Talk:Electronic cigarette

Cited source contradicts claim

The fourth paragraph of the article starts with "Nicotine is harmful and highly addictive.[14][15]". The first source (Mishra et al, 2015, "Harmful effects of nicotine") supports that claim, but the second source (Royal College of Physicians, 2016, "Nicotine without smoke: tobacco harm reduction") actually argues against nicotine being significantly harmful:

Nicotine is not, however, in itself, a highly hazardous drug (see Chapters 4 and 5). It increases heart rate and blood pressure, and has a range of local irritant effects, but is not a carcinogen. ... Although the nature and extent of any long-term health hazard from inhaling nicotine remain uncertain, because there is no experience of such use other than from cigarettes, it is inherently unlikely that nicotine inhalation itself contributes significantly to the mortality or morbidity caused by smoking. The main culprit is smoke and, if nicotine could be delivered effectively and acceptably to smokers without smoke, most if not all of the harm of smoking could probably be avoided.

DecipheredStones (talk) 00:27, 13 June 2022 (UTC)

• The disputed sentence says two things. (1) Nicotine is harmful, and (2) Nicotine is highly addictive. I think both contentions are supported by both sources.—S Marshall T/C 21:34, 13 June 2022 (UTC)

User:S Marshall

• The Royal College of Physicians' report says, "if nicotine could be delivered effectively and acceptably to smokers without smoke, most 'if not all' of the harm of smoking could probably be avoided" (emphasis mine).

• See also page 125 of the same report:

As use of nicotine alone in the doses used by smokers represents little if any hazard to the user, complete substitution of smoking with conventional NRT products is, for practical purposes, the equivalent of complete cessation in almost all areas of harm to the user

https://www.rcplondon.ac.uk/file/3563/download?token=Mu0K_ZR0

I agree with User:DecipheredStones that the statement in question contradicts the Royal College of Physicians' report.

Zvi Zig (talk • contribs 05:40, 19 July 2022 (UTC)

• Are you contending that nicotine by itself isn't harmful?—S Marshall T/C 12:21, 19 July 2022 (UTC)

According to the RCP report cited above (and the FDA etc.) nicotine poses little, if any, hazard to the user. It is incorrect to blanketly state that it is harmful.

Zvi Zig (talk • contribs 00:08, 20 July 2022 (UTC)

• But what about Mishra et al 2015?—S Marshall T/C 07:03, 21 July 2022 (UTC)

Mishra et al 2015 is published in a journal with an impact factor of 0.223. Its position that nicotine is a carcinogen and causes other deadly diseases is contradicted by the world's leading medical organizations, like the IARC the FDA and others

Zvi Zig (talk • contribs 01:07, 22 July 2022 (UTC)

• What's the proposed revised sentence?—S Marshall T/C 08:50, 23 July 2022 (UTC)

Nicotine is addictive, but poses little, if any, hazard to the user.Zvi Zig (talk • contribs 03:28, 1 August 2022 (UTC)

I don't see that the FDA or IARC agree with what you're saying. I believe what you're doing is called original research, which is not permitted on wikipedia. The FDA simply says that the lethality of cigarettes comes mostly from other things, but it does not say that nicotine is harmless. Nicotine does indeed have multiple negative effects in the human body, even if the majority of harm from cigarettes is from other chemicals. Nicotine is still bad for you, and likely increases risk of cancer apart from other additives in tobacco. [1] [2] Ultra high doses of nicotine are associated with multi-organ toxicity and even death due to impaired respiratory muscles.[3][4] What we know is that nicotine on its own is probably less bad for you than everything else in cigarettes. But it does not mean that nicotine is "not harmful" as you assert above. — Shibbolethink ^{(♔ ♕)} 14:23, 9 November 2022 (UTC)

I've integrated your edits with high quality MEDRS to meet somewhere in the middle. I think this is the best summary of available evidence, doesn't sugar coat it, but also doesn't say nicotine is the devil. Let me know what you think — Shibbolethink ^{(♔ ♕)} 15:16, 9 November 2022 (UTC)

References

Nicotine "highly addictive" in context of vaping?

According to a Public Health England 2018 report

Other aspects of nicotine products may potentiate addictiveness. These include the monoamine oxidase (MAO) inhibitors in tobacco smoke, substances added to tobacco such as sugars and polysaccharides, flavourings such as menthol or alkaline additives, as well as design characteristics. . . . In summary, nicotine addictiveness depends on a number of factors including presence of other chemicals, speed of delivery, pH, rate of absorption, the dose, and other aspects of the nicotine delivery system, environment and behaviour. Tobacco smoking with rapid delivery of nicotine to the lungs and absorption, has been demonstrated to be highly addictive, compared with the NRT patch, for example, which has much lower dependence potential and long term use. Addictiveness is related to pleasure as well as severity of withdrawal discomfort, which are hard to tease apart. The addictive potential of other nicotine products is likely to be within the two extremes set by the cigarette and NRT patch, with some products, eg snus, also being addictive. It is thus inaccurate to say that nicotine per se is highly addictive, such statements need to be more nuanced, as addictiveness is dependent on the delivery system (emphasis added).

