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Debunking the claim that abstinence is usually healthier for smokers than switching to a low-risk alternative, and other observations about anti-tobacco-harm-reduction arguments

Old (2009), but with interesting contents regarding THR

Published: 03 November 2009

Positive: Yes

Link to publication:



Carl V Phillips


Nicotine is so desirable to many people that when they are given only the options of consuming nicotine by smoking, with its high health costs, and not consuming nicotine at all, many opt for the former. Few smokers realize that there is a third choice: non-combustion nicotine sources, such as smokeless tobacco, electronic cigarettes, or pharmaceutical nicotine, which eliminate almost all the risk while still allowing consumption of nicotine. Widespread dissemination of misleading health claims is used to prevent smokers from learning about this lifesaving option, and to discourage opinion leaders from telling smokers the truth. One common misleading claim is a risk-risk comparison that has not before been quantified: A smoker who would have eventually quit nicotine entirely, but learns the truth about low-risk alternatives, might switch to an alternative instead of quitting entirely, and thus might suffer a net increase in health risk. While this has mathematical face validity, a simple calculation of the tradeoff — switching to lifelong low-risk nicotine use versus continuing to smoke until quitting — shows that such net health costs are extremely unlikely and of trivial maximum magnitude. In particular, for the average smoker, smoking for just one more month before quitting causes greater health risk than switching to a low-risk nicotine source and never quitting it. Thus, discouraging a smoker, even one who would have quit entirely, from switching to a low-risk alternative is almost certainly more likely to kill him than it is to save him. Similarly, a strategy of waiting for better anti-smoking tools to be developed, rather than encouraging immediate tobacco harm reduction using current options, kills more smokers every month than it could possibly ever save.


While it is logically possible that lowering the risk from an exposure could increase population risk, the (1-x)/x calculation shows this is not plausible for THR. The suggestion that, despite the lower population risk, many individuals might still face greater risk is also logically possible, but the calculation presented here shows that this is not a substantial practical worry.

On average, someone who would die from smoking who is going to take more than a month to quit entirely (or will experience relapses that will have a similar health impact – probably roughly a total of one month worth of days) will have less total health risk by switching immediately, even if he never quits the alternative product. The typical pattern of even dedicated quitters, starting and stopping smoking for a year or two, will cause much more risk than switching to a low-risk alternative. Moreover, even an average smoker who was going to successfully quit after only a week or two more will suffer only a tiny net increase in physical health risk from switching now, a change so trivial compared to the net benefits of switching for smokers who will not quit for years or ever that it is clearly inconsequential.

The practical implications of this analysis do not change based on plausible variations in the input parameters, including the risk from using ST. Even if we use a completely implausible high risk from ST use, say that it causes 10% of the risk of smoking, then if an average smoker would have taken ten months to quit entirely, he would have had lower risk had he switched immediately. The break-even might be as low as about half a year – recall the conservative assumption built into the calculation. Thus, even discovering that ST use is an order of magnitude worse than the ample current evidence suggests would not fundamentally change the implications of the analysis.

Since this analysis is based entirely on mortality risk, it ignores other contributions to welfare. The reason that current smokers have not already quit, in spite of the health benefits of doing so, is that it would have resulted in substantial costs to them and, similarly, whenever a smoker chooses to switch it implies that there is a net welfare benefit (compared to either smoking or abstinence) to using the alternative product. This welfare gain from switching rather than quitting probably dwarfs the welfare implications of the mortality risk from low-risk products, though quantifying that is beyond the present scope.

Finally, it is worth noting that someone who switches from smoking to a low-risk alternative still has the option of quitting entirely, lowering his risk slightly more still. Indeed, there is reason to believe that eventually quitting alternative products is easier. This means that even the young smokers who might have been better off with several more months of smoking rather than a lifetime of THR product use stand a good chance of quitting entirely anyway (if they decide that the benefits of consumption are outweighed by the benefits of quitting), further favoring the option of switching now. Even those smokers who cannot afford another day of smoking but fortunately switch just in time (who are likely from older demographics that are the primary target for THR) could then survive long enough to quit nicotine entirely.

