arguments are sourced, is to this particular review, which gives no indication as to whether these are medical or public health policy arguments." Do you actually think that review is the only place that those kind of arguments are sourced? One of the main arguments is Safer does not mean absolutely safe. A review found "However, they can hardly be considered harmless."[10] I have read all the reviews on this topic. Shall I continue? QuackGuru (talk) 02:13, 17 July 2017 (UTC)
When making an argument then you need to use reviews that actually argue what you state, and you didn't in the Farsalinos&Le Houesec case. I don't know why you suddenly argue the "safer does not mean absolutely safe", as if any of us disagree with this. All reviews state that there is a risk - the question is whether Risk(vaping)<Risk(smoking), and there the preponderence of reviews are in agreement - even the Pisinger & Døssing review that you cite now, is in agreement that vaping is probably less harmful than smoking (and Pisinger is anti-vaping, as i should know, since i regularly debate her). It is nice that you (also) have read all reviews on this topic - but that is quite obviously from this discussion, not a guard against you misusing sources. --Kim D. Petersen 04:36, 17 July 2017 (UTC)
The reviews found "Based on 76 studies, ECs cannot be regarded as safe, even though they probably are less harmful than CCs."[11] This confirms from review to review that vaping is not considered safer than smoking. They use words such as "may", "likely", or "probably" and so on. It is not pro versus anti. It is maintaining a Neutral Point Of View. This means vaping is not safe (according to Pisinger). QuackGuru (talk) 16:24, 17 July 2017 (UTC)
Of course we shouldn't say or indicate that vaping is without risk. No sources say that. What we must do, is state that the risk is lower than cigarettes - because that is what the preponderance of evidence states. How much lower is another controversy - but that is a bridge we must cross then. --Kim D. Petersen 12:59, 15 July 2017 (UTC)
You say "What we must do, is state that the risk is lower than cigarettes - because that is what the preponderance of evidence states." But there is also evidence that e-cigarettes "with higher voltages and can release carcinogens, such as formaldehyde, in levels similar to those of conventional tobacco smoke."[12] Asserting that the risk is lower when there are e-cigarettes that can produce carcinogens at levels similar to normal cigarettes appears to go against WP:NPOV. QuackGuru (talk) 15:58, 15 July 2017 (UTC)
Unless you have sources/evidence that claim that the entire risk of cigarettes lies in (for instance) formaldehyde emissions - then you are wrong (as simple as that). What the preponderence of sources say, is that there is less risk from vaping than from smoking - but not that there is no risk at all. One of the risks that still are there are things like formaldehyde levels and others - but that is only a small part of the risk-envelope for cigarettes. The major risk factor in smoking is from what is popularily called "tar", and that part is completely missing from vaping. Other smaller factors are aldehydes etc. but in most cases these are found at significantly lower levels in vaping. To repeat: the preponderence of sources state that there is less risk from vaping, but that it is not risk-free.
But show me wrong: Find reviews that state that e-cigarettes are just as (or more) harmfull than cigarettes. --Kim D. Petersen 17:47, 15 July 2017 (UTC)
A review stated "E-cigarettes that deliver nicotine in water vapor may be safer than tobacco smoking."[13] They don't assert it is safer. They are being neutral. There are many things we just don't know yet. For example, "The short- and long-term effects of e-cigarette use are still unclear, but their use is increasing."[14] QuackGuru (talk) 20:18, 15 July 2017 (UTC)
Do you understand what WP:WEIGHT means? One paper stating "may" does not change that the preponderence of sources state that vaping is less harmful than smoking. (nb. the paper that you quoted here, was in the context of surgery and not general, and it also states in the conclusion "Other than the vasoconstrictive effects of nicotine, e-cigarettes are likely safer than smoking traditional cigarettes before and after otologic surgery." - please stop cherry-picking!). --Kim D. Petersen 23:38, 15 July 2017 (UTC)
The part "likely safer" does not mean they are safer. See "The rapid acceptance of electronic cigarettes may be attributed in part to the perception created by marketing and the popular press that they are safer than combustible cigarettes."[15] What the popular press say and what is reality is very different. A Cochrane review found "The long-term safety of ECs is unknown."[16] This means we don't know if they are safer. QuackGuru (talk) 02:17, 16 July 2017 (UTC)
Context is key QG. Something can be dangerous in the specific situation of surgery, while being absolutely essential for living a healthy life. You cannot use a paper about vaping in the context of surgery, to determine anything about vaping in the general context. Stop it please. --Kim D. Petersen 11:56, 16 July 2017 (UTC)
A paper may be mainly about one thing, but there could be other things there are also relevant. QuackGuru (talk) 15:18, 16 July 2017 (UTC)

