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Dual Use

Summary
An examination of the issues surrounding dual-use of ecigs and cigarettes, and whether it can be regarded as a positive or negative for individual or public health. The clear conclusion is that dual-use is the single most successful route to smoking cessation today.


E-cigarette use is, by definition, dual-use: only a minority of smokers quit smoking immediately they try vaping.

There would be very little ecig use at all without dual-use. Therefore - QED - dual-use cannot overall be a bad thing as it is almost exclusively the route to complete substitution (replacement of cigarettes by a nebuliser), or in some cases total cessation.

In the UK, because the number of smokers grew steadily since smoking prevalence reduction ceased in 2008, then started to fall at the end of 2013, and by 2014 smoking prevalence was clearly falling at a rate equivalent to the number of smokers who quit via ecigs, we know beyond any doubt that vaping is the primary route to smoking cessation in the UK. The vast majority of ecig use is dual-use with cigarettes, as the median time-to-quit is measured in months not minutes. (We don't know what this average time period is because little research of any real value is carried out; the majority of 'research' connected with vaping is junk science produced for rival commercial funders in order to try to restrict access to vaping products.)

Therefore, it is abundantly clear that dual-use is now the primary mechanism by which smoking prevalence in the UK is reduced.

Perhaps it might be considered that extended dual-use is a negative outcome. In order for this to have any validity, we need to look at exactly what any negatives might be, and if any are found, then exactly how long is 'too long'.

The three dual-use outcomes

Use of ecigs (EV or electric/electronic vapouriser use, hereinafter) concurrent with smoking (dual-use) will lead to one of three possible outcomes:

  1. Smoking cessation
  2. Reduction in smoking
  3. Failure and relapse to smoking


1. Smoking cessation
If EV use leads to permanent cessation of smoking, either by (a) permanent use of an EV or (b) by eventual total cessation, this is a clear benefit to individual and public health. In practical terms there is little difference between the two outcomes because:

  • Currently, EV use cannot be classed as more hazardous than coffee consumption, so that a transition to exclusive, ongoing EV use has no quantifiable negative health impact at this time. There is no 'too long'.
  • If nicotine consumption is considered an issue for some reason, then there would need to be some clinical evidence that extended pure nicotine consumption has on average any health impact apart from benefits; there is none.
  • Vapers routinely reduce the amount of nicotine consumed, over time, in any case.

No morbidity is caused by vaping, and there is no elevation of risk measurable at this time. On the other hand, quantifiable benefit occurs in the form of (a) removal of risk from smoking, (b) improvement of quality of life, as the vaper is happier (than if not smoking or vaping), and (c) supplementation of dietary nicotine has obvious benefits for many while having no negative clinical significance.


2. Reduction in smoking
A reduction in smoking must create a benefit, unless there is no difference in health outcomes between smoking 1 cigarette a day and smoking 40 cigarettes a day. There has been much argument about this issue, but logic dictates that the less smoked, the better. If the benefit is hard to quantify statistically then perhaps the issue lies more with the power of the statistics than with the basic issue: otherwise there would be no point in smoking less, and smokers might as well smoke 60 a day. This is clearly ridiculous.

NICE for example state that smoking less = harm reduction (see NICE PH45). We might quibble about the exact definition of 'harm reduction' here, or whether other methods might be more efficient; but the takeaway is that, officially, smoking less is beneficial to health. UK doctors can tell patients, with official blessing, that smoking less is beneficial to health. Indeed, doctors are officially instructed to tell patients this.

In dual use, any vaping at all must translate into less smoking. The more vaping the better and the less smoking the better. Added to this we already know that EV use is unique among smoking substitution products (including NRTs) because there is an unmotivated vaping-increase / smoking-decrease effect seen nowhere else: people unintentionally vape more and smoke less; and this can even lead to unintentional quitting. As long as the right products are selected - which is usually related to unhindered access plus expert mentoring - it seems as if vaping may be subconsciously preferred, at least by some smokers, and it increases at the expense of smoking. This effect is unintentional and is probably unique (and is certainly unrecognised in smoking cessation practice, never mind explained).