Many of the claims about health risk made to try to discourage the adoption of THR have been proven to be out-and-out false. This includes the « total social health risk will increase » claim. The present analysis does not relegate the « some people would be stopped from quitting entirely and thus have worse health outcomes » claim to universal falsehood – it will still inevitably be true for a very few individuals. But this is common in public health interventions, from automobile safety equipment to vaccines – the net social effects are overwhelmingly beneficial, though some people (who cannot be identified ex ante, and often not even ex post) suffer net harm rather than benefit. The analysis shows that only a tiny portion of all future quitters will be quitting soon enough that they would have higher expected risk by switching immediately. Moreover, the net increase in expected risk even for those individuals would be extremely small, and the net welfare effects would still be positive. Clearly, then, the claim does not represent a sufficient concern to override the huge net expected social benefit, to say nothing of the ethical requirement that smokers be informed about their options. The claim is thus relegated to being a distraction from rational and honest discourse on the subject, not a contribution to it.

This calculation emphasizes the cost of delaying the adoption of THR at the individual level also: Those of us who promote THR are familiar with smokers who, upon learning about THR, insist that they do not need to consider that option because they will eventually be exercising the « perfect » option of quitting anyway. But many such individuals never quit, and almost none quit in time for it to be a healthier choice. Similarly, each additional month that anti-THR activism keeps a potential switcher from learning about THR is more likely to kill him than is a lifetime of using ST or another low-risk nicotine product. To put it bluntly, anti-THR activism and disinformation do far more damage to public health than smokeless tobacco, electronic cigarettes, or other THR products ever could.

Since THR can be self-tailored and requires no clinical or government intervention, it does not matter that there may be smokers for whom no low risk product is an adequate substitute or that there is no political will to actively endorse it. THR can be adopted by individuals who do find an acceptable substitute, and likely will be widely adopted if smokers were simply given accurate information. The usual explanation for the lack of such information is that anti-tobacco extremists promulgate disinformation it and then even the opinion leaders who are genuinely concerned about public health repeat the inaccurate claims because they have been misled. But an alternative explanation is misplaced optimism on the part of the public health leaders: That is, many may not be misled by the disinformation about THR, but may genuinely believe that most smokers will successfully quit using nicotine very soon or that a perfect new anti-smoking method, policy, or product will be developed and cause everyone to quit soon, reducing their risks more than THR would. The present analysis shows just how overly-optimistic that belief needs to be in order to justify the failure to immediately promote THR using current technology.

Whatever the explanation for it, the present analysis shows that anti-THR activism is deadly. Hiding THR from smokers, waiting for them to decide to quit entirely or waiting for a new anti-smoking magic bullet, causes the deaths of more smokers every month than a lifetime using low-risk nicotine products ever could.

Continuer la lecture de Debunking the claim that abstinence is usually healthier for smokers than switching to a low-risk alternative, and other observations about anti-tobacco-harm-reduction arguments

Harmful effects of nicotine

With the advent of nicotine replacement therapy, the consumption of the nicotine is on the rise. Nicotine is considered to be a safer alternative of tobacco. The IARC monograph has not included nicotine as a carcinogen. However there are various studies which show otherwise. We undertook this review to specifically evaluate the effects of nicotine on the various organ systems.

Published: 19 February 2015

Positive :  No

Link to publication:


Aseem Mishra
Pankaj Chaturvedi
Sourav Datta
Snita Sinukumar
Poonam Joshi
Apurva Garg


With the advent of nicotine replacement therapy, the consumption of the nicotine is on the rise. Nicotine is considered to be a safer alternative of tobacco. The IARC monograph has not included nicotine as a carcinogen. However there are various studies which show otherwise. We undertook this review to specifically evaluate the effects of nicotine on the various organ systems. A computer aided search of the Medline and PubMed database was done using a combination of the keywords. All the animal and human studies investigating only the role of nicotine were included. Nicotine poses several health hazards. There is an increased risk of cardiovascular, respiratory, gastrointestinal disorders. There is decreased immune response and it also poses ill impacts on the reproductive health. It affects the cell proliferation, oxidative stress, apoptosis, DNA mutation by various mechanisms which leads to cancer. It also affects the tumor proliferation and metastasis and causes resistance to chemo and radio therapeutic agents. The use of nicotine needs regulation. The sale of nicotine should be under supervision of trained medical personnel.