Evidence review of e-cigarettes and heated tobacco products 2018 (publishing.service.gov.uk) Similarly, the National Academies of Sciences, Engineering, and Medicine report on e-cigarettes says

whether e-cigarettes cause dependence and what the relative magnitude of risk is relative to combustible tobacco cigarettes are questions that cannot be answered solely by the translation of knowledge about nicotine and combustible cigarettes . . . . Conclusion 8-2. There is moderate evidence that risk and severity of dependence are lower for e-cigarettes than combustible tobacco cigarettes.

https://www.ncbi.nlm.nih.gov/books/NBK507163/

Therefore, I think that writing that nicotine is "highly addictive" in the context of vaping is not supported. Zvi Zig (talk • contribs 21:50, 29 July 2022 (UTC)

This is an extremely misleading misunderstanding of the evidence. There is an extensive and thorough research base supporting the fact that nicotine itself is the cause of addiction in cigarettes, and that it carries over to mediums like e-cigs. Nicotine is highly addictive, though e cigarette use as part of a SUPERVISED program may help people quit. This has nothing to do with whether or not nicotine is "highly addictive." It is. See:

National Institute on Drug Abuse Research Report on Tobacco, Nicotine, and E-Cigarettes:

The pharmacokinetic properties of nicotine, or the way it is processed by the body, contribute to its addictiveness. When cigarette smoke enters the lungs, nicotine is absorbed rapidly in the blood and delivered quickly to the brain, so that nicotine levels peak within 10 seconds of inhalation. But the acute effects of nicotine also dissipate quickly, along with the associated feelings of reward; this rapid cycle causes the smoker to continue dosing to maintain the drug's pleasurable effects and prevent withdrawal symptoms.[5][6]

FDA "Nicotine Is Why Tobacco Products Are Addictive":

Nicotine is a highly addictive chemical compound present in a tobacco plant. All tobacco products contain nicotine, including cigarettes, non-combusted cigarettes (commonly referred to as “heat-not-burn tobacco products” or “heated tobacco products”), cigars, smokeless tobacco (such as dip, snuff, snus, and chewing tobacco), hookah tobacco, and most e-cigarettes... To date, no e-cigarette has been approved as a cessation device or authorized to make a modified risk claim, and more research is needed to understand the potential risks and benefits these products may offer adults who use tobacco products. [7] — Shibbolethink ^{(♔ ♕)} 15:48, 9 November 2022 (UTC)

You have entirely ignored the issue mentioned above. Public Health England clearly states:

It is thus inaccurate to say that nicotine per se is highly addictive, such statements need to be more nuanced, as addictiveness is dependent on the delivery system

Similarly, the National Academies of Sciences, Engineering, and Medicine report on clearly says

whether e-cigarettes cause dependence and what the relative magnitude of risk is relative to combustible tobacco cigarettes are questions that cannot be answered solely by the translation of knowledge about nicotine and combustible cigarettes

https://www.ncbi.nlm.nih.gov/books/NBK507163/

Zvi Zig (talk • contribs 18:59, 11 November 2022 (UTC)

That is not in line with our most reliable sources [8] [9] [10] [11] [12] [13] [14] [] [15] [16], and so therefore it would be WP:UNDUE to put overemphasis on it in our article text.

Sorry, but we have an overwhelming consensus of the experts, health organizations, and international and national medical bodies that nicotine is highly addictive, even in the context of electronic cigarettes. I linked sources from the WHO, the American Academy of Pediatrics, the NIDA, the FDA, and the CDC, who all agree with this consensus.

In terms of your sources, what they say is that nicotine addictiveness may be modified by the way it is consumed. They do not say "nicotine in e-cigarettes is not addictive" which is what they would need to say to over-rule this established consensus.

Also, the sources you linked say a lot more than your quotes that appear to have been cherry-picked to support the conclusion you're making. Those sources also say: (emphasis mine)

PHE report:

"It is possible that the addictiveness of tobacco cigarettes may be enhanced by compounds in the smoke other than nicotine....As e-cigarettes have evolved, their nicotine delivery has improved. This could mean that their addiction potential has increased, but this may also make them more attractive to smokers as a replacement for smoking. It is not yet clear how addictive e-cigarettes are, or could be, relative to tobacco cigarettes."

NASEM report:

"cigarettes contain liquids (referred to as e-liquids) that are aerosolized upon operation of the device. E-liquids typically contain nicotine (although some users prefer zero-nicotine solutions), flavorings, and humectants. Nicotine is a well-understood compound with known central and peripheral nervous system effects. It causes dependence and addiction" — Shibbolethink ^{(♔ ♕)} 19:37, 11 November 2022 (UTC)

Major scientific reviews by the National Academies of Sciences, Engineering, and Medicine and UK government are highly authoritative. They are certainly not WP:UNDUE! Zvi Zig (talk • contribs 20:53, 11 November 2022 (UTC)

I would encourage you to read WP:MEDASSESS. What you have provided is two "narrative review" or "expert opinion" pieces. Both of which don't even wholly agree with your point, as evident in the quotes I provided. But then we have clinical practice guidelines which say that nicotine in e-cigarettes is addictive. In MEDRS situations, we go with the preponderance of what our best available sources say. — Shibbolethink ^{(♔ ♕)} 20:58, 11 November 2022 (UTC)

See WP:MEDORG:

"Statements and information from reputable major medical and scientific bodies may be valuable encyclopedic sources. These bodies include the U.S. National Academies (including the National Academy of Medicine and the National Academy of Sciences), the British National Health Service, the U.S. National Institutes of Health and Centers for Disease Control and Prevention, and the World Health Organization. The reliability of these sources ranges from formal scientific reports, which can be the equal of the best reviews published in medical journals, through public guides and service announcements, which have the advantage of being freely readable, but are generally less authoritative than the underlying medical literature."

