If it ain’t broke…..

 

Crocodile tears.

Just today the BBC reported that “More than half of UK vapers ‘have given up smoking’.

Some 1.5 million vapers are ex-smokers, compared with 1.3 million who still use tobacco, a survey of 12,000 adults for Action on Smoking and Health found.

Good news for the people who said e-cigs would work as a complete replacement for lit tobacco products. Bad news for them too, as ASH point out;

But Ash said the message that vaping was much less harmful than smoking had not yet got through to all smokers.

I wonder why? No doubt those lamenting this misinformation will blame ‘the media’, not bothering to point out that the media get their information from the same people now crying crocodile tears over this. All the campaigning and lobbying to have e-cigs declared medicines, banned from public use and rushed press releases of every junk science ‘study’ that adds to the fear, uncertainty, and doubt couldn’t be the cause as it’s intention was good, right!                                            

DICK PUDDLECOTE covers this in his blog today, I’ll just leave this pic here!

 

 

 

 

 

 

And how are things at home?

Meanwhile back in Ireland, The IMO had their AGM. Offered the chance by Dublin GP Dr Garrett McGovern to “endorse” e-cigarettes as an effective tool and as a “far safer alternative to tobacco”, they instead voted to “recognise” e-cigarettes as a potentially effective tool for smoking cessation and a far safer alternative to tobacco.” The result of concerns raised by the IMO Public Health and Community Health Doctors Committee. I wonder what these concerns were exactly? Probally the usual, “we dont know enough yet” “gateway” and the rest of the tosh.

Still, as much as I suspect it was the inate concervatism of the medical establishment that caused this change, I also think they got it right, even if for the wrong reasons.

Lately their has been an effort by anti smoking groups to gain control of vaping, at least to control the narative around them. This rush to embrace e-cigs as effective cesation products is not in the interest of either vapers or smokers. It will not lead to an ease of restrictions or regulation, it will not lead to greater uptake by smokers, in fact the oposite is far more likly. Once e-cigs are seen as cesation products, then they either ‘work’ or ‘don’t work’. Which misses the point of vaping. It works as what it is; an alternative to smoking. If the side effect of that is less smoking then that’s a bonus but it’s not the point.

The IMO recognising that vaping has a role in reducing the prevelence of smoking but not endorsing them as cesation products might be the exact position e-cigs should hold in tobacco control. A potential allly but not a servant to tobacco control. I know that’s not what the IMO intended but it would be the right call.

 

 

HIQA tell it like it is

The HIQA ” Report on the results of the public consultation on the draft health technology assessment (HTA) of smoking cessation interventions” is published. Yes, it’s a hell of a title and it’s a hell of a document. 182 pages not counting the appendices.

It’s available on their website here; HTA of smoking cessation interventions

 

For those of you wondering who HIQA are,

The Health Information and Quality Authority (HIQA) is an independent authority
established to drive high quality and safe care for people using our health and social
care services in Ireland. HIQA’s role is to develop standards, inspect and review
health and social care services and support informed decisions on how services are
delivered.

“In January 2016, HIQA commenced a health technology assessment (HTA) of
smoking cessation interventions following a request from the Department of Health
for HIQA to examine the clinical and cost-effectiveness of a range of different
treatments to help people quit smoking. The aim of the HTA is to inform health
policy decisions about potential improvements to the provision of smoking cessation
services within Ireland’s public health service.”

The message the government got!

Tasked with this, they critically examined all the cessation methods, pharmacopeia and self-help, counseling, patches, lozenges, and e-cigarettes. They duly published a draft report and held a public consultation. At the time, the draft report was covered in the media as saying e-cigs work.  They were almost as effective as combination therapy and at half the cost. We all cheered and thought that this evidence would mean that e-cigs would now find a place in the tobacco-free Ireland toolbox. Not that we give a damn about a tobacco-free Ireland, it just means we get less stick for vaping.

So we sent in our submissions and waited for the set of recommendations.

Scratch that, we didn’t exactly inundate them with responses. Though the largest reaction was to e-cigarettes, only 13 of those were from individuals. 13! 48 responses and only 13 from individuals!