Nicotine is the fundamental cause of addiction among tobacco users. Nicotine adversely affects many organs as shown in human and animal studies. Its biological effects are widespread and extend to all systems of the body including cardiovascular, respiratory, renal and reproductive systems. Nicotine has also been found to be carcinogenic in several studies. It promotes tumorigenesis by affecting cell proliferation, angiogenesis and apoptotic pathways. It causes resistance to the chemotherapeutic agents. Nicotine replacement therapy (NRT) is an effective adjunct in management of withdrawal symptoms and improves the success of cessation programs. Any substantive beneficial effect of nicotine on human body is yet to be proven. Nicotine should be used only under supervision of trained cessation personnel therefore its sale needs to be strictly regulated. Needless to say, that research for safer alternative to nicotine must be taken on priority.

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Former WHO scientist: ‘Smoking kills, nicotine doesn’t’

A great article in today’s spectator.

Dr Derek Yach, who developed the World Health Organisation’s Framework Convention on Tobacco Control, talks about vaping in no unclear terms.

Why are we in this position? One reason is that governments have become addicted to tobacco excise tax and may fear that, as e-cigs take off, they will lose a valuable source of revenue. Many leading NGOs and academics exert strong influence at WHO, within governments, in the media and among the general public. In the past, they helped bring tobacco control out of the shadows and into the mainstream of health policy. Now, alas, their intransigence threatens more profound progress.

And further down the page

His support for electronic cigarettes and vaping products rests on what he regards as the stark truth: that they help people quit smoking more effectively than other remedies. It is therefore not just unfortunate but scary that the World Health Organisation persists in treating them as if they were almost as dangerous as cigarettes.

Counseling Patients on the Use of Electronic Cigarettes

Published: January 2015

Positive: No

Link to publication:



Jon O. Ebbert, MD, MS
Amenah A. Agunwamba, ScD, MPH
Lila J. Rutten, PhD, MPH


Electronic cigarettes (e-cigarettes) have substantially increased in popularity. 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. The effectiveness of e-cigarettes for smoking cessation is modest and appears to be comparable to the nicotine patch combined with minimal behavioral support. Although a role for e-cigarettes in the treatment of tobacco dependence may emerge in the future, the potential risk of e-cigarettes outweighs their known benefit as a recommended tobacco treatment strategy by clinicians. Patients should be counseled on the known efficacy and potential risks of e-cigarettes.


Clinicians are ethically obligated to promote smoking cessation using evidence-based treatment strategies. Smokers will ask about e-cigarettes, and we must be prepared to offer appropriate counseling. With the evidence available to date, clinicians must be circumspect in recommending e-cigarettes for use by cigarette smokers interested in quitting smoking for the following reasons:

1. They are not demonstrably superior to FDA-approved medications for smoking cessation.

2. They may not be effective for smoking cessation and dual use (ie, using e-cigarettes and continuing to smoke) will prolong exposure to tobacco.

3. They are not FDA-approved for the treatment of tobacco dependence.

4. Short-term safety data suggest they may cause airway reactivity.

5. The long-term health risk of exposure to e-cigarette constituent chemicals is unknown.

6. No regulatory oversight, such as requirements for good manufacturing practices, is currently in place for e-cigarette devices or e-juice.

More clinical safety data and increased product reliability and regulation are needed before e-cigarettes can assume a place in the standard clinical approaches to the treatment of tobacco dependence.

Continuer la lecture de Counseling Patients on the Use of Electronic Cigarettes

Use of e-Cigarettes among Current Smokers: Associations among Reasons for Use, Quit Intentions, and Current Tobacco Use.

Research has documented growing availability and use of e-cigarettes in the U.S. over the last decade.

We conducted a national panel survey of current adult cigarette smokers to assess attitudes, beliefs, and behaviors relating to e-cigarette use in the U.S. (N=2254).