None of the alternate statements you provided from NASEM or PHE contradict their position that nicotine's "highly addictive" status in conventional cigarettes cannot be automatically translated to e-cigarettes. It may be shown in the future that certain e-cigarettes are as addictive as cigarettes. But as of now, that is not the case, and NASEM has concluded (in a systematic review) that There is moderate evidence that risk and severity of dependence are lower for e-cigarettes than combustible tobacco cigarettes.. Zvi Zig (talk • contribs 21:27, 11 November 2022 (UTC)

"lower for e-cigarettes than combustible tobacco cigarettes" does not contradict that nicotine in e-cigarettes is still highly addictive. Indeed, we have systematic reviews and meta-analyses which say the opposite, that electronic cigarettes outside of a medical therapeutic relationship actually either decrease or do not help with rates of quitting, and those who do "quit" with e-cigarettes outside of medical therapy are often just trading one for the other : [17] [18][19]

And then we have clinical practice recommendations (not "public guides" or "service announcements") which state unequivocally that nicotine in e-cigarettes is still highly addictive, even if less than tobacco. These reports and guidelines are from the NIH, AAP, CDC, Surgeon General's office, etc. [20] [21] [22]

So overall, sorry, but no. It is clear at this point that consensus here on this talk page is against you, as shown above. if you are interested in getting the changes you seek, based on conflicting evidence, most of which is from higher quality sources and contradicts your position, you should consider starting an RFC or going to a noticeboard to plead your case (in a neutral fashion). Because otherwise, you will be editing against consensus. See also: WP:1AM

It is at this point that it is clear to me that conversing further with you about this is unlikely to be productive. So have a great day, a nice life, etc. But I will not be responding. You may feel free to have the last word. Let me know if you find better evidence that consensus has changed, or if you end up starting an RFC, and I will gladly participate showing the evidence above. — Shibbolethink ^{(♔ ♕)} 22:20, 11 November 2022 (UTC)

The point of the NASEM quote was to show that (a) nicotine's "highly addictive" status in conventional cigarettes should not automatically be translated to e-cigarettes and (b) as of now it has not been shown to be as addictive as conventional cigarettes (rather the opposite). Zvi Zig (talk • contribs 07:10, 13 November 2022 (UTC)

@Zvi Zig I think you're on the wrong track here as plenty of sources can confirm the statement. Best to look for other ways to improve the article. Pyrrho the Skipper (talk) 16:57, 12 November 2022 (UTC)

Wikipedia must reflect WP:NPOV. If major governmental scientific review on e-cigarettes concludes, "It is thus inaccurate to say that nicotine per se is highly addictive'' and that "It is not yet clear how addictive EC are, or could be, relative to tobacco cigarettes" then stating otherwise violates WP:NPOV.

Zvi Zig (talk • contribs 01:05, 13 November 2022 (UTC)

Shibbolethink provided nine sources that support the statement as is. You have provided one that disputes it. You have not yet addressed why you believe your one statement outweighs the overwhelming consensus among global medical organizations. Pyrrho the Skipper (talk) 01:21, 13 November 2022 (UTC)

The 9 sources include only one scientific review which does not say that e-cigarettes are highly addictive. Another included source says: "e-cigarettes may be as, or less addictive, than nicotine gums, which themselves are not very addictive." Another included citation is primary research that also does not address the question. Another citation is a Powerpoint presentation. The rest are webpages.

Other reviews I am aware of (and there are likely more) state similar conclusions to PHE and NASEM:

1. UK Royal College of Physicians' review: "the addiction potential of currently available e-cigarettes is therefore likely to be low"
2. Glasser et al. systematic review "These studies suggest that the current class of ENDS products may have significantly lower ability to induce dependence than cigarettes but are capable of inducing some level of satisfaction and dependence, especially when using second-generation ."
3. The Balfour et al. narrative review (jointly authored by 17 past presidents of The Society for Research on Nicotine and Tobacco) states: "Jackson et al. recently reported that the e-cigarette‒driven increase in nicotine product use among high-school students is not associated with an increase in population-level dependence. Among tobacco-naïve youths, in addition to low vaping prevalence (9.1% in the past 30 days in 2020) and frequency (2.3% vaping ≥ 20 days in the past 30 days), small percentages exhibited signs of nicotine dependence."

Zvi Zig (talk • contribs 04:57, 13 November 2022 (UTC)

Sorry, you've already got the correct aap link: [23], the other is a mispaste I'll fix. But the one you linked says:

Specific to youth, nicotine addiction and dependence leading to lifelong tobacco use is a major concern when considering e-cigarette use...Nicotine addiction is an adaption to nicotine exposure over time, and thus the high concentrations of nicotine in e-cigarettes are of major concern. Studies of e-cigarette use have revealed that, depending on duration of use and user puffing topography, serum levels of nicotine can be as high with e-cigarette use as with use of a conventional cigarette. In 1 study, the urinary cotinine concentrations (a biomarker for nicotine exposure) among adolescents using JUUL was even higher than the urinary cotinine concentrations of those who smoked conventional cigarettes

If you cannot see how that source supports the phrase "nicotine is highly addictive" then I cannot help you. I hope you find what you're looking for on Wikipedia.

We also have this AAP Policy statement on e-cigarettes (2020): [24]

Nicotine is highly addictive and hasnegative effects on brain development from the prenatal period into adolescence.

And the American Cancer Society:

Many e-cigarettes sold in the U.S. contain far more nicotine than e-cigarettes sold elsewhere, which increases the risk of addiction and harm to the developing brains of youth and young adults.

And the American Association for Cancer Research and American Society of Clinical Oncology:

Some ENDS products can result in rapid delivery of a similar amount of nicotine as modern American cigarettes, which contribute to high addiction potentials...As stated above, flavors are a key driver of youth initiation of ENDS, with the pharmacology of nicotine leading to addiction and continued, repetitive use

And the NHMRC (Australia):

Never smokers

There is high certainty of evidence that nicotine-containing e-cigarette use can result in increased dependence on e-cigarettes (1, 13). Findings from cross-sectional studies indicate that nicotine-containing e-cigarette dependence may be associated with earlier age of initiation, daily use and later generation/more powerful devices.

