E-cigarette advocate Riccardo Polosa, along with pro-harm reduction colleagues from around the world, recently published Respiratory symptoms among e-cigarette users without an established smoking history in the VERITAS cohort. Their paper presents strong evidence that sole e-cigarette users (i.e., people who are not also smoking cigarettes) are significantly more likely to experience respiratory symptoms than nonsmokers who did not use e-cigarettes.
They base this on the Respiratory Symptom Evaluation Score developed by Juul and Juul contractor Pinney and Associates, that sums up how frequently respondents experienced (1) morning cough with phlegm or mucous; (2) cough frequently throughout the day; (3) shortness of breath that makes it difficult to do normal daily activities; (4) becoming easily winded during normal daily activities; and (5) wheezing or whistling in the chest at times when not exercising or doing other physically strenuous daily activities in the last 30 days.
In addition to finding statistically significantly more overall symptoms (p<0.001) in the vapers than the nonsmokers, Polosa and colleagues found significantly more frequent occurrence of for 4 or the 5 individual symptoms (all but number 3, shortness of breath; Table 2 of their paper).
As Polosa and colleagues note, this finding is important because most adults who use e-cigarettes currently or formerly smoke cigarettes, so it is important to investigate whether e-cigarettes adversely affect respiratory function in nonsmokers. Their positive finding of adverse respiratory effects of e-cigarettes in nonsmokers is an important contribution to the evidence base that e-cigarettes independently harm lungs.
Despite the fact that Polosa and colleagues state that, “Evidence for direct harms that are uniquely attributable to EC use is lacking,” the fact is that their findings of adverse respiratory effects of e-cigarettes in nonsmokers is not new. For example, our meta-analysis of the association between e-cigarette use and disease reported:
Studies of never smokers definitively exclude the possibility that [the increased odds of disease associated with e-cigarette use] is confounded by current or former smoking. Most (8/14) studies of asthma and 6/8 found significantly elevated [odds] associated with e-cigarette use among never smokers. Indeed, the pooled OR [odds ratio] for asthma (OR=1.49; 95% CI 1.30-1.77) and COPD: (2.29; 1.52-3.46) were higher than the estimates based on the entire sample, which included current and former smokers (asthma: 1.24; 1.19-1.30; COPD: 1.46; 1.31-1.61; Table 1). [citations dropped] [PubMed link]
Thus, the VERITAS results are consistent with the larger literature.
VERITAS is cross-sectional, internet-based survey conducted in Africa & Middle East, North America, Latin America & South America, Asia–Pacific, Western Europe, Eastern Europe.
Polosa and colleagues spend most of the paper minimizing the importance of the results
Rather than stressing the importance of the results and the consistency with the larger literature, Polosa and colleagues spend most of their paper dismissing their results on the grounds that the effect is not big enough to worry about and that the study uses cross-sectional data. Neither of these arguments is particularly compelling given the high level of confidence in the conclusion that vapers had different respiratory function than nonsmokers (p<0.001). Rather, they argue that magnitude of the degraded respiratory function did not reach Juul and Pinney’s “threshold for clinical significance.”
Of course, Juul has a strong interest in coming up with arguments for ignoring information showing adverse effects of e-cigarettes.
This work was supported by Global Action to End Smoking (formerly known as Foundation for Smoke-Free World), which has an established record of “producing tobacco industry-friendly research and opinion; obscuring industry involvement in science; funding third parties which denigrate science and scientists that may threaten industry profitability; and promoting tobacco industry credibility.”
Here is the abstract:
Prior research on e-cigarettes’ health impacts is inconclusive due to confounding by previous tobacco smoking. Studies of e-cigarette use among people without an established smoking history are informative for this question. A cross-sectional survey was administered across six geopolitical world regions to adults aged 18+ without a history of established cigarette smoking or regular use of other nicotine/tobacco products. Two cohorts were defined based on e-cigarette use: “Vapers Cohort” (N = 491) who used e-cigarettes in the past 7 days and “Control Cohort” (N = 247) who never regularly used e-cigarettes. Frequency of respiratory symptoms (Respiratory Symptom Evaluation Score (RSES)) were compared between cohorts, adjusting for sociodemographics. Tobacco use history and patterns of e-cigarette use was also examined. Respiratory symptoms were rare among both the Vapers and Control Cohorts: 83.3% and 88.4%, respectively, reported “rarely” or “never” experiencing all five RSES items (p = 0.125). The Vapers (vs. Control) Cohort reported modestly more frequent respiratory symptoms (adjusted mean RSES 1.61 vs. 1.43, respectively, p < 0.001); however, this difference (0.18) did not reach the threshold of clinical relevance (0.57). The Vapers (vs. Control) Cohort more often reported former cigarette experimentation (30.8% vs. 12.1%) and former infrequent use of other nicotine/tobacco products (18.1% vs. 5.8%). The Vapers Cohort most often used disposable devices (63.7%) and multiple flavors (approximately 70-80% across primary device type). In this cohort of adults without a history of established combustible tobacco use, e-cigarette use was statistically linked to more frequent respiratory symptoms, though not in a clinically meaningful way. The cross-sectional design of this study cannot establish causality between e-cigarette use and respiratory symptoms.
The full citation is: Goicoechea JZ, Boughner A, Lee JJC, Mahajan A, Yeo K, Sproga M, Russell C, Coughlan M, Selya A, Caci G, Caponnetto P, Tomaselli V, Polosa R. Respiratory symptoms among e-cigarette users without an established smoking history in the VERITAS cohort. Sci Rep. 2024 Nov 18;14(1):28549. doi: 10.1038/s41598-024-80221-8. PMID: 39558006; PMCID: PMC11574031. It is available here.
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