Is big tobacco abandoning smokes for e-cigarettes?

Posted January 8th, 2016 in News by Steve

E-cigarettes. For a product barely anyone had heard of five years ago, they now seem to be on everyone’s lips. While much has been written about the safety of these products and their potential to either support or sabotage efforts to reduce smoking rates, it’s timely to consider why the global tobacco industry has taken such a keen interest in buying e-cigarette companies.

Despite e-cigarettes seemingly dominating public and academic debate on tobacco control, the global e-cigarette market is minuscule compared to traditional tobacco products. Euromonitor estimates that the global e-cigarette market was worth US$3 billion in 2013.

Compare this to the global tobacco market, one of the most valuable fast moving consumer goods industries, worth an estimated US$800 billion – more than 260 times the size of the e-cigarette market. This highly profitable tobacco market, outside of China, is dominated and controlled by just five major players: Japan Tobacco International, Imperial Tobacco, British American Tobacco, Philip Morris International, and Altria/Philip Morris USA.

All the major global tobacco companies now have a stake in the e-cigarette market, with most buying up independent e-cigarette companies.

Philip Morris International, known as PMI, has taken it a step further: in addition to recently purchasing UK e-cigarette company Nicocigs Ltd, it will be launching the Marlboro HeatStick. Unlike e-cigs, which vapourise liquid nicotine, the HeatStick takes normal tobacco and heats it to 350 degrees Celsius to create a tobacco vapour.

PMI plans to introduce the Marlboro HeatStick in test markets in Japan and Italy later this year. Similar sorts of products were introduced in the 1990s, but failed dismally when smokers rejected both the taste and lack of smoking satisfaction. PMI appears hopeful this latest generation of heat technology will be more acceptable to smokers.

On the surface, it might look like the tobacco industry is simply buying up these companies before they become a major threat to its profits. Or even, that it sees a bright future for e-cigarettes and wants to control the market.

But considering just how much more profitable traditional cigarettes are than e-cigarettes, and the tobacco industry’s long and chequered corporate history, it’s important to question what other motivations they might have.

Tobacco advertising on television is nearly universally banned, the tobacco-friendly states of Indonesia and Zimbabwe being two holdouts. It has been decades since a tobacco ad appeared on television screens in the United States and United Kingdom. But e-cigarette marketing is a booming business in both countries with controversial television ad campaigns and celebrity endorsements.

Using celebrities, sex, glamour, adventure, rebelliousness, youth and beauty to sell addictive products is very familiar territory for the tobacco industry. These sorts of campaigns contradict the tobacco industry’s pubic relations message that it is only interested in selling e-cigarettes to adults who are unable to quit smoking.

Add to the fact that PMI can no longer show packs of Marlboro on store shelves or splash the iconic red Marlboro chevron on Formula One cars, it can promote the US$69 billion Marlboro brand by putting it on the HeatStick product.

E-cigarettes could also help the tobacco industry undo the effects of policies that have seen cigarettes pushed out of social settings that kept people smoking. While smoking bans are principally about protecting people, especially workers, from secondhand smoke, they have an additional positive benefit of reducing smoking rates.

Pushing to allow e-cigarette use in pubs and restaurants means there is no need to quit, because when you can’t smoke, simply use an e-cigarette instead. But, don’t forget to keep smoking the real stuff when you can too.

Since acquiring e-cigarette brands, not one tobacco company has stepped out of the way of tobacco control policy makers working to reduce smoking. The industry has not raised a white flag and agreed to no longer oppose effective tobacco control policy reform.

It is business as usual: oppose, lobby and litigate when countries implement laws that impact on cigarette sales. Which is why the global treaty to reduce tobacco use, the World Health Organization’s Framework Convention on Tobacco Control, is explicit in banning tobacco industry influence in tobacco control policy. Finding a “fundamental and irreconcilable conflict of interest” between the industry and public health means the industry is not a welcome stakeholder in formulating public health policy.