35 were from organizations, health bodies, charities, business orgs and such. Which means at best only 12 other people sent in a response!! I would call that bloody exasperating and downright disheartening. Oh well.

Of those  48 responses, most were negative both to e-cigs and also to the treatment with the most actual evidence backed success rate, varenicline in combination with NRT. Remember this was found to be the most cost effective and effective solutions in the draft report. It’s almost as if a large section of the country’s health charities don’t want to see a tobacco-free Ireland at all.

Anyway, what is interesting about this is the fact that in the draft report, HIQA found combination varenicline and NRT as the most cost effective and e-cigs a close second. When the recommendations to the government are published, it turns out their’s not enough evidence for e-cigs and the recommendations are to wait until there is. I suspect the strength of the negative responses had more influence on this than the research data.

Evidence-based ?

A complete synthesis of the available evidence in relation to the long-term health
effects of e-cigarette use is beyond the scope of this HTA. However, the work of
other public health bodies did not indicate that there was sufficient evidence of
harms to exclude e-cigarettes as a smoking cessation intervention in this HTA

This quote, the emphasis is mine, shows that someone in HIQA “gets it” and seems intended to scold the naysayers.

there is a concern that a policy decision for smoking cessation practitioners to
advocate the use of e-cigarettes by those attempting to quit may contribute to
increased e-cigarette use among people who have never smoked. This type of e-
cigarette use may act as a gateway to smoking combustible tobacco. It is difficult to
estimate the relative contribution of promoting e-cigarettes as a smoking cessation
aid to any growth in the use of e-cigarettes among people who have never smoked,
as it is likely to be influenced by a range of other factors, such as marketing of e-
cigarette companies and regulations on the sale of these products. Estimating the
proportion of people who would later switch from e-cigarettes to smoking (but would never have started smoking were it not for having been e-cigarette users) is even more uncertain.

They even access the gateway theory correctly, yet give it sufficient credence to reject recommending e-cigs. Cognitive dissonance?

Now we get to the real reason for the objection to e-cigs,

The underlying issue that connects all of these comments is the impact these
issues will have on the uptake rates of the most effective quitting interventions.

Yes, impact on incumbent players, remember that the draft report ranked e-cigs second in cost effectiveness. Of course one of those incumbent players is lit cigarettes but whatever.

In fairness to HIQA, they did an excellent job of evaluating the evidence, sifting through hundreds of reports, analyzing the data, rejecting reports that lacked credibility and offering the result in an impartial manner. My main fault with it is, it examines the issue through a medical lens. Harm reduction is mentioned and I get the impression HIQA wish harm reduction was part of their remit.

While considerations about harm reduction, including the potential role of e-
cigarettes among the subgroup of smokers who do not want to make a quit
attempt, are beyond the scope of this HTA, the feedback received on this issue
provides a valuable resource for smoking cessation policy-makers to consider as
part of the wider approach to tobacco control in Ireland.

Shame they didn’t force this point more, ahem, forcibly.

Page 31 is someone calling for outdoor bans on smoking, to be expected but infuriating as it has no benefit to anyone other than aesthetic. This is supposed to be about health measures.

Anyway, I’ve spent too much time on this already, it’s an excellent report, carefully worded and well researched. It holds it’s focus on it’s brief; government funded interventions and the cost-benefit assessment of them.

The biggest shame is that lobbying had such influence on the final report over the draft report. It certainly shows that making the effort to respond is important.

The message the public got!

Concerns vaping may act as ‘gateway’ to tobacco cigarettes

That’s the Examiner being used as an example of the kind of spin the report got. Pretty much the same in the Irish Times and RTE online. Here it is being discussed on RTE’s Drivetime;

HIQA report on e-cigerettes

Note the misrepresentation of the subject of the actual report in the title!

 

I thought it must have been the emphasis given in the press release from HIQA

HIQA press release

Yep, it’s right there. Not surprising as e-cigs drew the biggest response during the consultation period. What is disappointing is how their position moved from the draft report.