Therefore we need to factor in these two unique effects of vaping, unseen with any other cessation strategy:

  • Vaping (and by definition, dual-use) can lead to unintentional smoking cessation.
  • There is a tendency to vape more and smoke less, which appears to be unintentional even in inveterate smokers, and requires dual-use by definition.

A proportion of vapers will totally quit (quit smoking via vaping, then quit vaping), and the route to this is dual-use by definition - since few smokers quit on Day 1 of vaping. In addition, as noted above, the transition can be involuntary: smokers vape more and then quit.

Thus, dual-use leads to smoking cessation and may lead to total cessation.


3. Relapse to smoking
Some prospective vapers fail and relapse to smoking. This can occur at any point: it can happen in Week 1 or Week 12. The longer a person continues with vaping, the more successful it is likely to be: a graph could probably be drawn that shows relapse rates decreasing over time, with high rates at first, and low relapse rates after 6 months. This tends to mirror what normally happens with smoking cessation quit rates, although the mechanism may be different.

Potential negatives with dual use

It has been suggested that dual-use may lead to failure to quit:
a. Permanent failure to quit: continuation of smoking
b. Relapse to exclusive smoking and failure to ever quit
 

a. Continuation
If a smoker continues to dual-use and never transitions to exclusive vaping or relapses to exclusive smoking, is this a negative in any way? And does this happen in significant numbers?

It is very likely that every ecig usage session replaces a cigarette smoked. A claim has been made that each cigarette reduces expected lifespan by 11 minutes, but a similar claim can hardly be made for ecig use, so there appears to be a benefit to extended use per se.

Currently we are not aware of large numbers of dual-users who have stayed as such for several years, and surveys do not currently appear to have the power to measure such figures. It is worth noting that transitioning to exclusive EV use can certainly take up to a year, particularly in the case of a smoker who has no intention of quitting. Indeed this is one of the features of the EV: it can cause smokers to quit who had no intention of ever doing so - but this may well take time. Extended dual-use is the pathway to eventual smoking cessation for smokers who have no intention of quitting. They may have originally intended to use an ecig in situations where they could not smoke; but, for smokers exposed to the correct product choice for the individual, the EV 'grows on you' and can lead to involuntary cessation.

We have to hope that eventually the dual-user encounters a mentor who will be able to assist them to locate a better solution, since extended dual-use is directly connected to poor product choice or usage; it represents a failure of the specific vaping solution chosen to work properly. This is one area where the large and dedicated EV user community have a role to play: online support is very effective via forums and social media.

Is a smoker who vapes more likely to encounter an experienced vaping advisor than an exclusive smoker? Quite possibly. A simple scenario for example is that a smoker may only be aware of the existence of first-generation products (mini ecigs or 'cigalikes') since they are the type widely advertised and available. These products are well-known to be inefficient, and ineffective in the long term, for most smokers. A smoker using one who encounters a more experienced vaper may well be offered the chance to try a far more efficient model and/or refill - and we know from the community that (a) this has occurred thousands of times, and (b) has led to thousands of smokers upgrading successfully to better products. This is far less likely to occur for a smoker since many vapers do not freely offer advice on vaping to smokers; but they may well do so if encountering a beginner-vaper using a mini ecig.


b. Relapse to exclusive smoking and failure to ever quit
Relapse is certainly an expected outcome. A percentage of vapers will eventually fail and relapse to exclusive smoking. In fact this will be the majority, under normal conditions - since it requires good advice (mentoring) to achieve good success rates, as anyone familiar with traditional smoking cessation practice will know. Ecigs are not a magic bullet that somehow evades all norms and succeeds where everything else fails: it is simply the best answer so far, but no more than that. Smoking is addictive (very much so for some), and suggesting that the simple provision of an alternative will fix that is not being realistic - especially where the solution is complex and highly dependent on free consumer choice and good advice (or luck) in order for a successful outcome, as is the case with vaping.

There are thousands of choices but only a few of them will work well for any given individual. There is absolutely no single-choice solution.

Therefore in a climate where the least efficient and effective products are the norm (minis), where no mentoring is likely to be available, where true and realistic advertising is prohibited, where the facts are suppressed, and where spurious counter-arguments are given prominence, then it is obvious that most prospective vapers will fail and revert to smoking. This is inarguable.