E-cigarettes are a potentially useful tool in giving the tobacco industry a seat back at the policy table. If it can point to e-cigarettes as “proof” it cares about consumers and is working to reduce tobacco harms, then perhaps it will no longer be shut out of the regulatory process. No matter that e-cigarettes are a tiny portion of its total business.

And finally, e-cigarettes are a huge distraction to tobacco control advocates and policy makers. No doubt the tobacco industry celebrates witnessing the debate and division among tobacco control colleagues over the utility of e-cigarettes in reducing the harms of tobacco use. The less attention paid to the deadly US$800 billion arm of the business the better.

Vaping could be a trojan horse for real cigarettes

Posted January 1st, 2016 in News by Steve

The American Surgeon General published the first federal government report linking smoking and ill health 50 years ago. The report also demanded that the American government take appropriate remedial action to reduce the harm caused by smoking.

Since then the percentage of Americans who light up has fallen from 42% to 18% and in some states the percentage of regular smokers can almost be counted in single figures. Similar reductions have occurred elsewhere. Almost half the UK population smoked in 1974. Now, less than a quarter do. The figures in Australia are even healthier.

This is very good news because smoking causes a number of different diseases and is the primary cause of preventable deaths in many countries. Indeed, smoking may have killed as many as 100m people in the 20th century and the World Health Organisation estimates that the figure for the 21st century could be a mind-boggling 1 billion.

About 50 years ago another significant “smoking related” event happened: the first e-cigarette was patented. This was a device that produced vapour from tobacco without combustion. For many decades “vaping” remained a minority activity. But over the past few years these not-quite-so newfangled nicotine delivery devices have become rather popular. And concern has been raised over their use and particularly uptake among young people. While figures from Ash suggest a negligible number of e-cig smokers, a recent US-based study found that the proportion of middle and high school students in America who had ever used an e-cigarette more than doubled between 2011-2012. Some analysts have even predicted that vaping may become more popular than smoking within a decade.

Modern e-cigarettes are battery-powered devices that vaporise nicotine for inhalation. They normally consist of a cartridge containing liquid nicotine and a heating element designed to produce an aerosol. Many also include flavourings like menthol – a fact which has been criticised on the grounds that flavourings may make e-cigarettes more appealing to children.

Although vaping (and passive vaping) may well be safer than smoking (and passive smoking) a number of toxicological analyses have shown that e-cigarettes contain many dangerous chemicals. The good news is that e-cigarettes are primarily used by people as a popular smoking cessation aid. But it’s far from clear how effective e-cigarettes are in helping people to quit smoking in the long term. More worryingly, some studies have shown that a number of “never smokers” have tried vaping. This is of particular concern because e-cigarettes could act as a “gateway drug” to conventional cigarettes.

The relative lack of evidence about the safety, effectiveness and ultimate impact of e-cigarettes has led to the adoption of radically different approaches to the import, production, sale, distribution and advertising of these devices. Some countries, such as Argentina, effectively prohibited them. But most jurisdictions allow e-cigarettes to be sold and consumed subject to varying degrees of regulation. The EU, for example, has taken a relatively hard line, but it is unclear at this stage what impact these new rules will have.

Ethically speaking, it would seem wise to be wary. E-cigarettes may not represent a modern day Trojan horse, but the recent interest shown by tobacco companies in these devices should give us all pause for thought. This does not mean that vaping should be entirely proscribed. Quite aside from the fact that our liberty rights dictate otherwise, there is, as noted above, good reason to think that e-cigarettes are less dangerous than regular cigarettes and so the net impact on health (and longevity) may well be positive.

But given the serious risk that vaping might re-glamourise smoking, especially amongst the young, a cautious regulatory approach is warranted. This should include a ban on the sale of e-cigarettes to children and a New York City-style ban on vaping in public indoor spaces and private office buildings. It also seems eminently sensible to put in place regulations to ensure that the marketing of e-cigarettes is restricted to current smokers.