“HIQA’s analysis shows that increased uptake of e-cigarettes as an aid to quitting would increase the number of people who successfully quit compared with the existing situation in Ireland and would be cost-effective, provided that the currently available evidence on their effectiveness is confirmed by further studies,”

Again this shows the value of letting them know. Perhaps if hundreds or thousands of the current users of e-cigs had replied to the consultation instead of a paltry 13, we would have had a more positive result.

Lesson to be learned,

Use the opportunities given to tell them your story. No use complaining when it’s all regulated away from you if you made no effort. While this report is now finished, it’s only advisory and goes to the Joint Committee on Health and to the minister for further discussion and decisions. In other words, their’s one last chance to have your say. E-mail, write or personally contact the committee or its members. Tell them your story and emphasize how any move to further restrict e-cig access or use will have a damaging effect on you. Tell them how they helped you, it’s not about having e-cigs included as cessation therapies. It’s about not having e-cigs treated as smoking, taxed as smoking and restricted in availability to smokers.

Contact details here;

Joint Health Committee

And list of the members on this page;

Joint Committee on Health – Membership

 

 

Ashes to Ashes!

 

“This time next year Rodney….”.

Yeah, we all do it, make resolutions which we immediately abandon. The big one is losing weight, followed by giving up smoking. Get a gym membership, join a slimming club, try an e-cig. No?

No! No, No! Not an e-cig! Not according to ASH Ireland who are “against vaping as a solution, saying that quitters should use patches or gum instead”. They went on a media blitz with this message on January the first, getting coverage in most national newspapers, radio stations and online publications. It was to be expected, this has been ASH’s position since e-cigs first turned up around 8 years ago and despite the lack of emerging evidence of harm and the emerging evidence of their usefulness as tools to reduce smoking prevalence. ASH has not budged. (They do on the other hand sing the praises of Plain Packs which they say are proven to reduce smoking despite the lack of empirical evidence. It seems projections are good enough if it’s a measure they like.)

Dr Patrick Doorley, Chairman of ASH Ireland said today;“The New Year is a good time for people to consider quitting smoking and I encourage them to do so. Many people quit for good at this time each year. For most people they will make a number of attempts before finally quitting – so I would encourage those who have tried before to try again. People can attempt to quit on their own, or call the National Quitline on: Callsave 1850 201 203.”

Not super encouraging for people thinking of quitting, it’s almost as if ASH aren’t that pushed if you do or don’t. Pat isn’t too bothered because he has put his faith in Plain Packs;

“In Ireland we have lost some time with the full roll out of the plain packaging legislation, however, the final legislative process will be completed in the New Year and it is vitally important that the Government then push ahead and get the plain packs on the shelves as a matter of urgency.”

 

Being the sceptical kind, I paid little attention to this apart from sighing and rolling my eyes when they turned up on the telly or radio. (I did this a lot, I do it a lot anyway but this week had me working overtime) However, by the next day, I did notice something, a slight change of tone, a small uncertainty in the condemnations. January the third, things got even stranger, ASH now were qualifying their initial warning and instead of “vaping doesn’t work” they were saying “there is some evidence but not enough…” Did someone somewhere have a word in their shell-like?

A week is a long time in politics and make no mistake, this is politics not health. On Jan the fifth  HIQA released the draft of their Health Technology Assessment on smoking cessation therapies. I’ll add a link at the end if you want to plough through it, it’s long, detailed and has lots of graphs and tables if that’s your thing.

I’ve gone through it and to be fair, it’s a pretty good if over cautious assessment of the current evidence on e-cigarettes. Heavy on the caution in regards to both their usefulness and the studies available. Stating that most were inconclusive at best and not supported by the real world evidence at worst. Here are some highlights pulled from the document;

if e-cigarette use in Ireland (26%) rose to the levels currently reported in England (45%), the number of prescriptions required could fall by nearly 40%

e-cigarettes and combination varenicline and NRT the most cost-effective strategies when individual therapies are compared to each other.

regulating vaping products as tobacco products may give the message that both are of similar risk

Any smoking cessation intervention must be made available in a way that promotes the autonomy of the individual by providing information on the risks and benefits associated with the particular intervention.

provision of inaccurate information on comparative risk is fundamentally unethical as it fails to allow consumers to make informed choices

Continuing increases in the uptake of e-cigarettes are likely to improve the cost-effectiveness of the overall mix of cessation interventions in Ireland, by increasing the number of successful quit attempts at an acceptable cost .