Current smokers

There is low certainty of evidence that nicotine-containing e-cigarette use may result in increased dependence on e-cigarettes (1, 13). There is also low certainty of evidence that nicotine-containing e-cigarette use may have lower abuse liability[4] than tobacco cigarettes but may have a higher abuse liability than nicotine-replacement therapies

And the Thoracic Society of Australia and New Zealand:

The addictive power of nicotine, particularly in the developing adolescent brain, and its adverse effects should not be underestimated

And a position statement from the Forum of International Respiratory Societies:

The appeal to users and primary concern for health advocates is nicotine, which is highly addictive

— Shibbolethink ^{(♔ ♕)} 05:16, 13 November 2022 (UTC)

Can you cite the part that contradicts the PHE? Zvi Zig (talk • contribs 05:46, 13 November 2022 (UTC)

The burden is on you, the person who seeks to make changes on the article, not on me. WP:BURDEN.

I do keep finding these sources, though:

A position statement from the American Academy of Otolaryngology (2021);

Many adolescents do not understand that e-cigarettes deliver nicotine and do not understand how addictive they are, often much more than traditional cigarettes... E-cigarettes containing high levels of nicotine are highly addictive for nicotine naïve teens.

A position statement from the National Safety Council (2019):

ENDS contain nicotine, a highly addictive drug

— Shibbolethink ^{(♔ ♕)} 05:47, 13 November 2022 (UTC)

1. The policy statements cited above are not on the WP:MEDRS level of NASEM or UK government scientific reports.
2. The majority of your sources above do not say that e-cigarettes are "highly addictive". Only the 2014 Forum of International Respiratory Societies statement clearly calls nicotine in the context of e-cigarettes "highly addictive".

They are certainly not sufficient to make NASEM, PHE etc. WP:UNDUE. Zvi Zig (talk • contribs 06:38, 13 November 2022 (UTC)

Wiki Education assignment: Technical and Scientific Communication

This article was the subject of a Wiki Education Foundation-supported course assignment, between 22 August 2022 and 9 December 2022. Further details are available on the course page. Student editor(s): Cbyler22 (article contribs).

— Assignment last updated by Cbyler22 (talk) 14:17, 21 September 2022 (UTC) I added results from more recent research studies (2021-2022). There are more symptoms and medical conditions that have been correlated with usage of e-cigarettes and I thought it worthwhile to add these relationships. Also, more recent studies show more youths using e-cigarettes than what was last added to the article. This usage among youths is continuing to accelerate in many countries but more severely in Canada and United States. The last topic that I included was an experiment done on women on the effects of dual smoking. These results were interesting and could possibly relate to a larger portion of the population who dual smoke and have trouble sleeping. — Preceding unsigned comment added by Cbyler22 (talk • contribs) 14:29, 3 October 2022 (UTC)

Because e-cigarettes are so new, they haven't been studied enough to fully understand them. What I find to be most curious is what the long term effects of e-cigarettes will be. They haven't been out long enough to have reliable studies done showing the long term effects on the human body. When research about that does come out in the future it will be interesting to see the results and I hope to see them in this wikipedia article. — Preceding unsigned comment added by Cbyler22 (talk • contribs) 01:45, 5 October 2022 (UTC)

Disputed changes to the lede, September 2022

User:Zvi Zig, I assure you that I'm aware of WP:NPOV. I invite you to reconsider your efforts to remove Wang et. al. and Hedman et. al. from the lede. These are recent meta-analyses, i.e. sources of the absolute utmost reliability. I have restored the longstanding consensus text for the time being, as would be expected in an editing dispute.—S Marshall T/C 20:20, 25 September 2022 (UTC)

@S Marshall Firstly, these meta-analyses do not make claims in relation to cause and effect. For example, Hedman et al write

"The different results between observational studies and RCTs can be explained by several features. First, controlling for confounders is stricter in RCTs than in observational studies. Other than sex, age and socioeconomic factors, there are many other confounders that may affect the association between e-cigarette use and smoking cessation in observational studies."

Secondly, meta-analyses of observational studies of limited quality (ie, subject to systematic bias) are considered to be a low grade evidence. Zvi Zig (talk • contribs 21:44, 25 September 2022 (UTC)

• When I re-checked the conclusions sections of both of those meta-analyses just now, I felt that they both quite unequivocally support the disputed sentence.—S Marshall T/C 22:05, 25 September 2022 (UTC)

Young People Should Be Updated

The statistics cited are a couple years old, I think with the rapid rise in e-cigarettes, we should find new sources and update some of the metrics. EZMedMan (talk) 16:11, 4 November 2022 (UTC)

Wiki Education assignment: Research Process and Methodology - FA22 - Sect 201 - Thu

This article was the subject of a Wiki Education Foundation-supported course assignment, between 21 September 2022 and 8 December 2022. Further details are available on the course page. Student editor(s): Lbw119 (article contribs).

— Assignment last updated by Lbw119 (talk) 07:00, 5 November 2022 (UTC)

Second paragraph of lead

I've been aiming at an lead that would be understood by a curious high school child who is considering taking a puff. This would include children in lower attainment quartiles. The recent edits to the second paragraph have hugely raised the reading age. We've made the article more specific and accurate, but the cost in accessibility has been very high. I'm minded to move the current second paragraph right down into the body text, and restore the previous version of paragaph 2.—S Marshall T/C 16:25, 9 November 2022 (UTC)

I think we can also just decrease the density of the language... Lemme give it a try — Shibbolethink ^{(♔ ♕)} 16:55, 9 November 2022 (UTC)

Better? — Shibbolethink ^{(♔ ♕)} 17:10, 9 November 2022 (UTC)

AHA

@Zvi Zig, please follow WP:BRD and discuss this before reverting. Do not edit war to keep your preferred version of the text. The AHA is an established health authority, and it has this opinion as described in its policy statement. The fact that it disagrees with other sources is the point. We are showing that there is controversy, as we describe several sentences before. We also describe where the controversy comes from (animal studies) in plain language. What is the issue? — Shibbolethink ^{(♔ ♕)} 11:40, 14 November 2022 (UTC)

The AHA review does not conclude with this concern. They mention this concern at a preliminary point in the review, where biological plausibility is addressed. Subsequently, the review presents clinical and epidemiological human evidence which does not support atherosclerosis or heart attacks being caused by nicotine.