Many will complain that too many restrictions on the sale and consumption will be counter-productive. Some experts have even claimed that quality control regulation is, more or less, all that is needed, and that vaping might make smoking redundant. But this approach seems overly lax. After all, there’s (usually) no vapour without fire.

E-cigarettes are too good to quit, but not for under 18s

Posted December 25th, 2015 in News by Steve

The sale of e-cigarettes to under 18s is to be banned under new legislation, which will also see adults prohibited from buying cigarettes to then give or sell to youngsters.

Current evidence suggests that very few youngsters buy e-cigarettes, so some might wonder why it is happening. But it is a sensible precaution in order to prevent problems in the future. The problem is not so much about the harm to health from e-cigarettes themselves but a theoretical risk that adolescents might start using e-cigarettes and then go on to tobacco.

E-cigarettes have become very popular in many countries around the world and in Britain there are an estimated 1.5m users – the vast majority of whom are smokers or ex-smokers trying to stop or cut down on smoking. The prevalence of e-cigarette use in adults who have never smoked regularly is around 0.5%. And according to a report by anti-smoking group ASH, youngsters who used e-cigarettes were those who had already tried smoking.

Help quitting

E-cigarettes have spurred debate but there is reason to believe that e-cigarettes can help smokers to stop smoking who have not succeeded by other methods; and even if users carry on with them indefinitely, they are much safer than smoking. This is because they deliver nicotine but not the other toxins and poisonous gases produced when tobacco is burned.

And while nicotine is addictive – the reasoning behind the under 18s ban – it is not the main cause of smoking-related diseases.

E-cigarettes also vary quite considerably in the quality of manufacture and their ability to deliver nicotine. There is a large and enthusiastic community of “vapers” and visiting a few of their websites should provide useful information about which brands are worth trying and how best to use them.

Switching from tobacco

The opportunity provided by e-cigarettes to save millions of lives by getting to switch from tobacco is something I don’t think we can pass up.

But there are two areas of concern about e-cigarettes that seem to me to be legitimate. One is that they may be marketed in a way that blurs the boundaries with smoking so we end up with more rather than fewer smokers. The other is that many smokers might turn to these products when they would have been better off using one of the existing methods to quit which can be highly successful.

Both of these concerns can probably be addressed. Marketing could be highly regulated; and more could be done to ensure that smokers are aware of all the options available for stopping, as well as the evidence supporting them.

Spotless Leopards? Decoding Hype on E-Cigarettes

Posted December 17th, 2015 in News by Steve

E-cigarettes are the latest innovation in nicotine delivery products to fly the harm-reduction flag. They follow the massive failures of cigarette filters. Over decades, filters falsely reassured millions of smokers that they were reducing their exposure to harm and so could keep smoking.

We also had the lights and milds fiasco – which saw 80% of Australian smokers select those misleadingly labelled brands, which the ACCC outlawed from 2005 as a consumer fraud.

Along the way we saw reduced carcinogen brands and even asbestos filtered cigarettes.

There was massive publicity about harm reduction from filters and low tar, and massive consumer uptake, but not a blip in the incidence of tobacco caused disease in those who still smoked.

Thanks to harm-reduction arguments, countless smokers continued smoking who might otherwise have quit. The tobacco industry drove these arguments and was supported by many in public health who innocently thought they were no-brainers. Nigel Gray, a giant of global tobacco control, later admitted that the decades-long, well-intentioned low-tar harm-reduction policy was a disaster.

Meanwhile, we continued with the core policies of trying to prevent uptake, encourage quit attempts and denormalise smoking via smoke-free policies to protect non-smokers. Together, these objectives have delivered Australia the lowest smoking prevalence in the world.

For 35 years since the early 1980s, we have seen continually falling incidence rates of tobacco-caused disease. Female lung cancer seems likely to never reach even half the peak we saw in males. Awkwardly for some, Australia has become a world leader in reducing smoking without any mass cessation clinic network or major embrace of e-cigarettes.