No quibbles with any of that. I noticed that a lot of the data on e-cigs,  smoking prevalence and smoker demographics is from UK or US sources because such data isn’t available for Ireland. Which raises the question, what the hell do the Tobacco Free Research Institute of Ireland do exactly?

However, it’s not all good. While mostly well done, the ideological bias shows through when they give credence to this kind of nonsense;

1.Although there is clear benefit to existing smokers from switching to e-cigarettes, there are concerns that if it becomes socially normalised, large numbers of people who have never smoked might take up smoking e-cigarettes

2.It is also possible that e-cigarettes will have a ‘gateway effect’ for non-smokers who take up e-cigarettes, and they may later migrate to tobacco cigarettes or marijuana.

3.Smokers who use e-cigarettes as a smoking cessation aid may in effect be swapping tobacco for another dependency,

1.No evidence this is happening so this is nothing more than a biased opinion which should have no part in a policy document.

2.Marijuana! OFFS! gateway theory is nonsense and needs to be buried with phrenology and Humourism. This is just reefer madness all over again.

3. Sounds reasonable until you realise tobacco dependence is a synonym for nicotine dependence so it’s not swapping anything, it’s replacing something with a harm reduction alternative. But “The tobacco control community are wary of accepting harm reducing products, such as e-cigarettes” and “If e-cigarettes make smoking socially acceptable, this could be seen as a retrograde step after decades of anti-smoking efforts”. 

Vaping is NOT smoking, how hard is it to understand?

There is a consultation process attached to this draft and if you want to add your voice, it’s available on the same page as the draft report linked below.

Anyway, the publication of this draft does give us a clue as to why ASH have had a full week of backpedalling on their New Years message.Here’s a free tip for the lads at ASH, it’s never a good idea to start with bold claims and then have to back down. It makes you look incompetent. If you’re explaining, you’re losing as they say.

I’m going to do what I do every year as far as resolutions go, I hope you take my advice and do the same. ASH might be better to not adopt this approach, I recommend they resolve to keep up with the literature and adjust position as the evidence indicates.It could save them further embarrassment!

 

Link to the draft report and the consultation paper

 

 

Movie Night, popcorn essential!

On Monday, the Irish showing of Aaron Biebert’s  film A Billion Lives took place at the Odeon cinema in Dublin. It’s a documentary about vaping or “A True Story of Government Failure, Big Business, and the Vaping Revolution” as the promo puts it.

First off, let’s get the title out of the way. The use of the billion number has upset some people who dispute it’s accuracy. Which is fair enough but it’s a dispute that needs to be taken up with the anti-tobacco movement, it’s their number. This movie is using it to draw attention and give context to the argument it’s making.

Being somewhat passionate about this subject, I’m probably not the best person to review it. I happen to be better informed than the average punter who doesn’t smoke or vape. And this average punter is the target for this documentary, not me. I’m going to have to wear two hats for this review, vaper and disinterested viewer. We’ll get the disinterested viewer one out of the way first.

Not enough personal stories!

So I’m looking for a movie to watch, a documentary and I’ve selected A Billion Lives. Would I be impressed? Probably. This is well shot, well edited and makes its case in increments so I can keep up. The cinematography is especially impressive, there are some beautiful shots of landscapes, streetscapes (did I catch a glimpse of Dublin in there?) and buildings. If there is one area it falls on, it’s people. Not enough personal stories to frame the debate in the context of actual people at risk from the decisions made. The title tells us there’s a billion of them, I would like to have seen more of them.