Published: 14 January 2015

Positive: Yes

Link to publication:



Rutten LJ
Blake KD
Agunwamba AA
Grana RA
Wilson PM
Ebbert JO
Okamoto J
Leischow SJ


Among current cigarette smokers, 20.4% reported current use of e-cigarettes on some days and 3.7% reported daily use. Reported reasons for e-cigarette use included: quit smoking (58.4%), reduce smoking (57.9%), and reduce health risks (51.9%). No significant differences in sociodemographic characteristics between e-cigarette users and non-users were observed. Prior quit attempts were reported more frequently among e-cigarette users (82.8%) than non-users (74.0%). Intention to quit was reported more frequently among e-cigarette users (64.7%) than non-users (46.8%). Smokers intending to quit were more likely to be e-cigarette users than those not intending to quit (OR=1.90, CI=1.36-2.65). Those who used e-cigarettes to try to quit smoking (OR=2.25, CI=1.25-4.05), reduce stress (OR=3.66, CI=1.11-12.09), or because they cost less (OR=3.42, CI=1.64-7.13) were more likely to report decreases in cigarette smoking than those who did not indicate these reasons. Smokers who reported using e-cigarettes to quit smoking (OR=16.25, CI=8.32-31.74) or reduce stress (OR=4.30, CI=1.32-14.09) were significantly more likely to report an intention to quit than those who did not indicate those reasons for using e-cigarettes.


Nearly a quarter of smokers in our study reported e-cigarettes use, primarily motivated by intentions to quit or reduce smoking. These findings identify a clinical and public health opportunity to re-engage smokers in cessation efforts.

Continuer la lecture de Use of e-Cigarettes among Current Smokers: Associations among Reasons for Use, Quit Intentions, and Current Tobacco Use.

E-cigarettes: methodological and ideological issues and research priorities

Cigarette combustion, rather than either tobacco or nicotine, is the cause of a public health disaster. Fortunately, several new technologies that vaporize nicotine or tobacco, and may make cigarettes obsolete, have recently appeared.

**Note: this is an article, not a study per se.

Published: 16 February 2015

Positive: Yes

Link to publication:



JF Etter



Cigarette combustion, rather than either tobacco or nicotine, is the cause of a public health disaster. Fortunately, several new technologies that vaporize nicotine or tobacco, and may make cigarettes obsolete, have recently appeared. Research priorities include the effects of vaporizers on smoking cessation and initiation, their safety and toxicity, use by non-smokers, dual use of vaporizers and cigarettes, passive vaping, renormalization of smoking, and the development of messages that effectively communicate the continuum of risk for tobacco and nicotine products. A major difficulty is that we are chasing a moving target. New products constantly appear, and research results are often obsolete by the time they are published. Vaporizers do not need to be safe, only safer than cigarettes. However, harm reduction principles are often misunderstood or rejected. In the context of a fierce ideological debate, and major investments by the tobacco industry, it is crucial that independent researchers provide regulators and the public with evidence-based guidance. The methodological and ideological hurdles on this path are discussed in this commentary.


A window of opportunity is now open but will soon close. In the United States, the Food and Drug Administration is developing regulations that will apply to e-cigarettes and vaporizers, and European Union Member States are now transposing the Tobacco Products Directive into national laws. Once these regulations are in place, they will be very difficult to change. However, because harm reduction strategies are often misunderstood or rejected [14], there is a risk that e-cigarettes and vaporizers will be excessively regulated. Regulators must consider the unintended consequences of excessive regulation, and should be held accountable for any such consequences. Given that e-cigarettes and vaporizers are already much safer than combustible cigarettes, any benefit of regulations will be small, whereas the unintended consequences can have a large negative impact. Unfortunately, current proposals for regulation are often worse than the status quo. It is sad that this is happening with the help of some public health professionals, scientists and elected representatives of the people.

Continuer la lecture de E-cigarettes: methodological and ideological issues and research priorities

Electronic cigarettes: assessing the efficacy and the adverse effects through a systematic review of published studies

To investigate the efficacy and the adverse effects (AEs) of the electronic cigarette, we performed a systematic review of published studies.

Published: 9 August 2014

Positive: Yes

Link to publication:

doi: 10.1093/pubmed/fdu055


Maria Rosaria Gualano
Stefano Passi
Fabrizio Bert
Giuseppe La Torre
Giacomo Scaioli
Roberta Siliquini


Methods We selected experimental and observational studies examining the efficacy (as reduction of desire to smoke and/or number of cigarettes smoked and/or quitting or as reduction of nicotine withdrawal symptoms) and the safety of EC (AEs self-reported or clinical/laboratory). The following search engines were used: PubMed, ISI Web of Knowledge and Cochrane Controlled Trials Register.