Today, demands are being made to rush in soft-touch regulation to allow e-cigarettes to be manufactured, flavoured, promoted and used virtually without restriction.

This is all being done on the shoulders of an argument that insists that after 50 years of tobacco control, there remain many smokers who can’t or don’t want to give up their nicotine dependence, and that in just a few years, sufficient evidence has already accumulated to show that e-cigarettes are both benign and great for cessation.

But the “can’t quit” argument has received remarkably little critical interrogation. We know that hundreds of millions of often heavily dependent smokers have quit since the early 1960s, most without any assistance at all.

We know that today’s smokers smoke fewer cigarettes per day than at any time in the past, exactly the opposite of what the hardening hypothesis would predict.

The demands of the “we don’t want to quit/we love nicotine” vaping activists for unregulated access to e-cigarettes and to use them without restrictions must be balanced against the risks of what these demands might mean for population-wide progress toward the goal of keeping smoking heading south.

Comprehensive tobacco control is not just about the preferences of vapers. It is most importantly about continuing to starve the tobacco industry of new recruits and ensure that smoking is made history.

If we think of e-cigarettes as a transformative genie in a bottle, we need to think very carefully before letting it out, because putting genies back in their bottles is much more difficult than impulsively letting them out. If they prove to be benevolent, all’s good. But if they bring false hopes and keep many people smoking, we may be looking at the early days of a third major false god of tobacco harm reduction.

That genie is well out of the bottle in England and the United States, and other countries need to watch what is happening there very closely.

Today, I want to examine four cornerstones of the public health case being megaphoned for e-cigarettes.

1. E-cigarettes are benign and the risks of nicotine are “like drinking coffee or something …”

No one sensible makes the argument that e-cigarettes are likely be even remotely as harmful as smoking.

The 2015 Public Health England report endorsed the “95% less harmful” than smoking estimate. They took this from a consensus report authored by 12 people. Six of these were subsequent signatories to the 53 signature letter to Dr Margaret Chan at the WHO calling for minimal regulation. Six had no research track record or experience in tobacco control whatsoever. Two had financial ties to the tobacco or e-cigarette industries (see here and here).

There is no transparency about how this group was selected. But this was plainly not a group which was ever likely produce a consensus that was anything but glowing about e-cigarettes.

But let’s assume they may have been in the risk comparison ballpark. If e-cigarettes are 5% as harmful, then we would only see 300,000 deaths a year globally from e-cigarettes, instead of six million if every smoker switched.

On present trends, (England’s Robert West suggests e-cigarette growth may have already plateaued in England) that scenario is as likely as pigs flying.

A far more likely scenario – as I will argue – is one that sees a continuing stream of smokers quitting mostly unaided as they always have; significant numbers attributing their quitting to e-cigarettes; but a slowing in overall quit attempts as many dual-using vaping smokers keep smoking at reduced rates, in the erroneous belief that they are reducing harm.

The quality of evidence we have for declaring e-cigarettes to be benign has been described in another review as very poor. A 2014 review concluded:

Due to many methodological problems, severe conflicts of interest, the relatively few and often small studies, the inconsistencies and contradictions in results, and the lack of long-term follow-up, no firm conclusions can be drawn on the safety of ECs [e-cigarettes]. However, they can hardly be considered harmless.

This review was not even referenced in the Public Health England review.

The health problems caused by tobacco develop over decades. Every year will bring us more and more information about what the consequences of the typical daily vaper inhaling nicotine, propylene glycol, and an unregulated cocktail of fine and ultra fine particles like flavouring agents approved for ingestion in foods but not for inhalation an average 120 times a day (43,800 times a year).

We will also see what the International Agency for Research in Cancer has to say about whether nicotine is carcinogenic, having declared in 2014 its assessment to be one of its priorities.