────────────────────────────────────────────────────────────────────────────────────────────────────No. The Cochrane review you cite is very clear on the relative safety and found that:
"Expert consensus broadly holds that, based on all available evidence, ECs are considerably safer than traditional cigarettes (McNeill 2015; RCP 2016), but further studies are needed to establish their safety profile compared with established smoking cessation aids."[17]
Your shameful agenda is again duly noted.--TMCk (talk) 11:44, 16 July 2017 (UTC)

This is getting ridiculous. Can we please all get acquainted with the idea that "overall safety is uncertain" or "still needs further research" is not incompatible with "less harmful than cigarettes". --Kim D. Petersen 12:08, 16 July 2017 (UTC)
The Cochrane review did not "assert" they are safer. They said it was the "Expert consensus" expressing this view. The "Expert consensus" they are referring to is the UK-centric views. It was the opinion of McNeill 2015 and RCP 2016 to be precise. My ability to be accurate is now noted. QuackGuru (talk) 15:18, 16 July 2017 (UTC)
At a population level it is also unknown according to MEDRS compliant sources. See "Although there is increasing evidence of e-cigarette use among youth and adults, the population health impact of e-cigarettes is unknown."[18] Also see "At this time, data are not sufficient to confirm a long-term benefit for users or a public health benefit for the population at large."[19]. QuackGuru (talk) 17:59, 9 July 2017 (UTC)
it's redundant with (1) "likely to be safer than" and (2) "the long-term health effects are not known... ". What's not clear about in the above if not to overemphasize a viewpoint on this highly controversial topic?Zvi Zig (talkcontribs 20:52, 9 July 2017 (UTC)
One is dealing with overall safety (at the individual and population levels). What follows is looking at the individual level and with respect to one comparator. Doc James (talk · contribs · email) 22:49, 9 July 2017 (UTC)
In plain English, "The health risks of e-cigarettes... " does not refer to indirect population effectsZvi Zig (talkcontribs 00:57, 10 July 2017 (UTC)
Why would it not refer to population level risks? Yes I know the industry want to concentrate on only individual risk but that does not mean we should. Doc James (talk · contribs · email) 03:06, 10 July 2017 (UTC)
The average reader (quite rightly) doesn't understand the statement in relation to population level risks. Imagine the Paracetamol page opening, "The health risks of paracetamol are [adjective]" in relation to the adverse population level effects of suicidal overdose. It certainly would be highly misleading to the normal reader. Here too.
Conversely, "The public health effects of e-cigarettes... " would indeed relate what you mean.
Still, the statement would be go against WP:NPOV. The Royal College of Physicians concluded that "in the interests of public health it is important to promote the use of e-cigarettes, NRT and other non-tobacco nicotine products as widely as possible as a substitute for smoking in the UK".
I have am not industry and have no conflicts of interests here. Wikipedia Talk is not a place for innuendo. I'm surprised, User:Doc James. Zvi Zig (talkcontribs 19:43, 10 July 2017 (UTC)
There was no innuendo. I disagree with efforts to downplay positions other than those of the UK. The PHE has even stated that their position is at odds with much of the rest of the world. We should present both which we currently do. Doc James (talk · contribs · email) 19:54, 10 July 2017 (UTC)
I absolutely agree that we must display both sides. Currently, the lead opens with overemphasized blanket uncertainty, which not only is contrary to WP:NPOV in relation to UK, but is an exagerated representation fo the US/WHO position.Zvi Zig (talkcontribs 20:04, 10 July 2017 (UTC)
As long as we are using neutral sources. For example, if one source was shown to be overtly bias such as have direct ties to the Big Tobacco things could rapidly change. See WP:MEDBIAS QuackGuru (talk) 20:11, 10 July 2017 (UTC)
When you have evidence that a source is biased or has ties to industry, then we can open a discussion. Meanwhile, let's stick to the issue: The opening blanket uncertainty in the lead doesn't represent the literature and certainly goes against WP:NPOV. Any valid point the opening statement relates is understood from the subsequent more nuanced statements. Zvi Zig (talkcontribs 20:30, 10 July 2017 (UTC)