None the less the narrative carries you along. From the early days of smoking, it’s growth as an industry, the realisation smoking causes loss of life, right through to the growth of the anti-smoking movement. It uses the Winston Man, David Goerlitz as the vector for this story. Through his eyes, we see the glamour and attraction of smoking. He tells us how he came to view smoking as dangerous and how he turned against the tobacco industry. This section takes up about a third of the movie and while interesting in its own right, it could be shorter. This is 2016, we get it, smoking is bad, big tobacco is evil.

Plot twist!

Once the movie moves to e-cigarettes, it gets more interesting. If this was a fictional drama, this is the where the twist in the plot comes. The good guys become conflicted and in a convergence of interest take the same side as the bad guys. A Billion Lives shows this quite well without resorting to conspiracy theories. It presents the evidence and leaves us to draw our own verdict. Again it frames the story around David Goerlitz. Backing up his story with clips of contributors from both sides of the argument. Historical clips from TV shows from the anti side and face to face interviews with the pro side.  I might criticise the lack of contribution from the anti-vaping section of tobacco control but as we learn just before the credits roll, they refused to comment or contribute to the movie. I would have stated this verbally in the movie rather than as text at the end. It’s an important part of the story.

All in all a well-made documentary, done with a passion for its subject. Recommended viewing for anyone interested in how, even with the best intentions money corrupts those intentions.

OK as a vaper and advocate of harm reduction, what did I think?

Well, I liked the film, it presented a clear case and did so without exaggerating that case. I would have liked more science around vaping. I felt it took for granted that the audience was fully aware of the evidence. I would love to have seen the anti side present their case and seen it countered but they declined to do so. I do understand this was less about vaping as such, and more about what influences positions. It started with the assumption that vaping was the solution to the tobacco problem. I suspect Arron was so convinced of this he forgot it might not be as obvious to everyone else.

Will it help our cause? Yes, if it gets seen. It should act as a rallying point for e-cig advocates and is a useful contribution to the debate. It’s not going to change the minds of confirmed ANTZ but it might tilt the  ones sitting on the fence. More importantly, it brings the conflict of interest of the anti side out in the open for the undecided. The audience should be doctors and health professionals especially those working in smoking cessation, they have the most to gain from watching this.

Right now it’s being shown on demand, someone has to organise a showing, do all the promotion and hope they get enough bums on seats for the show to go ahead. Real grassroots stuff. Hopefully, it will make it to Netflix or one of the on-demand streaming services where it will find a wider audience. If you get a chance to watch it, don’t miss it.

IMDB Page

Official Site

YouTube Trailer

 

 

Just a spoonful​ of sugar….

You know I’m often astonished at the stuff that science turns up. Stuff like carbon dioxide can be trapped in solid rock, the Higgs bosun, their’s a ninth planet and the earth has two moons. In fairness, I learned the last one from QI but they got it from science. People doing long involved research, publishing papers so the rest of us can share in the wonders of this universe. It’s not all big stuff either, the first new antibiotic in 30 years was discovered last year, common swifts can stay airborne for 10 months. Try that Ryan Air!

As astonishing as this stuff is, what’s even more astonishing is the amount of bad science that gets published. You have to assume that the people who discovered quantum levitation are pretty smart people. So how does a paper like this get past reviewers, editors, and publishers?

Detection of 5-hydroxymethylfurfural and furfural in the aerosol of electronic cigarettes

It sounds serious and scholarly and all kinds of clever until you actually read it. In the abstract it states

Saccharides, which are commonly used to impart a sweet flavour to ECIG liquids, thermally degrade to produce toxic compounds, like aldehydes and furans.

A good hypothesis except for the fatal flaw that saccharides are not used in e-liquids. I have no idea why they assumed sugar would be used as everyone knows that when heated sugar caramelizes and would ruin your e-cig coil. They tell us that there are over 7000 e-liquid flavors and these fall into 6 groups, tobacco, menthol, fruits, beverages, sweet flavours and others. The sweet category is the one these geniuses decided to concentrate on. Telling us that;

The ‘sweet’ category, which is popular among ECIG users,7 lists sugar, caramel and honey as advertised ingredients.