2. How good are e-cigarettes for smoking cessation?

Earlier this year, a paper co-authored by five of England’s best tobacco control researchers, including Robert West and Ann McNeill, reported the world’s first prospective cohort data on the question of quitting via vaping versus other methods.

Their data are of great importance because by distinguishing daily from non-daily vapers, they allow the differentiation of casual and experimental users from daily users. Their study also provides data on outcomes 12 months later.

The paper commenced by noting that:

Smoking prevalence in England has been declining from 20% in 2012 to 18.4% in 2014, and in 2014 smoking cessation rates were the highest since at least 2008. This simultaneous increase in e-cigarette use and cessation may be coincidental, and it is therefore vitally important for longitudinal studies to be conducted to assess the impact of e-cigarette usage on quitting behaviour.

So what did the study find?

Daily use of e-cigarettes while smoking appears to be associated with subsequent increases in rates of attempting to stop smoking and reducing smoking, but not with smoking cessation. Non-daily use of e-cigarettes while smoking does not appear to be associated with cessation attempts, cessation or reduced smoking.

A companion paper broke down the data further by type of e-cigarette product. Daily tank system users were the only group which showed a significant improvement in smoking cessation.

But of 1,643 smokers followed up at 12 months, only 69 – just 4.2% – were daily tank vapers at 12 months. And just over one in four of these – only nineteen or 1.2% of the total sample – had quit. This is hardly the stuff of revolutionary dreams for population-wide cessation!

In addition to the Ann McNeill-led studies I just mentioned, Robert West’s group’s Smoking Toolkit study has been monitoring tobacco use in England every month since 2007, including e-cigarettes since 2011.

While the McNeill group has reported that 2014 smoking cessation rates were the highest since at least 2008, the latest data from August in the Smoking Toolkit study show the lowest percentage of English smokers trying to quit since 2007 (31.6% down from a high of 42.5% in 2007).

These two data sets thus appear to show quite different, perhaps incompatible results about the proportion of smokers making cessation attempts and actual cessation. Greater clarity on this key issue is badly needed.

In August, the English Smoking Toolkit study reported that the large majority (over 80%) of e-cigarette users are dual users: they also continue to smoke.

Many vaping advocates downplay this gigantic elephant in the room with fingers-crossed optimism that dual use should always be seen as just a transitory phase that smokers go through before they quit smoking. As I will argue soon, the tobacco industry has other ideas about this.

So putting these studies together for England – “e-cigarette central” – where, in plain language, are we today?

  • Non-daily vaping has no impact on cutting down or quitting.
  • Daily vapers make more quit attempts than non-vaping smokers.
  • But they don’t succeed any better than those who don’t vape.
  • Daily tank vapers do better at quitting, but the numbers involved are very small.
  • 80-90% of vapers are dual users.

And while this has been happening, the English Toolkit study reports that:

  • Quit attempts among English smokers at large are at the lowest level since 2007.

3. Do vaping smokers cut back more than non-vaping smokers?

The Brose et al paper from England reported that at 12 months, 13.9% of daily e-cigarette users reduced cigarette smoking substantially.

But let’s turn the last figure around.

Even among those smokers who vaped daily, 86.1% did not even cut back smoking substantially. That’s how good e-cigarettes are at just reducing smoking. They are far less successful, for example, than workplace smoking bans, where we see 20% reductionsfrom reduced smoking opportunities.

I’m sure you’ll agree that all the Big Tobacco companies now selling both cigarettes and e-cigarettes must be simply mortified by this news.

4. But does reducing daily smoking substantially (>50%) reduce deaths from smoking caused disease?

Let’s suppose that most daily, sustained vapers did cut back substantially (which they don’t), would this be harm reducing?

We’ve known for decades that three synergistic variables (age of smoking onset, amount smoked and duration of smoking) are critical in predicting mortality from smoking. There is a dose-response relationship that no one disputes here: those who smoke more are more likely to die from their smoking than those who smoke less.

