Category Archives: e-cigarettes

Paris children used as pawns in EU e-cigarette battle

(Thanks to Aaron Frazier who pointed the way to a post by Sylvain Filatriau).

A new study out of Paris is about as badly (falsely) titled as this post about it.

In the Open Journal of Respiratory Diseases, Dautzenberg et al. author a study called E-Cigarette: A New Tobacco Product for Schoolchildren in Paris. What I learned from this title was that 1. e-cigarettes are a tobacco product! and 2. e-cigarettes are produced for schoolchildren in Paris!


Actually, the article is a little more restrained than the title.

3409 Paris school children were asked “have you ever tried an e-cigarette?” Fair enough but this does not distinguish among those who tried one puff and handed it back and those who, if there were any, were daily users. The results as reported:

277 (8.1%) of the 3409 schoolchildren studied (including 575 non responders to this question) reported having had an experience with e-cigarette. Experimentation rate is 6.4% among the 12 – 14-year-old, 11.8% among the 15 – 16-year-old and 9% among the 17-year-old schoolchildren. Among the 12 – 14- year-old schoolchildren, 64.4% of e-cigarette experimentation was by non-smokers. Of the 17-year-old teenagers who had used e-cigarettes, 12.4% were non-smokers. For the whole population, 33.2% of those having tried e-cigarette are non-smoker, 22.7% occasional smoker, 3.6% ex-smoker and 40.4% daily smoker. Those who experiment cannabis, shisha or binge-drinking are more frequently users of e-cigarette.

What Dautzenberg et al. concluded from this was:

Conclusion: For teenager’s, e-cigarettes have become not a product to aid quit tobacco but a product for experimentation and initiation of cigarette use. Regulation is urgently needed to control the emergent use of this new tobacco product by children.

What I learned from this was that the authors were able to determine without any longitudinal arm in their study that the e-cigarette experimenters were going to end up as cigarette smokers. Again, wow!

But I have to question why any product would serve as a quitting aid for people who are not at the stage of life where they are quitting anything. And as for there being a link between using cannabis, shisha, binge drinking and e-cigarettes – the simplest observation could be summed up as “those kids who like to try some new things will try other new things”.

Concluding that regulation is required to limit the exposure of children to nicotine products is something that everyone pretty well agrees on and in many places this is either already the case. Where it is not actually on the books, most vendors restrict their sales to adults.

Overall though it is no surprise that experimentation of youth with e-cigarettes will grow as they gain popularity in general. Kids will try everything that is out there whether is it e-cigarettes, their parents’ Nicorette, or even their parents’ cars.

Successful harm reduction applies to experimentation too. Better that kids try something that is 99% safer instead of cigarettes. And if a child is going to take up smoking anyway, the earlier they switch to a safer product the better.

These experimentations do not justify limiting availability of the product to legitimate users. The state has no right interfering with my joy of drinking Scotch because some kid steals from their parent’s liquor cabinet or my nicotine because some child steals a cigarette from their older brother.

E-cigs and cruise ships: will a no always outweigh a yes?

Tip of the hat to Michael McFadden for drawing this to my attention.

Dick Puddlecote wrote a post about the changes in smoking policies on cruise ships which led Michael to this e-cigarette smoking policy from Princess Cruise Lines.

Electronic Cigarettes
The use of electronic cigarettes is permitted in all areas onboard with the exception of dining areas and the Princess Theater. However, should a fellow passenger in the vicinity feel inconvenienced and complain, even after being told the difference between electronic cigarettes and real cigarettes, we will ask the passenger to refrain from smoking the electronic cigarette.

Let’s just translate that into alcoholese:

The use of alcohol is permitted in all areas onboard with the exception of dining areas and the Princess Theater. However, should a fellow passenger in the vicinity feel inconvenienced and complain, even after being told the difference between a glass of water and a glass of vodka, we will ask the passenger to refrain from drinking the water.

In other words, being right or wrong is irrelevant when it comes to nicotine. Even worse, wrong and delusional is granted authority over right and real. And to compound matters, this judgement will encourage the complaining twit to further their behavior.

Ever since vaping appeared on the scene, there have been complaints from the anti-smoking brigade that because vaping looked like smoking it should not be permitted. Its not the first time they have gotten things exactly wrong.

It is precisely because it looks like smoking that vaping should be permitted. It educates the public and particularly smokers who have not heard about it yet.

Given the threat to so many vested interests, the absurd amount of money dependent on keeping smoking dominant (and thus supporting the tobacco and pharmaceutical industries, the anti-smoking groups, and the government revenues) this kind of reaction is no surprise and yet for so many of thus we naively expected that this would have been the great OMG moment in public health.

More Chicken Little from Alberta Action on Smoking and Health

Today in the Edmonton Journal (Flavoured products a blatant ploy to target youth, Alberta anti-tobacco group declares) Keith Gerein wrote

New survey results indicating large numbers of Alberta teenagers are hooked on flavoured tobacco products is evidence enough that the province should immediately ban the items, medical professionals and advocates said Tuesday.

The supposed source for this statement was Health Canada’s 2010-2011 Youth Smoking Survey. To wit

Among youth who had ever tried smoking a cigarette, 30% (about 218,000) had used at least one flavoured tobacco product in the last 30 days, compared to only 1% (about 29,000 ) of youth who had never tried smoking a cigarette.

In my lexicon hooked is not quite the same as having tried something once in the last 30 days. Nor does this seem to be much of a problem if only 1% of non smokers try them (again maybe no more than once in the last 30 days).