This AHA review is similar to all other reviews co-authored by Benowitz (the US expert on nicotine) on the cardiovascular effects nicotine. At the outset, a range of concerns relating biological plausibility of harm are presented. Subsequently, more reassuring human clinical and epidemiological evidence is inferred from from NRT and snus. These concerns are not presented in the conclusion, but rather in the preliminary stage, and should be viewed as such.

It is impossible for nicotine to cause hypertension and atherosclerosis when NRT and snus do not cause these effects. I think it is wrong to interpret the AHA review as such.Zvi Zig (talk • contribs 22:45, 14 November 2022 (UTC)

it is impossible for nicotine to cause hypertension and atherosclerosis when NRT and snus do not cause these effects.

I seem to remember you spent several comments above explaining why it was inappropriate to use one mode of tobacco consumption (or derivative thereof) to prove or suggest anything about another (smoked tobacco for nicotine). Why is that acceptable now? And do you have a source to support the conclusion that nicotine does not cause transient hypertension? Because I agree with you, it is inappropriate to draw conclusions about nicotine delivered in a different form based on research on tobacco products like SNUS or highly regulated specifically dosed nicotine products like NRT.

I would add that the position you take on Bhatnagar 2014 (which was authored by quite a few more people than just Benowitz) is not compatible with the interpretation that the Surgeon General has on that same review, which it summarizes as:

American Heart Association (AHA) (Bhatnagar et al. 2014): There are no reports of e-cigarette safety in patients with known cardiovascular disease...For patients with existing cardiovascular disease and stroke, or at risk of a cardiovascular disease event, intensive cessation counseling should be offered as soon as possible.

Why do you think your personal interpretation is so different from that of the Surgeon General's office? On wikipedia, we use authoritative sources to help us determine how to interpret other sources, and which sources to pay attention to, which parts to emphasize, and which parts to de-emphasize. We don't use our own personal interpretations, which are considered original research.

I’m happy to remove the heart attack part given that it’s more poorly sourced. But we actually have 5 or 6 reviews which support the idea of transient hypertension, tachycardia, and atherosclerosis. Happy to cite those, as well as the Surgeon General's report, or another AHA source instead. — Shibbolethink ^{(♔ ♕)} 23:51, 14 November 2022 (UTC)

1. The NASEM and PHE reviews note that MAO inhibitors in tobacco smoke likely increase nicotine's addictiveness. Furthermore, differences in nicotine delivery can affect the level of addiction. Snus, however, produces a robust nicotine delivery similar to cigarettes, and is not associated with any increase in atherosclerotic plaque (2017 review).
2. Nicotine certainly causes a transient increase in blood pressure. However, this is not known to be harmful. Many healthy activities transiently increase blood pressure, including drinking coffee, exercise and calculating arithmetic.
3. I agree with the Surgeon General's report. The AHA does indicate concern about EC use in patients with cardiovascular disease. This does not support the statement in question.

Zvi Zig (talk • contribs 16:11, 15 November 2022 (UTC)

How about "The American Heart Association and others have raised concerns about the impact of nicotine on cardiovascular health, especially in those with preexisting cardiovascular problems." — Shibbolethink ^{(♔ ♕)} 16:37, 15 November 2022 (UTC)

In the conclusion, the concerns raised in relation to cardiovascular health in relation to nicotine are limited to those with preexisting cardiovascular disease. I think that this is something worth mentioning, but not in the lede, which already reflects possible risk. Zvi Zig (talk • contribs 04:19, 16 November 2022 (UTC)

• Can we please not devote the third paragraph of the lead to this he-said-she-said. It is helpful to the kind of person who understands the value and importance of Public Health England and the Royal College of Physicians, as well as those US authorities. It does not help a curious high school child who is considering taking a puff.

What that high school child needs to know is: (1) that if you don't smoke, taking up vaping isn't the greatest idea in the world; (2) if you're already addicted to tobacco, then you should seek a medical professional's assistance to quit with NRT; and (3) that electronic cigarettes are one of the forms of NRT that might help you. I feel strongly that this should be the message from the third paragraph. The he-said-she-said belongs much further down the article in the body text.

When we do get far enough down to talk about the authorities, the reason we should trust PHE and the RCP is because we know where their funding is coming from. The US attitude, to vaccines as well as quitting smoking (and abortion and climate change and many other medical and scientific things) is so resoundingly denialist that I suspect some big tobacco funding in their science. I would propose that the most reliable source for this paragraph is the Cochrane library here and we should follow it closely.—S Marshall T/C 10:14, 16 November 2022 (UTC)

I actually agree that entire paragraph belongs in the body if it’s going to keep multiple viewpoints. But I disagree that PHE is more trustworthy than the surgeon general, CDC, and NIH. Who also are entirely government funded. There’s an extensive history of the English health authorities being more lax about tobacco than US health authorities. When I asked my friends in the CDC about it, they literally laughed and said “That’s just the British.” But you don’t have to trust me, there’s also an extensive history in the sources of how this divide has developed (see below). I’m overall not saying we shouldn’t include the PHE stuff, we absolutely should, it’s due and relevant. But I am saying that to only include UK health authorities on this would be a massive disservice to our readers, and run afoul of NPOV, which would tell us in this situation to include multiple countries, including the UK, Australia, US, and international agencies like the EU and WHO. And hence, to include all of those and be compliant with NPOV, we would want to move it to the body.