From this, it’s understandable that many smokers believe that, just as they know water to be wet, cutting down the number of cigarettes they smoke will reduce their harm.

But this is quite a different claim. The epidemiological data on lifetime risk is about total pack years and does not consider the question of whether the cumulative risks of smoking can be “reverse engineered” by reducing.

But there is large-scale research on this and it is not good news for the “cutting down obviously reduces risk” dogma. Four cohort studies published since 2006 have reported on whether reducing smoking, as opposed to stopping smoking altogether, confers any mortality benefit.

A Norwegian cohort of 51,210 people followed from the 1970s until 2003 found:

no evidence that smokers who cut down their daily cigarette consumption by >50% reduce their risk of premature death significantly.

A Scottish study of two cohorts followed from the 1970s to 2010 also found no evidence of reduced mortality in reducers, but clear evidence in quitters. It concluded that:

reducing cigarette consumption should not be promoted as a means of reducing mortality.

The largest study, from Korea involving nearly half a million men followed for 11 years, found no association between smoking reduction and all cancer risk but a significant decrease in risk of lung cancer, but with the size of risk reduction being “disproportionately smaller than expected”.

Vapers who keep on smoking – which is most of them – are fooling themselves if they think they are seriously reducing risk.

I now turn to the future of vaping. “Think of the children!” is a common sarcastic slur made daily by vaping activists across social media. These self-absorbed misanthropes, today’s WC Fields clones in their disdain for children, could not care less about the implications of e-cigarettes for teenagers.

All they care about is their unhindered access to unregulated vape gear and their rights to vape anywhere: in workplaces, next to you on planes, and presumably while driving the school bus, inside child care centres and hospitals.

They want access to flavours like Gummy Bear and Bubble Gum that would cause a riot at a three-year-old’s birthday party.

Vape is apparently so close to pure air that any restrictions are totally unwarranted.

In England, vaping by non-smoking kids is very uncommon. Nearly everyone thinks that is self-evidently a good thing.

But the same cannot be said about the United States where data from the US National Youth Tobacco Survey show that while cigarette smoking continues to fall ammong US teenagers, e-cigarette use has been dramatically increasing since 2011. It is now way ahead of cigarette smoking: there are now some 67% more middle and high school kids vaping than are smoking.

Apologists for teenage vaping actually try to argue that this is a good development! You see, all those teenage vapers would have been smoking were it not for e-cigarettes.

The small problem here is that this rise was not associated with a rise in dual or multiple tobacco or nicotine product use, and the decline in cigarette smoking had been falling before e-cigarettes arrived.

Some argue there is no problem in having tobacco- and nicotine-naïve youth taking up e-cigarettes and becoming addicted to nicotine.

Others would prefer authorities, such as the US Surgeon General and the International Agency for Research in Cancer, not vape shop owners and industry spin merchants, to assure us there’s nothing to worry about with such uptake. But as yet they have not.

Nearly all businesses survive and flourish by retaining existing customers and critically, stimulating new customers to start. If you sell tractors or sheep dip chemicals, you will have little expectation of finding new customers who don’t own sheep or land where a tractor might be needed.

But if you are selling products which have potential to be used by more than those already using them, you are vitally interested in non-users. Cigarette and e-cigarettes fit that description perfectly.

Leopards don’t change their spots. For decades the tobacco industry told us – and still does – that it is not the least bit interested in teenage smoking. If BAT succeeds in getting its hands on the Cancer Council Victoria’s teen smoking data, we all can be assured that it will keep the contents strictly within its opposition to plain packs division and never show the data to its salivating “capturing new smokers and vapers” divisions.

The global e-cigarette market today is a mixture of big tobacco-owned brands and those owned by start-up incumbents. The tobacco industry is rapidly acquiring those minnows it regards as likely to be most profitable and strategic.

Wide-eyed vaping advocates would have us seriously believe that the tobacco industry, with its billions of dollars in assets and long history of acquisitions, will not somehow soon swallow up most of these just as it did small tobacco companies all over the world.