The critical factor is always mentoring, that is to say good advice that is available on an ongoing basis. The first thing this advice will lead to is correct user technique, which is very different from smoking (as using an electronic nebuliser has little or no relationship to smoking). The second thing it will provide is a much improved route to product choice - which is everything, in vaping. Unfortunately, such advice can only be provided by family members, friends or work colleagues - so in an environment where there are few vapers, or where they are artificially restricted from vaping openly, mentoring will be limited in availability.

Over time this will change simply as EV use grows by natural progression: once the genie is out of the bottle it cannot be put back in, and use will grow. This means the availability of mentoring will grow. This means EV use will grow more. This means EV users will become more expert. This means EV use will grow more as there is a feedback loop that leads eventually to conversion of the maximum number of smokers (limited by other factors). It means the sight of vapers, opportunity for vaping, resistance to corrupt laws designed to force people to smoke, and the number of potential mentors, will all grow.

In a climate where EV use grows significantly every year, products improve every year, access to better products improves every year, the quality of advice potentially offered by mentors improves every year: then the result is smoking prevalence shrinks every year, and vaping gradually replaces smoking. It then becomes clear that concerns about non-conversions of smokers leading to never-quitting are not valid. This is confirmed by the Swedish experience: male smoking will not exist soon (male smoking prevalence falls at 1% per year, has done so since 2003, and will be just 5% by 2016). If no one is smoking then all hypothetical concerns are revealed as without substance (and almost certainly agenda-based).

Note that Snus is mostly used by men, so that the effects are easy to confirm since they are not seen in the female population, who are - uniquely - by far the greater smokers now. Sweden is the only country in the world where smoking has any realistic chance of being removed, at least for men, in the foreseeable future; and where the female population are the greater percentage of smokers (and a very much greater percentage). Smoking is a female pursuit in Sweden due to the free availability of a THR product that appeals mostly to men; perhaps we will even see female smoking reduced there by a 'drag-down' effect, as very few Swedish men will be smokers in the near future.

It is absolutely clear that, in Sweden, all the arguments why THR potentially may not work, or may potentially be a bad idea, are utterly worthless: when hardly anyone is smoking any longer and all the smoking-related mortality and morbidity figures have fallen through the floor, this is obvious. The same thing will be shown soon enough in countries where EVs are freely available without hindrance (if there is to be such a thing). Or, where the black market successfully evades laws implemented by commercial rivals and monopolists, designed to severely restrict EVs and limit their manufacture and distribution in order to protect the smoking economy.

Hard statistics on dual-use

We therefore know that dual-use is a very good thing: it leads to reduction in smoking, smoking cessation, and total cessation. All these are a positive for the individual since (a) all have health benefits, and (b) they are voluntary and self-motivated positive choices, whichever is chosen.

What we do not currently know is the profile of dual-use over time: what is the percentage of smokers who remain permanent dual-users (if any); what is the average time point to failure and relapse to smoking; what is the average time point at which smoking cessation occurs. Until we have better statistics, some things will remain hard to evaluate fully - though we do know the end results.

We now have an overall picture: the latest UK stats tell us that, in early 2014 when measured, about one-third of vapers had quit smoking. This figure is higher than had been expected and is extremely encouraging.
[Q2 2015 update: the latest figures show there are 2.6 million vapers in the UK, the number has grown by around 0.5m in the last year, and 1.1 million are now ex-smokers due to vaping; this is around 40% of all vapers and ex-vapers.]

Thus we can state with absolute accuracy that the new reductions in smoking prevalence that we can now expect every year, which has been static for so many years (since 2008 in fact), are due almost entirely to dual-use. This is an important concept to grasp, and is critical to correct evaluation of EV usage trajectories.
 

Dual-use is a very good thing. Indeed, it is probably the principal mechanism by which smoking (or even total) cessation occurs, at least in the UK: since smoking prevalence reduction stalled there in 2008 and remained so until EV use entered the picture, we can also state factually that dual-use is therefore exclusively responsible for virtually all current reduction in smoking in the UK, and will probably continue as the single most important factor in UK smoking cessation.

 

 


created 2014-05-27
update 2015-05-28