Results Finally, six experimental studies and six cohort studies were included. In the prospective 12-month, randomized controlled trial, smoking reduction was documented in 22.3 and 10.3% at Weeks 12 and 52, respectively (P < 0.001 versus baseline). Moreover, two cohort studies reported a reduction in the number of cigarette/day (from 50 to 80%) after the introduction of the EC. ‘Mouth and throat irritation’, ‘nausea’, ‘headache’ and ‘dry cough’ were the most frequently AEs reported.


The use of the EC can reduce the number of cigarettes smoked and withdrawal symptoms, but the AEs reported are mainly related to a short period of use. Long-term studies are needed to evaluate the effects of the EC usage after a chronic exposure.

Continuer la lecture de Electronic cigarettes: assessing the efficacy and the adverse effects through a systematic review of published studies

Biochemically verified smoking cessation and vaping beliefs among vape store customers

To evaluate biochemically verified smoking status, and electronic nicotine delivery systems (ENDS) use behaviors and beliefs among a sample of customers from vapor stores (stores specializing in ENDS).

Published: Not yet (as of 13 February 2015)

Positive: Yes

Publication link:

doi: 10.1111/add.12878


Alayna P. Tackett
William V. Lechner
Ellen Meier
DeMond M. Grant
Leslie M. Driskill
Noor N. Tahirkheli2
Theodore L. Wagener


Design, Setting, Participants

A cross-sectional survey of 215 adult vapor store customers at four retail locations in the Midwestern United States; a subset of participants (n=181) also completed exhaled carbon monoxide (CO) testing to verify smoking status.


Outcomes evaluated included ENDS preferences, harm beliefs, use behaviors, smoking history and current biochemically verified smoking status.


Most customers reported starting ENDS as a means of smoking cessation (86%), using newer generation devices (89%), vaping non-tobacco/non-menthol flavors (72%), and using e-liquid with nicotine strengths of ≤20 mg/ml (72%). There was a high rate of switching (91.4%) to newer generation ENDS among those who started with a first generation product. Exhaled CO readings confirmed that 66% of the tested sample had quit smoking. Among those who continued to smoke, mean cigarettes per day decreased from 22.1 to 7.5 (p <.001). People who reported vaping longer (OR=4.7, 95% CI = 2.0–10.8), using newer generation devices (OR=3.0, 95% CI = 1.0–8.4) and using non-tobacco and non-menthol flavors (OR=2.6, 95% CI = 1.1–6.1) were more likely to have quit smoking.


Among vapor store customers in the US who use electronic nicotine delivery devices to stop smoking, vaping longer, using newer generation devices, and using non-tobacco and non-menthol flavored e-liquid appear to be associated with higher rates of smoking cessation. Continuer la lecture de Biochemically verified smoking cessation and vaping beliefs among vape store customers

Comparison of select analytes in aerosol from e-cigarettes with smoke from conventional cigarettes and with ambient air


• The e-cigarettes contained and delivered mostly glycerin and/or PG and water.
• Aerosol nicotine content was 85% lower than the cigarette smoke nicotine.
• The levels of HPHCs in aerosol were consistent with the air blanks (<2 μg/puff).
• Mainstream cigarette smoke HPHCs (∼3000 μg/puff) were 1500 times higher than e-cigarette HPHCs.
• No significant contribution of tested HPHC classes was found for the e-cigarettes.

Published: 24 October 2014

Positive: Yes

Link to publication:


Rana Tayyarah
Gerald A. Long

Remarks: From Lorillard tobacco company


Leading commercial electronic cigarettes were tested to determine  bulk composition. The e-cigarettes and conventional cigarettes were evaluated using machine-puffing to compare nicotine delivery and relative yields of chemical constituents. The e-liquids tested were found to contain humectants, glycerin and/or propylene glycol, (⩾75% content); water (<20%); nicotine (approximately 2%); and flavor (<10%). The aerosol collected mass (ACM) of the e-cigarette samples was similar in composition to the e-liquids. Aerosol nicotine for the e-cigarette samples was 85% lower than nicotine yield for the conventional cigarettes. Analysis of the smoke from conventional cigarettes showed that the mainstream cigarette smoke delivered approximately 1500 times more harmful and potentially harmful constituents (HPHCs) tested when compared to e-cigarette aerosol or to puffing room air. The deliveries of HPHCs tested for these e-cigarette products were similar to the study air blanks rather than to deliveries from conventional cigarettes; no significant contribution of cigarette smoke HPHCs from any of the compound classes tested was found for the e-cigarettes. Thus, the results of this study support previous researchers’ discussion of e-cigarette products’ potential for reduced exposure compared to cigarette smoke.