Differences between US and UK on smoking and e-cigarettes
Reminder that I am not saying we should not include UK health authorities, but just that NPOV would dictate we also include other countries' health authorities as well.
Smoking in the United Kingdom Hunt, Katie (17 September 2019). "The US and UK see vaping very differently. Here's why". CNN. Retrieved 15 November 2022. Christopoulou, Rebekka; Lillard, Dean R. (February 2015). "Is smoking behavior culturally determined? Evidence from British immigrants". Journal of Economic Behavior & Organization. 110: 78–90. doi:10.1016/j.jebo.2014.12.014. ISSN 0167-2681. PMC 4298856. PMID 25620826. Zhang, Sarah. "The US: E-Cigs Very Bad! The UK: E-Cigs OK! All of Us: Huh?". Wired. Retrieved 15 November 2022. King, Ian (15 November 2019). "Sky Views: Vaping further proof that the US and Europe are worlds apart". Sky News. Retrieved 15 November 2022. Funk, Laura (1 November 2018). "Experiences of an American in London – Vaping and smoking culture". C3 Collaborating for Health. Retrieved 15 November 2022. MCGRADY, MICHAEL (27 November 2019). "How the British Approach to Vaping Puts the US to Shame". Filter. Retrieved 15 November 2022. Risk And Reason: Australia, England, And The US E-Cigarette Crisis Of 2019, Health Affairs (Project Hope), 22 April 2020, doi:10.1377/forefront.20200407.144029

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— Shibbolethink ^{(♔ ♕)} 11:53, 16 November 2022 (UTC)

How do you feel about the Cochrane study I linked? As I said, my position is that a recent Cochrane meta-analysis is the pinnacle of medically reliable sources, but I would wonder whether an American holds it in quite the same esteem that I do.—S Marshall T/C 13:23, 16 November 2022 (UTC)

I definitely hold Cochrane in extremely high esteem as a source, and that review is of very high quality, especially as a MEDRS. I generally hold Cochrane papers up as the best available systematic reviews. But I think WP:MEDASSESS tells us to hold clinical practice guidelines at the same or higher level. I think my position is that we should go mainly off of that Cochrane meta-analysis and fill in whatever we need from these various clinical practice guidelines to show any disagreements, diversities of opinion, etc. — Shibbolethink ^{(♔ ♕)} 14:50, 16 November 2022 (UTC)

Oh good, that's a relief.

I would deny that the UK authorities are more permissive towards tobacco. I think it's true that more Brits smoke than Americans, as a proportion of the adult population; but those Americans who do smoke, smoke more cigarettes per day. I think that's because we Brits have clearer and stronger restrictions on tobacco marketing and sale, and tobacco products are priced higher here. I think that Americans suffer more adverse health effects from smoking than Brits do. I think that in public health policy of addictive substances, there's excellent evidence in favour of the harm reduction strategy we follow here.—S Marshall T/C 15:34, 16 November 2022 (UTC)

I would deny that the UK authorities are more permissive towards tobacco
Oh I 100% agree. I think it's actually the opposite. More Brits smoke, and I would guess (only somewhat naively) that public health officers see these numbers and are more concerned with getting people off cigarettes so they don't trend more towards the US in deleterious outcomes and these same people, as a result, are more okay with any option that might get people to stop smoking. The other factor is, of course, that the UK has not had any cases of EVALI to date. And perhaps the third thing is that there haven't been renewed guidelines from PHE or RPC since 2015/2016 which have been as comprehensive and addressed these questions so directly. Whereas these other agencies have published more recent guidance that has been affected by EVALI (first case in late 2018 [25]) and other studies which supported some harms from vaping specific to additives and stabilizers common in US brand e-liquids.

There's also much more regulation in the UK market: [26]. You have an official register of all the ingredients of e-liquids, published by the MHRA, with maximum nicotine levels, etc. since 2015/2016 [27] A thing the US did not even come close to until 2019 [28] and still does not have for many products and ingredients, as these things work their way through our courts and some e-liquid suppliers and advocates vehemently deny that they are legally regulated [29]. There still is no maximum amount of nicotine in e-liquids in the US, and no banned substances [30], other than "non-menthol flavorings" and only then in "closed-system devices" [31] which is only ~51% of the market anyway [32]. It's really not fair to compare the two and decide "these UK agencies have it right" when much of the harm is delivered by these additives. To do so would be to make the article overly UK-centric.

While I agree there's evidence in favor of harm reduction, it would be absurd to state in the article that the harm reduction approach is the correct one, given how much disagreement we have among public health officials in different countries, including those outside the US such as the European Respiratory Society, and the NHMRC of Australia.

I don't want the article to be US-centric, either. I just don't think we should look at these harm reduction recommendations and think "this looks like the consensus" when we have lots of experts vehemently disagreeing, enough that they publish updated guidance that says "we were wrong if we ever said that was the right call" (e.g. American Cancer Society in 2019 [33]) — Shibbolethink ^{(♔ ♕)} 16:45, 16 November 2022 (UTC)

I think it's a pity that the Vaping-associated pulmonary injury article fails to make clear that the disease is geographically specific to the US. (OK, there have been a couple of cases here.)

I also think it's justified to say in Electronic cigarette that the precautionary advice against vaping is quite localized. I know there are some counterexamples, but I do feel a duty to explain that a good proportion of the opposition to e-cigarettes originates from red-state America.—S Marshall T/C 17:31, 16 November 2022 (UTC)

From where I'm sitting, the position of the WHO, European health agencies, New Zealand, and Australia (opposed to Harm Reduction without better quality evidence) makes this localized emphatic support from the UK, while everyone else is pretty tepid and waiting for more data.

