Electronic Cigarette Through the Eyes of a Professor Living Abroad

 Your Respiratory Health: An Interview with Prof Polosa

Professor Polosa recently completed his latest study examining the impact of vaping on respiratory health. We met with Riccardo Polosa to discuss how vaping can reverse harm, its potential to reduce infections, the recent debate on vaping and respiratory illness in the US, and more. 

You reiterated in a recent press release that vaping is at least 95%, possibly more than 95% safer than smoking. As you said, no one can prove that e-cigarettes are 100% safe because we don't have very long-term data. How sure can we be of a 95% safer figure?

Public Health England echoed this finding in last year's (2018) evidence update. Stating that vaping is at least 95% less harmful than smoking remains a good way to communicate the large difference in relative risk based on the available toxicological evidence. It has been repeatedly shown that vape aerosol contains far fewer toxins than cigarette smoke, and – just as importantly – the levels of these toxins detected in vape aerosol are significantly lower than tobacco smoke, often several times lower (10 times lower). ).

In your study, you mentioned that there is a need for long-term studies based on the analysis of medical records. How close are we to achieving this?

The collection of patient records varies widely between countries. In addition, patient records should report whether a person has vaped, how much and for how long they have smoked electronic cigarettes, and should include the same information regarding smoking or other tobacco use. This may be available in some countries now or in the near future, but never in others.

Research based on access to medical records is difficult due to ethical and privacy concerns, but where reports are available, studies may provide a key to understanding the long-term effects of vaping. Another way to control the long-term effects of electronic cigarettes is the science of epidemiology. As fewer people smoke, we expect to see a reduction in tobacco-related diseases (respiratory, cardiovascular, and cancers) over time. Using mathematics, we can apply population estimates of newspaper numbers to the number of reports of smoking-related diseases to observe correlations.

You also mentioned that studies examining the effect of vaping on people who have never smoked are needed to separate the negative effects of vaping from the existing harms caused by smoking. Given the small number of non-smokers who vape regularly, how easy would it be to find these people and how realistic would it be to conduct a large-scale study?

Newspapers that have never smoked regularly are the famous needle in a haystack. However, well-coordinated multinational efforts can gather study populations large enough to answer important research questions about the long-term health effects of vaping. It's the only way to go. We are fortunate enough to receive a generous research grant from the A Smoke Free World Foundation to achieve just that.

Your previous research suggested that electronic cigarettes may help reverse some smoking diseases.

In this review, it is particularly interesting to see that smokers suffering from COPD experience improvements in their health, while smokers who quit generally do not. Why do you think so?

Simple. In interpreting these studies, it is important to understand the difference between smokers who quit and have a smoking-related illness and those who do not (or have not developed) any medical conditions. Quits with an abnormal basis are relatively easy to show improvements (they have already damaged their health from smoking) - and I call this harm reversal. On the contrary, relatively healthy smokers already have a normal/healthy basis, so there is no room for improvement. The benefit of relatively healthy smokers lies in the ability to quit by reducing their risk of developing a future smoking-related disease – and that risk reduction.

To what extent do you think the anti-bacterial and anti-viral properties of propylene glycol in e-liquid could benefit newspapers?

PG in aerosol form has long been known to be an effective antibacterial and antiviral agent, possibly effectively preventing respiratory tract infections. Therefore, PG vaping can help users fight all kinds of bacteria, viruses and common infections (e.g. colds, tonsillitis, gingivitis) rather than creating an ideal condition for germs to multiply and spread. Also, daily vaping can be a practical way to prevent respiratory exacerbations associated with diseases such as asthma and COPD.

As you mentioned in the article, the technology contributes to improving the safety of vaping devices, especially mentioning automatic temperature control. Where should manufacturers focus their efforts to further enhance vaping safety?

Temperature regulation is very important. However, this is only one aspect of technological advancement in e-cigarette design. Manufacturers must invest in a new generation of batteries that can deliver power in the safest possible way, and develop new formulations that can guarantee maximum satisfaction with fewer chemicals. Ease of refilling and overall ease of use are key features. Public concerns about plastics and recycling should be another area for improvements, especially for capsules and other pre-filled devices.