The purpose of this study was to determine content and delivery of e-cigarette ingredients and to compare e-cigarette aerosol to conventional cigarettes with respect to select HPHCs for which conventional cigarette smoke is routinely tested. Routine analytical methods were adapted and verified for e-cigarette testing. Aerosol collection was conducted using conventional smoking machines and an intense puffing regime. As machine puffing cannot, and is not intended to, mimic human puffing, results of this study are limited to the scope of the comparisons made between the e-cigarette and conventional cigarette products tested.

The main ingredients for the e-cigarettes tested were consistent with disclosed ingredients: glycerin and/or propylene glycol (⩾75%), water (⩽18%), and nicotine (∼2%). Machine-puffing of these products under a standardized intense regime indicated a direct transfer of these ingredients to the aerosol while maintaining an aerosol composition similar to the e-liquid. Nicotine yields to the aerosol were approximately 30 μg/puff or less for the e-cigarette samples and were 85% lower than the approximately 200 μg/puff from the conventional cigarettes tested.

Testing of the e-cigarette aerosol indicates little or no detectable levels of the HPHC constituents tested. Overall the cigarettes yielded approximately 3000 μg/puff of the HPHCs tested while the e-cigarettes and the air blanks yielded <2 μg. Small but measurable quantities of 5 of the 55 HPHCs tested were found in three of the e-cigarette aerosol samples at 50–900 times lower levels than measurable in the cigarette smoke samples. Overall, the deliveries of HPHCs tested for the e-cigarette products tested were more like the study air blanks than the deliveries for the conventional cigarettes tested. Though products tested, collection parameters, and analytical methods are not in common between this study and others, the results are very consistent. Researchers have reported that most or all of the HPHCs tested were not detected or were at trace levels. Burstyn (2014) used data from approximately 50 studies to estimate e-cigarette exposures compared to workplace threshold limit values (TLV) based on 150 puffs taken over 8 h. The vast majority of the analytes were estimated as ≪1% of TLV and select carbonyls were estimated as <5% of TLV. Cheng (2014) reviewed 29 publications reporting no to very low levels of select HPHCs relative to combustible cigarettes, while noting that some of the tested products exhibited considerable variability in their composition and yield. Goniewicz et al. (2014) tested a range of commercial products and reported quantifiable levels for select HPHCs in e-cigarette aerosols at 9- to 450-fold lower levels than those in cigarette smoke that in some instances were on the order of levels determined for the study reference (a medicinal nicotine inhaler). Laugesen, 2009 and Theophilus et al., 2014 have presented results for commercial e-cigarette product liquids and aerosols having no quantifiable levels of tested HPHCs, or extremely low levels of measurable constituents relative to cigarette smoke. Additionally, findings from several recent studies indicate that short-term use of e-cigarettes by adult smokers is generally well-tolerated, with significant adverse events reported relatively rarely (Etter, 2010, Polosa et al., 2011, Polosa et al., 2014, Caponnetto et al., 2013, Dawkins and Corcoran, 2014 and Hajek et al., 2014). Thus, the results obtained in the aforementioned studies and in the present work broadly support the potential for e-cigarette products to provide markedly reduced exposures to hazardous and potentially hazardous smoke constituents in smokers who use such products as an alternative to cigarettes.

Additional research related to e-cigarette aerosol characterization is warranted. For example, continued characterization of major components and flavors is needed. Establishment of standardized puffing regimes and reference products would greatly aid sharing of knowledge between researchers. Continued methods’ refinement may be necessary for improved accuracy for quantitation of analytes at the low levels determined in this study. To that end, it is critical that negative controls and steps to avoid sample contamination be included when characterizing e-cigarette aerosol since analytes are on the order of what has been measured in the background levels of a laboratory setting. Though researchers have reported quantification of select analytes, great care must be taken when interpreting results at such trace levels.