I get how you might be concerned that the WHO is often very US-centric. But why would Australia, New Zealand, and the EU agree? These are not places that typically pride themselves on copying America. — Shibbolethink ^{(♔ ♕)} 17:56, 16 November 2022 (UTC)

Well, this has made progress. I think we've agreed that where other sources contradict Cochrane, we should follow Cochrane, unless there's a clinical practice guideline to take into account.

It's important that we've agreed this, because the second half of this article is largely authored by User:QuackGuru ("QG"), who is no longer allowed to edit this article because it's within the scope of one of his various topic bans. (I've managed to start revising the earlier parts of it since he got topic-banned, but it's slow going.) I would say that QG is an anti-e-cig hawk who doubts all science that doesn't come from America.

I would therefore hope to channel your expertise and zeal towards the second half of the article?—S Marshall T/C 18:47, 16 November 2022 (UTC)

Yes, I'd be happy to help bring it towards NPOV, but I must also say that real-world obligations mean I will be extremely slow at such a task :).

I think there are some ways in which it is too pro-e-cig and anti-e-cig at the same time, if that makes sense? Too many places where contradictory or dually outdated viewpoints are presented, and the correct move is to use one or several close to neutral sources to draw the controversy from a neutral viewpoint (which the Cochrane Collab is quite good at, but not perfect at). For example, there are clear biases against e-cigs in the Surgeon General's report (their MO, for sure) and pro-e-cig in the PHE report (likely a cultural thing, as described above). But we should be able to draw the most neutral statements from other sources to use instead of quoting contradicting sources all the time. Such as "more evidence is needed" "preliminary evidence suggests that X" etc. That is scientific language and caveat at its finest, and likely to be very prevalent in this article. Consensus via compromise. The only places where we should be presenting dueling viewpoints like this is where we are describing what the medical societies think. That's where this kind of dueling language belongs, probably not anywhere else. — Shibbolethink ^{(♔ ♕)} 19:25, 16 November 2022 (UTC)

@Zvi Zig you cannot use one agency's opinion to modify what another agency has said [34]: The evidence is sufficient for the RCP and PHE, who I would suggest are not less reliable than whichever US authority that is. Each health agency gets to say their peace, and we attribute those claims to that agency. We should never water down the attributed claims of one agency based on the claims of another, as this would violate WP:V. — Shibbolethink ^{(♔ ♕)} 12:26, 16 November 2022 (UTC)

I don't think that I've done so. Can you please be more clear? Zvi Zig (talk • contribs 01:48, 18 November 2022 (UTC)

You edited one agency's statement and referenced another agency's statement as justification. — Shibbolethink ^{(♔ ♕)} 02:01, 18 November 2022 (UTC)

Categories

In the categories, can someone replace "Nicotine products with harm-reduction claims" and "Heated tobacco products" with "Category:Non-tobacco nicotine products"?

Thanks. Lordal Planquette (talk) 21:59, 17 November 2022 (UTC).

 Done. I see that one of those categories was CfD'd to a redirect, and the other does not involve nicotine e-liquid. So makes sense to me — Shibbolethink ^{(♔ ♕)} 22:19, 17 November 2022 (UTC)

Substances found in EC vapor that are not present in cigarette smoke

The article states that EC vapor contains "some harmful substances not found in cigarette smoke". However, the source [35] refers to "substances", not "harmful substances" not present in tobacco smoke.

Below is the full paragraph in the source (AJPH review):

Among potentially toxic substances common to both products, cigarette smoke generally contains substantially larger quantities than e-cigarette aerosol.^42–44 However, e-cigarette aerosol contains some substances not found in cigarette smoke.⁴⁵

The substances present in tobacco smoke are described as "potentially toxic", but those exclusive to e-cigarettes are not. Indeed, the reference[36] for the last sentence above relates to phenolic compounds detected at nanogram levels (ppb). It also states that its authors did not evaluate whether their presence will lead adverse consequences.

Phenolic compounds and flame retardants are certainly concerning at high levels, but it would be misleading to say that e-cigarettes contain "harmful substances not found in cigarette smoke" based on ppb levels not known to cause harm. As Paracelsus states

All things are poison, and nothing is a poison; The dosage alone makes a thing not a poison.

More generally, PHE writes of chemicals exclusive to e-cigarettes, "the main chemicals present in e-cigarettes only have not been associated with any serious risk"[37]. Zvi Zig (talk • contribs 07:37, 18 November 2022 (UTC)

• The qualifiers are important. Of the chemicals present in e-cigs and not in tobacco cigs, PHE doesn't think any of the main ones are associated with serious risk.—S Marshall T/C 18:08, 18 November 2022 (UTC)

  1. Which qualifier(s) are you referring to, PHE's use of the word "serious"?
  2. PHE's allowing for certain substances to be "associated with a non-serious risk" can reflect scientific caution in relation to long-term effects. This does not establish them as "harmful". Can you identify a single harmful substance absent in tobacco smoke that is present in e-cigarettes at a level that is known to cause harm?

  Zvi Zig (talk • contribs 19:54, 18 November 2022 (UTC)

  Oh, sorry. "Qualifiers" is an editors' term of art for adjectives and adverbs -- in this case adjectives. It means the words I put in italics.—S Marshall T/C 20:59, 18 November 2022 (UTC)

• I feel "harmful substances" is an absolutely fair summary of the content in question. I prefer the more stable version. Watering things like this down to make the substances in question seem safer is precisely not what we should be doing! — Shibbolethink ^{(♔ ♕)} 19:53, 18 November 2022 (UTC)

  So please provide a source showing that harmful substances absent from tobacco smoke are generally present in e-cigarette vapor (at levels known to cause harm). Zvi Zig (talk • contribs 19:57, 18 November 2022 (UTC)

  we never say they're present at the levels required to harm. We say the substances themselves are harmful. The evidence is not really there yet either way as to whether or not those substances will cause harm to humans in the amount present in e-cigarette vapor, as we already go on to say further on in the paragraph. — Shibbolethink ^{(♔ ♕)} 20:10, 18 November 2022 (UTC)

  Do you think "potentially harmful" is too watered-down? Firefangledfeathers (talk / contribs) 20:15, 18 November 2022 (UTC)

  No I think that's probably appropriate based on the sources. Would definitely agree with that phrasing. @S Marshall @Zvi Zigwould you be okay with "potentially harmful" ? — Shibbolethink ^{(♔ ♕)} 20:18, 18 November 2022 (UTC)

  "Potentially harmful" may be appropriate for chemicals present quantities estimated reasonably be harmful at their detected quantities.