A lot of effort has been made in the UK over the past few years to improve the safety of e-liquid by identifying and eliminating potentially harmful components in e-liquid. How much can this work contribute to improving vaping safety?

Different flavors have different chemical profiles and therefore different levels of toxicity. Newspapers should have assurance that the fluids have been tested and meet current quality/safety guidelines. Concerns about poor quality/safety products are currently being addressed by the European Standardization body's Technical Committee (CEN TC437) for e-cigarettes and e-liquids.

However, when looking at the highest priority for safer vaping, the careful toxicological characterization and risk assessment of flavors in vape aerosols immediately comes to mind. We have recently circulated a revised draft proposal for work aimed at building a toxicological database of common commercially available flavors and possibly determining upper limit thresholds for the use of certain ingredients. Aerosols will be tested using cell on chip technology, a more cost-effective way to understand the in vitro toxicological impact of flavors.

Your literature review appears to be a catalog of errors made by researchers from time to time. These include exposing animals to e-cigarette emissions at concentrations much higher than cigarette emissions in comparative tests, not adjusting for the weight of the animals used in the research, and not using a control group. Why are there so many problems in studies on electronic cigarettes? Is this simply due to low standards, or are the standards deliberately manipulated to support a desired outcome?

No manipulation here. Vapor product research is relatively new, so researchers have had to make their own decisions about appropriate tests. As a result, many of the research designs have not been adequate or have relied on pharmaceutical testing where overdose is a common procedure.

Also, when investigating the impact of real-world interventions and epidemiology, traditional study designs are not fit for purpose, and it is difficult to reconcile more appropriate study designs with good scientific principles. Finally, sometimes the problem is a lack of funds for testing equipment, so researchers use whatever they have on hand, even if it's less valid or reliable. It goes without saying that this area of ​​research urgently needs critical scrutiny and reform.

You also mentioned some encouraging initiatives to standardize research methods in the e-cigarette field. Do you think there is a desire to adopt them throughout the field?

Definitely. For example, ISO (International Standards Organization) establishes testing standards for the analytical chemistry of vaping machines and vape aerosol components. In addition, we are about to conduct a series of reviews on the quality of research techniques, as well as the one just published, which addresses the quality of research in the respiratory field.

We aim to provide a set of guidelines and frameworks for better quality in tobacco and e-cigarette research by discussing the problems and shortcomings with a large number of current research articles in the field. The framework is envisioned to be used by journal editors as a best practice code or checklist for future research papers. Researchers want to use best practices.

We've seen reports of vaping bouts recently in the US and UK. In the UK it was clear that these were linked to vaping illicit drugs, but this was less clear in the US. What is behind these seizures, how interested are they, and how do they linger with the findings of your research?

Surprisingly, very little research has been done on nicotine use and seizures in humans, with tobacco or vape. In this case, animal studies do not apply to humans. US reports do not document the substance(s) these individuals vaporize, and awareness of vaping other drugs appears low in the US (and elsewhere). Self-report on illicit drug use in the United States can be low because disclosure can result in arrest or denial of payment for emergency services. Where clusters of seizure reports occur, it suggests a common source. In addition, no other adverse event records reported an increase in seizure occurrence.

Finally, what would you say to a smoker who is considering switching to vaping but is concerned about the media reports about the dangers of vaping?

The job of the media is to make headlines and news. What you need is good information. You have a right to know that vaping is much less toxic than smoking. Public Health England did a lot of research on their findings that e-cigarettes are much less harmful. It is generally accepted by the research community that e-cigarettes are significantly less toxic than continuing to smoke.

To achieve the most risk reduction, a vaper should quit smoking completely as soon as reasonably possible. As we know in harm reduction, substitution is easier to obtain than abstinence. Even smoking 2 or 3 cigarettes a day carries about half the cancer risk from smoking 20 cigarettes a day.

I would stress that newspapers should vape in moderation and avoid excessive vaping (e.g. cloud chasing, excessive daily e-liquid consumption) due to the increase in potential health and safety risks.