No tobacco company currently acquiring e-cigarette brands is desisting in any way from attacking effective tobacco control. Plain packs are being attacked. Every day BAT bleats on Twitter about how high tobacco tax – the most important plank in comprehensive tobacco control – is causing more illicit trade.

The message is clear: taxes should be lowered, to make smoking more affordable and to arrest brutal falls in smoking.

Quite obviously, this is not an industry which wants smokers to stop smoking. It’s an industry with a business plan to have smokers keep smoking and to also vape when they can’t smoke.

It is an industry that understands how to erode the nicotine consumption “downtime” caused by smoke-free policies that have badly reduced sales. And guess what? This is exactly what most smokers who vape are doing.

The concept of e-cigarettes being a “gateway” into smoking has been rightly criticised as being an imprecise and vague, often being little more than crude “after therefore because of” reasoning.

But glib dismissals of the rapid rise of teenage use in “kids just try stuff” throw-away lines ignores the many appeals of vaping to teenagers and the fact that youth smoking is the lowest on record. Increasingly, most kids don’t “just try” smoking.

A very useful model of how e-cigarettes may work as a catalyst for smoking has recently been published. The authors provide a causal hypotheses for the initiation of e-cigarette use and for the potential transition to tobacco smoking that highlights the combined factors of:

  • perceived negligible risk
  • attractive taste options
  • lower price
  • inconspicuous use
  • higher level of peer acceptance.

This model could stimulate important research into understanding e-cigarette uptake and any apparent transition to smoking.

We are well on track to see the end of the tobacco epidemic in this country. E-cigarettes may have a role in that. Time will tell. But there are major concerns about the core claims being made for e-cigarettes.

Australia should consider any policy changes in harm reduction very carefully. We should all be open to quality evidence that might suggest that this time we have something different. But equally, we do not want to repeat mistakes of the past.

Do E-Cigarettes Really Not Have Any Secondhand Effects? Three Common Myths Busted

Posted December 16th, 2015 in News by Steve

In the past few years, e-cigarette use has exploded in the United States, with sales more than doubling annually. It’s expected that by 2017, the e-cigarette industry will be worth over $10 billion a year, and by 2021, e-cigarettes will take over the tobacco market with more sales than traditional cigarettes.

Their popularity stems from their deliverance of addictive nicotine without the other effects of traditional smoking. But few medical debates attract the level of passion and venom as the current battle over e-cigarettes. A growing number of scientists and medical professionals are condemning e-cigarette use (or “vaping”), with opponents claiming that e-cigarettes are simply an avenue for increased nicotine addiction, pulling in teens and children with fruity flavors and ubiquitous advertising. On the other hand, proponents say that these battery-operated nicotine vaporizers are saving lives by providing an alternative to smoking, one of the most deadly habits a person can have.

With all of the opinions flying around, it can be hard to tease apart the facts from the rhetoric. Here are the most common myths about e-cigarettes so you can make your own informed decision.

Myth 1: E-cigarettes are completely safe.

Fact: E-cigarettes are less toxic than conventional cigarettes, but still pose health risks.

You may have seen the recent pronouncement from Public Health England stating that e-cigarettes are “95 percent safer” than conventional cigarettes. While some question the validity of the number, the fact is, e-cigarettes do produce fewer carcinogenic toxins than regular cigarettes — thus, yes, they are “safer” than smoking regular cigarettes.

But “safer” doesn’t mean “safe”: Studies have shown that e-cigarettes produce the same kinds of short-term changes in lung function as cigarettes, and there are no current evaluations of long-term effects from vaping. And more recently, a new study from found that e-cigarette flavorings contain compounds that are linked to lung disease. As one review concludes, “electronic cigarettes can hardly be considered harmless.”