Continuer la lecture de Comparison of select analytes in aerosol from e-cigarettes with smoke from conventional cigarettes and with ambient air

Hidden Formaldehyde in E-Cigarette Aerosols

Not a study per se, but a letter to the editor of the NEJM. This letter has been totally debunked, and is proved to have no value whatsoever (except for mouses who vape).

Published: 22 January 2015

Positive: No

Link to publication:

Comment from the author:

Comment from Clive Bates:

Comment from Dr Farsalinos:

Comment from Dr Michael Siegel:

Comment from Pr Hajek:

Comment from Pr Dautzenberg (in French):


R. Paul Jensen, B.S.
Wentai Luo, Ph.D.
James F. Pankow, Ph.D.
Robert M. Strongin, Ph.D.
David H. Peyton, Ph.D.


To the Editor:

E-cigarette liquids are typically solutions of propylene glycol, glycerol, or both, plus nicotine and flavorant chemicals. We have observed that formaldehyde-containing hemiacetals, shown by others to be entities that are detectable by means of nuclear magnetic resonance (NMR) spectroscopy,1 can be formed during the e-cigarette “vaping” process. Formaldehyde is a known degradation product of propylene glycol that reacts with propylene glycol and glycerol during vaporization to produce hemiacetals. These molecules are known formaldehyde-releasing agents that are used as industrial biocides.5 In many samples of the particulate matter (i.e., the aerosol) in “vaped” e-cigarettes, more than 2% of the total solvent molecules have converted to formaldehyde-releasing agents, reaching concentrations higher than concentrations of nicotine. This happens when propylene glycol and glycerol are heated in the presence of oxygen to temperatures reached by commercially available e-cigarettes operating at high voltage. How formaldehyde-releasing agents behave in the respiratory tract is unknown, but formaldehyde is an International Agency for Research on Cancer group 1 carcinogen.4

Here we present results of an analysis of commercial e-liquid vaporized with the use of a “tank system” e-cigarette featuring a variable-voltage battery. The aerosolized liquid was collected in an NMR spectroscopy tube (10 50-ml puffs over 5 minutes; 3 to 4 seconds per puff). With each puff, 5 to 11 mg of e-liquid was consumed, and 2 to 6 mg of liquid was collected. At low voltage (3.3 V), we did not detect the formation of any formaldehyde-releasing agents (estimated limit of detection, approximately 0.1 μg per 10 puffs). At high voltage (5.0 V), a mean (±SE) of 380±90 μg per sample (10 puffs) of formaldehyde was detected as formaldehyde-releasing agents. Extrapolating from the results at high voltage, an e-cigarette user vaping at a rate of 3 ml per day would inhale 14.4±3.3 mg of formaldehyde per day in formaldehyde-releasing agents. This estimate is conservative because we did not collect all of the aerosolized liquid, nor did we collect any gas-phase formaldehyde. One estimate of the average delivery of formaldehyde from conventional cigarettes is approximately 150 μg per cigarette,3 or 3 mg per pack of 20 cigarettes. Daily exposures of formaldehyde associated with cigarettes, e-cigarettes from the formaldehyde gas phase, and e-cigarettes from aerosol particles containing formaldehyde-releasing agents are shown in Figure 1.

Inhaled formaldehyde has a reported slope factor of 0.021 kg of body weight per milligram of formaldehyde per day for cancer ( Among persons with a body weight of 70 kg, the incremental lifetime cancer risk associated with long-term cigarette smoking at 1 pack per day may then be estimated at 9×10−4. If we assume that inhaling formaldehyde-releasing agents carries the same risk per unit of formaldehyde as the risk associated with inhaling gaseous formaldehyde, then long-term vaping is associated with an incremental lifetime cancer risk of 4.2×10−3. This risk is 5 times as high (as compared with the risk based on the calculation of Miyake and Shibamoto shown in Figure 1), or even 15 times as high (as compared with the risk based on the calculation of Counts et al. shown in Figure 1) as the risk associated with long-term smoking. In addition, formaldehyde-releasing agents may deposit more efficiently in the respiratory tract than gaseous formaldehyde, and so they could carry a higher slope factor for cancer.