Evidence for this claim leads to this page; Bee Sweet, Rocket Fuel Vapes

Somehow our intrepid boffins mistake a description for an ingredients list! Bad enough to do this once but they include 3 examples of flavor descriptions as evidence of sugar as an ingredient. There is no link to an actual list of ingredients from the manufacturer or to the result of testing purchased samples for sugar content.

In fact no samples were purchased for testing, instead, assuming sugar was an ingredient, “Liquids with various concentrations of sucrose, glucose or sorbitol were prepared in a 70/30 PG/VG ratio”

Imagine if NASA had taken this;

as evidence of the composition of the moon and based all pre-launch testing on fatty dairy products!

That’s the level of stupid this study archives. Anything they found after this point is irrelevant to everything but the  samples they tested. No point reading any further because the pretty graphs and fancy math have no information about the subject they claim to have.

If they had purchased some e-liquid samples and tested them they would have found that the sweet flavor is achieved by adding Ethyl Maltol  Stevia or some other artificial sweetener because every fool (apart from the fools doing the research) knows, the molecules in heated sugar break down and produce several different compounds and its sweet taste is replaced by a more bitter flavor. It also caramelizes and ruins coils.

Chemistry Department, American University of Beirut, your study is bad and you should feel bad!

Funding Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number P50DA036105 and the Center for Tobacco Products of the US Food and Drug Administration.

National Institute on Drug Abuse of the National Institutes of Health, you should demand your money back!

 

The beatings will continue…

Sometimes you wonder if you inhabit the same planet as everyone else, what seems like common sense to you, seems unthinkable to others. I’m the kind of guy who thinks evidence should decide the course of action. If I am doing something and it’s not working, I naturally assume I should do something else, not do the same thing again and again. I don’t think, If I do this harder or do more of it, it should work. I tend to step back and admit defeat and try another approach.

Our government, on the other hand, think, bigger, better, more of what failed so far is the best policy. The New National Drug Strategy is a perfect example of this. The old national drug strategy hardly made a dent in the problem so building on a failed policy is in their opinion the best way forward.

 

They are currently running a consultation process on this and asking for submissions to help form the national drug strategy.

It’s an online questionnaire available here.Drugs Strategy

Now I have made clear my opinion that most of the harm from drug use is caused by the official response to drug use. Some will say “but Tom, harm reduction is specifically mentioned as one of the key areas, they must be trying to reduce the harm, why do you say they are the cause of harm”. OK, they do pay lip service to harm reduction but only in as much as the harms threaten themselves, infectious disease or littering. As far as any other harms are concerned, there is no sign of reducing any of them. In fact, it’s official policy to increase these harms.

Let us look at the framing of the questions on the questionnaire. All  harm increasing options, hardly a mention of education other than the “drugs are bad, you will be punished just say no” mantra that has failed to dissuade anyone in the past. Needle exchange hasn’t gotten past half the areas designated in the original program and their’s no mention of safe injecting rooms, pill testing facilities or decriminalization of so-called soft drugs. It’s entirely a token gesture. The fact that drug consumption rooms are going ahead is in spite of the drug strategy, not because of it.

If we look at the evidence, decriminalization is the most effective drug use reduction stratagem. It’s worked in Portugal, all drugs have been decriminalised and Portugal’s drug situation has improved significantly in several key areas.

Drug decriminalisation in Portugal: setting the record straight

This is apparent anywhere it’s been implemented. But our crowd tell us;

The Steering Group considered the legislative framework governing illicit substances. Most were not in favor of legalising, decriminalising or changing/redefining the legal status of certain illicit drugs (cannabis was the focus of most discussion in this context).

This despite the fact, which they acknowledge;

The issue of the legislative framework governing illicit substances was raised on a number of occasions, with some requesting a review of that framework. Some people were of the opinion that consideration should be given to potentially legalising, decriminalising or changing/redefining the legal status of certain illicit drugs (particularly cannabis) and the associated penalties for possession.

In other words, we have a plan, don’t bother suggesting anything else, just tell us how you think we should implement our plan.