  Otherwise, stating that "e-cigarette vapor contains fewer toxins at much lower quantities than cigarette smoke, but also contains some substances not found in cigarette smoke" sufficiently conveys that these substances are not established to be risk free. Zvi Zig (talk • contribs 21:20, 18 November 2022 (UTC)

  Disagree, I think that is an extremely vague sentence which tells me nothing about the substances not found in cigarette smoke. I want a reader to know that some of these substances are potentially harmful, or that they are possibly harmful. Because not enough data exist to exclude harm, and data does exist which suggest such substances could be harmful in e-cigarettes (e.g. EVALI, the ACS report, the Surgeon general's report, or a myriad of other studies showing that some substances carry potential harm) — Shibbolethink ^{(♔ ♕)} 21:45, 18 November 2022 (UTC)

  All products contain harmful chemicals, if we ignore quantity. It would be misleading to say that a product "contains harmful chemicals" when they are not known to be present at levels known (or likely) to cause harm.Zvi Zig (talk • contribs 20:43, 18 November 2022 (UTC)

  Yes but not all products have evidence of possible harm (e.g. EVALI) — Shibbolethink ^{(♔ ♕)} 20:44, 18 November 2022 (UTC)

My problem with "potentially harmful" in the lead is that it raises the reading age quite a lot. "Potentially" is one of those words that comes naturally to people like yourselves -- i.e. those in the upper reading attainment deciles. (I expect the median Wikipedian has at least a college degree.) It's an appropriate word to use in the body text, but I want to keep the lead super-accessible because it's so likely that high school children will turn to this article when deciding whether to take a puff. I think we're aiming at a Flesch reading ease score of 70+.—S Marshall T/C 20:59, 18 November 2022 (UTC)

"possibly"? Firefangledfeathers (talk / contribs) 21:17, 18 November 2022 (UTC)

"Potentially harmful substances" --> "Substances that could be harmful" is the highest-readability periphrasis that occurs to me.—S Marshall T/C 22:47, 18 November 2022 (UTC)

• Note EVALI has nothing to do with nicotine vaping. It is clearly linked to vitamin E acetate in adulterated THC oil (https://www.nejm.org/doi/full/10.1056/NEJMoa1916433). Vitamin E acetate has never been detected in nicotine e-liquid. Zvi Zig (talk • contribs 07:41, 22 November 2022 (UTC)

  Actually the CDC never ruled out (and continues to suspect the role of) substances in nicotine e-vapor. There were several cases in people who had never used THC products. It says as much in the EVALI article. What you're engaging in is called original research, which is not allowed in article space in wikipedia. — Shibbolethink ^{(♔ ♕)} 15:04, 22 November 2022 (UTC)

  1. The CDC stopped actively monitoring EVALI after "identification of the primary cause of EVALI"[38]. The 2022 UK government review on e-cigarettes says, "it is now clear that EVALI was not caused by nicotine vaping"[39].
  2. The NEJM study cited above reports on both confirmed and probable EVALI cases. 100% of the confirmed EVALI subjects had vitamin E acetate in BAL fluids. Among probable EVALI cases, only 3 out of 26 were negative to vitamin E acetate. Zvi Zig (talk • contribs 07:25, 23 November 2022 (UTC)

• A few paragraphs down in the body text, we say: Over 80 harmful chemicals such as formaldehyde and metallic nanoparticles have been found in e-liquids. Do we still think that's accurate?—S Marshall T/C 22:55, 23 November 2022 (UTC)

  Looks like a secondary peer-reviewed source to my eyes, so yes I think that's still accurate. — Shibbolethink ^{(♔ ♕)} 23:16, 23 November 2022 (UTC)

  OK. So we should replace "substances that could be harmful" with "harmful substances" again?

I'm a bit concerned with that and other QG-found sources, where he locates a good source, cherry-picks the most clearly anti-e-cig statement out of the abstract or first paragraph, puts that one statement into the article, and moves on. It's one of the behaviours that contributed to his tban.—S Marshall T/C 23:43, 23 November 2022 (UTC)

I agree with @S Marshall because according to other reviews, these chemicals are present at levels far below permissible levels according to occupational safety limits.

The page singles out "formaldehyde and metallic nanoparticles" as harmful, while PHE 2018 argues that formaldehyde was detected "far below" a safety threshold, and that "the levels of metals identified in EC aerosol do not give rise to any significant safety concerns".[40] Zvi Zig (talk • contribs 06:44, 24 November 2022 (UTC)

Yup. So there certainly are harmful substances in e-cigarette aerosol which aren't found in tobacco smoke, but they're at trace levels that shouldn't amount to a health concern. I think both the lead and body text should say this.—S Marshall T/C 09:08, 24 November 2022 (UTC)

My point is that it is misleading to blanketly refer to a trace substance as harmful, without reference to the quantity. Otherwise, all products contain toxic substances. If context about dose is added, that is reasonable.

Also note, formaldehyde and metals are also found in tobacco smoke (usually at greater quantities)[41]. Zvi Zig (talk • contribs 17:18, 24 November 2022 (UTC)