See Talk:Electronic cigarette#Represents the literature without bias. QuackGuru (talk) 20:40, 10 July 2017 (UTC)
Again, you evidence that a source is biased or has ties to industry.Zvi Zig (talkcontribs 20:22, 12 July 2017 (UTC)
I continue to cite independent sources, including recent reviews. I do not rely on using mostly UK-centric sources. If there is any disagreement it is from the UK. This means they are most likely the tiny minority. QuackGuru (talk) 20:38, 12 July 2017 (UTC)
The citations I started this section with are not UK. As an aside, PHE and RCP are the only health organizations to have writen such broad comprehensive reports in relation to the public health effects of e-cigarettes (unlike the Surgeon General's Report which only relates to children).Zvi Zig (talkcontribs 22:26, 12 July 2017 (UTC)
The citations you started with are irrelevant to their uncertainty. Both PHE and RCP from the UK hold a minority view in aggressively promoting vaping. QuackGuru (talk) 00:21, 13 July 2017 (UTC)
A review found "Overall, e-cigarettes have the potential to significantly harm the public’s health, with particular concern for the health of adolescents and individuals from certain underserved populations."[20] The UK-centric view is a tiny minority position. QuackGuru (talk) 20:11, 10 July 2017 (UTC)
The same review states explicitely that "A full discussion of the potential for “harm reduction” with e-cigarettes and the balance of their harms versus benefits is beyond the scope of this review;" - and thus cannot be cused to make the dismissal that you are doing here, since it doesn't in any way or form address the issue. We've said this before: Please read reviews entirely, and do not use it to cherry-pick sentences that may or may not support your personal views. --Kim D. Petersen 08:01, 11 July 2017 (UTC)
It is irrelevant whether the "full discussion" of the potential for harm reduction was beyond the scope of the review because it does not dismiss or contradict that the review did find that "Overall, e-cigarettes have the potential to significantly harm the public’s health, with particular concern for the health of adolescents and individuals from certain underserved populations."[21] It may not be a "full discussion" or an "in depth discussion" but regarding its overall potential to greatly harm the public’s health is a fact according to this source. It definitely touched on the issue without having to go into extreme detail. QuackGuru (talk) 14:27, 11 July 2017 (UTC)
Why do you continue to harp on a paper that specifically states that: It doesn't discuss/examine this (at all) because it is outside of the scope of its examination/review. It is a paper about regulation and policy - not about harm. --Kim D. Petersen 14:58, 11 July 2017 (UTC)
It is still a fact according to the source. They did not say there were joking when they stated, that overall, vaping could have the potential for considerable harm to the public's health. QuackGuru (talk) 15:01, 11 July 2017 (UTC)
No, they did not need to say that they were joking - they stated that such an assessment was outside of the scope of the paper, and thus are just relaying whatever non-specialized/non-expert/non-review opinions they have on that topic. And since it is specified as outside of the scope of the paper, this view is not reliable. --Kim D. Petersen 17:42, 11 July 2017 (UTC)
They did not say that specific statement was outside of the scope of the paper. They did not say it for no reason. Not having a "full discussion" is different than having a brief mention. QuackGuru (talk) 19:32, 11 July 2017 (UTC)
The part about its health effects being uncertain is different than comparing its safety to normal cigarettes. QuackGuru (talk) 01:29, 10 July 2017 (UTC)

Represents the literature without bias[edit]

See "Significant uncertainty exists about e-cigarette safety and efficacy, rendering patient discussions about these devices challenging."[22]

See "These devices are unregulated, of unknown safety, and of uncertain benefit in quitting smoking." See "Although research has improved our understanding of e-cigarettes since these initial 2011 recommendations, safety and efficacy remains uncertain."[23]

See "The USPSTF concludes that the current evidence on the use of ENDS for conventional smoking cessation is insufficient. Evidence is lacking and conflicting, and the balance of benefits and harms cannot be determined."[24] It does represent the literature used using WP:MEDRS sources. QuackGuru (talk) 20:40, 10 July 2017 (UTC)