Consultation is not what I call this, signaling is what I call it. This is the first stage of implementation of a plan which has been decided before any consultation. It’s theater! Its purpose is to pretend support for what is already decided. The main thrust of which is that the approach and rationale outlined in the current Strategy continue to be relevant and appropriate.

Yeah, it’s all about staying relevant and appropriate. If you continue with policies that fail you will always be relevant and in a job!

Go on fill out the questionnaire, it’s linked in the Drug Strategy page, do it because if enough people make a noise about harm reduction measures and decriminalisation, they will have to mention it. This is your opportunity to put your oar in, don’t miss it. Closing date for submissions is 5 pm, Oct 18.

Yeah sorry, I’m late letting you know but I didn’t come across it myself until this week.

If you want to read more thoughts on harm and harm reduction, Iv blogged about it here;

Where’s the harm?

 

Tonights guest is…

Ladies and gentlemen, it’s time to give you a break from my ponderings and let someone who knows what they are talking about have a say.

This week was a good one for vaping news. The smoking toolkit showed 18000 extra smokers quit by switching to e-cigs (yeah, it sounds low but it’s a conservative estimate based on complex math and stuff and it’s still over and above what would have quit if vaping had not figured).  An update to the Cochrane review showed e-cigs can help people quit lit tobacco and showed no evidence of harm short to medium term. Irish Health reported the story here E-cigarettes do help smokers quit  All good! I have however heard some commentators when speaking about this review say the quality of the studies are low which seems to imply that the Cochrane review itself should be taken with the proverbial quantity of salt. So to explain this issue I got someone far better able to do so than me. Sarah Jakes,  @Twigolet on twitter if you want to follow her. Sarah is a trustee of the UK charity New Nicotine Alliance (UK). She knows her stuff!

Over to Sarah;

Cochrane reviews are one of the most highly regarded review systems in the academic world, but sometimes they can leave you feeling a little, well, flat. Let’s face it, ‘E-cigarettes may help smokers quit but the quality of the evidence is low’ is not exactly the advocacy message of the century.

To understand why this finding is kinda better than it seems you have to first understand the purpose of a review. As anyone following the vaping debate knows, practically every day brings new studies and the conclusions of those studies are sometimes problematic. This could be down to the methodology used, or it could be due to bias. It would be an impossible task for decision makers who need a question answered to wade through literally decades of conflicting studies in order to come to the correct conclusion about what the evidence currently says. That is where reviews come in. Reviews will start with a question, find all of the research that addresses the question, assess not only the quality of the research itself but also, and importantly for our purposes, how well it answers the question and how much confidence the reviewers have that the resulting effect size will not change once more research is undertaken. The primary question asked in the latest Cochrane Review was – do e-cigarettes help people who smoke achieve long term abstinence from smoking?. The conclusion was a muted ‘yes’, with confidence in the accuracy of the estimates of the size of the effect being graded from low to very low. What this means is that the reviewers believe that with more research the effect size will change. In theory it could change in either direction. Both Cochrane Reviews on e-cigarettes found only two relevant randomised control trials and both were undertaken using now obsolete cigalike type devices.

Of course the effect size is going to change! Saying otherwise would be like testing a model T Ford for fuel efficiency and then assuming that result will apply to all cars forever more. There was absolutely nothing wrong with the two RCTs themselves, but they don’t tell us much about the effect that modern devices would have. At the time the review was written Cochrane had come across a further 15 ongoing RCTs which they say appear to be eligible for inclusion in future reviews. I wouldn’t mind betting there are more in the pipeline than that, although many could be excluded for various reasons. Let’s hope that the new studies incorporate factors missed so far such as improved nicotine delivery from modern tank systems, and study designs which take into account real world use patterns. Of course RCTs will never fully quantify the efficacy of e-cigarettes in real world use, but they’ll come close enough for those who need such answers, and the rest of us really don’t care.

So there you have it, next time you hear someone try to dismiss the Cochrane review by claiming its low quality you will know they are engaging in wibble. Take what they say and apply salt generously.