Professionals are particularly concerned about the so-called safety of e-cigarette use by children and teens. In 2014, the National Youth Tobacco Survey found that, for the first time, e-cigarettes overtook cigarettes as the most commonly used tobacco product among middle (3.9 percent) and high school students (13.4 percent). Some suggest that this sudden uptick is a result of TV, radio, and Internet advertising, which glamorize vaping — commercials that would be illegal today for other tobacco products. And while e-cigarettes might have fewer carcinogens than regular cigarettes, they still contain nicotine, which can impair brain development and cause mood disorders in adolescents.

Myth 2: E-cigarettes only emit water vapor, eliminating the dangers of secondhand smoke exposure.

Fact: E-cigarettes produce fewer toxic compounds, but the same amount of fine particles as conventional cigarettes.

Many people believe that e-cigarettes produce nothing that could lead to secondhand effects. The manufacturers are particularly to blame for this myth, as some still make the claim on their websites that their products only produce “harmless water vapor.” But research has shown that e-cigarettes, though “smokeless,” do produce potentially harmful vapors — just not to the same degree as regular cigarettes.

For example, a recent study found that while e-cigarettes produce less nicotine or other toxic compounds than traditional cigarettes, they produce the same amount of ultrafine particles that can become embedded in lung tissue and lead to respiratory problems. And vapors released from e-cigarettes are definitely harmful secondhand. So again, it’s a matter of degree — vaping is better than smoking, but the best thing for your body and those around you would be neither.

Myth 3: E-cigarettes are the most effective way to quit smoking.

Fact: Study results are mixed, with studies finding e-cigarette use reduces likelihood of quitting and may even lead to tobacco use.

One of the most hotly debated facets of e-cigarettes is whether they live up to claims that they help smokers quit. The World Health Organization estimates that smoking is responsible for almost 9 percent of all deaths worldwide, not to mention health care costs or reduced quality of life. Every cigarette costs the smoker 11 minutes of life, scientists say. So if e-cigarettes really do meaningfully reduce smoking, then they absolutely have life-saving potential.

But many argue that such claims are exaggerated or even false, and instead, that e-cigarettes are leading people — particularly teens — to smoke more. Critics of e-cigarettes are quick to point out that the electronic versions are not subject to the same advertising, flavoring, or sales restrictions as conventional nicotine products. They argue that money, rather than public health, is the main motivation of e-cigarette producers: “By moving into the e-cigarette market, the tobacco industry is only maintaining its predatory practices and increasing profits,” write medical and public health authorities in a letter to the World Health Organization Director-General Margaret Chan.

So what does the science say? Unfortunately, results to date are inconclusive. Some studies suggest that e-cigarettes might help smokers quit. For example, one study found e-cigarettes were more effective than other smoking-cessation aides. But another study found that while e-cigarette smokers were more likely to stay away from regular cigarettes, adding e-cigarettes on top of smoking didn’t reduce their bad habits. And other studies have found that e-cigarette use actually decreases a smoker’s likelihood of quitting. The evidence is all over the place. While that doesn’t mean e-cigarettes are useless, it does call into question the notion that they’re a quitting panacea.

But more troubling are recent studies that seem to bolster critics’ fears that vaping may even increase cigarette smoking, especially in adolescents. Studies are finding that students who’ve never used tobacco products regularly use e-cigarettes. And a study in the Journal of the American Medical Association found that ninth graders who had used e-cigarettes were more likely to start smoking within the next year. Similarly, a study of college smokers found that those which tried e-cigarettes didn’t reduce their habit, and instead, were more likely to continue smoking than those that didn’t.

The ultimate question becomes whether e-cigarettes should be regulated with the same laws as regular cigarettes. So far, governments seem to be leaning toward more stringent legislation, though current laws are still much more relaxed (there are even states where it is legal for minors to by e-cigarettes). One option is to list and regulate e-cigarettes as a medicine, like nicotine patches or other stop-smoking aides.

As for your health, e-cigarettes are better than smoking, but that’s a pretty low bar. The best thing for you and those around you is to kick nicotine for good.