Since smokeless tobacco, which as most who read this blog know, is about 99% safer than smoking, you can argue that 1. anytime those people who would have smoked used smokeless instead it was a good thing and 2. there is a chance that someone who might otherwise have become a smoker gravitated towards smokeless instead and ended up with the much less harmful habit. Of course no one wants the kids do be doing any of this – these are toys for adults.

One real problem with this survey is that the flavoured tobacco category conflated smokeless tobacco with menthol cigarettes and flavoured cigars. Considering the vast harm differences between inhaling and not inhaling smoke it would be no different than having a category consisting of e-cigarettes and menthol cigarettes together.

I suspect that Gerein did not read the survey which would have lead to quite a different sort of headline since the findings are that smoking (and marijuana and other drug use, and alcohol use) declined for all the groups. Isn’t that headline worthy? We can’t tell about smokeless tobacco since this was the first time that use was polled.

The language throughout the article suggests it was cobbled together from a press release from Les Hagen given the antiquated but incendiary cliches the anti-nicotine groups like to use. “Fruity spit tobacco” leads off the old argument that tobacco companies are targetting youth through the use of flavours. I have always found the implication that adults don’t like flavours odd. Humans like flavoured products. In fact, one of the things a lot of adult smokers found quite attractive about e-cigarettes, and sealed the switch, was the variety of flavours.

According to the article the most commonly used flavoured tobacco product by Alberta youth were cigarrillos. This seems to occasion a ban on flavoured tobacco products in general (again lumping them with the vastly different smokeless products). The real worry then from a harm reduction perspective is that flavoured smokeless tobacco has been gaining popularity as an alternative for smokers, and as a cessation aid. As the case is with e-cigarettes, once you introduce an effective and satisfying alternative to smoking, if you then remove it, you are then encouraging people back into a riskier lifestyle choice.

If we are going to ban something, why not ban groups from using public money (money from you and me) to agitate for removing healthier alternatives from the market?

Finally, the Health Canada report found that almost all youth obtained their products through social sources. In other words these products are not being sold to minors. I worry that if kids start liking Pernod even if they all get it from their parents that high minders will argue that it should be removed from liquor stores.

On a lighter note, the SAIT student paper had a nice little article by Sarah Pynoo – Health Canada’s E-Cig restrictions deserve to go up in smoke.

As for the criticism that cigarettes could lead towards children and young adults getting hooked on actual cigarettes, it seems a bit silly. For one thing, while both regular cigarettes and e-cigarettes have a variety of flavours, both are only available with ID to those over 18. Also, it’s pretty hard to imagine a kid getting hooked on candy-flavoured, nicotine-free vapour, and switching over to the harsh, lung-burning alternative of an actual cigarette.

Health Canada’s anti-cigarette stance: Cui bono

Thanks to Health Canada, the e-cigarette climate in this country is an inhospitable one to say the least. There is no problem vaping if you can get them but availability is hit and miss.

Though the view in the community has been that Health Canada does not understand the nature of the product and thus are wielding inapplicable arguments against suppliers and vendors, what remains somewhat confusing is trying to understand what Health Canada has to gain in its actions. (We will assume for the sake of debate that it is purposeful in its ways – we would like to think but cannot presume that it acts in the public interest).

There is no doubt that vaping is massively safer than smoking. It is so much safer that if the whole population vaped rather than just a small portion of the population smoked you would still have a great reduction in smoking related disease. Were there no impediments to obtaining e-cigarettes it is likely that many smokers would switch.

So why the anti-vaping stance of Health Canada? Or to put it this way – who stands to lose if vaping becomes more popular than smoking?

1. The cigarette industry – dropping sales.
2. The pharmaceutical industry – a superior alternative to products that are both less effective and more dangerous. Again dropping sales.
3. The anti-smoking groups – less smoking means less need for activist anti-smoking groups.
4. Government revenues – less collected from smokers and less from tobacco settlements.
5. Health budgets – people living longer lives means increasing the national health burden.

Many of these would not hurt Health Canada. They might face budget cuts along with other departments due to shrinking tobacco revenues but that should be offset by their increased responsibility with more older but ailing folks to take care of.

So again, what do they gain by protecting tobacco and pharmaceutical interests? Do they not chafe from the internal contradictions which arise from encouraging harm reduction in every area except this one?

Note: I am pleased to announce that I have begun consulting for ECTA. While I do not anticipate any conflicts of interest (our goals are the same – improve the availability of e-cigarettes for vapers and smokers in this country) I should stress that my writing here should not be construed as communication from ECTA, These are my opinions.

What I will be doing however is writing more and more about the Canadian situation (perhaps eventually a dedicated blog). It is clear that, even in countries where strong infrastructures supporting vaping exist, attempts at banning continue. One of the great challenges in this country is to build those supports and knowing that every day that goes by more smokers develop a smoking related disease. Hopefully the day will come when Health Canada bestows on smokers the same respect it bestows on every other citizen. The true hope is for collaboration rather than conflict.

E-cigarettes as medical or recreational devices – is there room for both?

In the latest New Scientist is a report on British American Tobacco’s acquisition of an e-cigarette company and apparently “is now planning to ask the UK authorities to recognise one of its products as a smoking-cessation medicine”.

Most of us pro-harm reductionists and vapers in general much prefer the recreational designation of e-cigarettes for more than one reason.

If medicalized they will 1. have the same sort of gestation times that new drugs to market do (years and years of testing) 2. limited availability 3. greater restrictions on the forms they might take (less choice for the consumer) and 4. power will be concentrated into fewer hands (only large companies like BAT will be able to afford the testing requirements).

If not medicalized, if recreational consumer products, they will 1. remain available subject to conforming to consumer protection guidelines 2. they will be as available as cigarettes (and isn’t that pretty important?) and 3. you are more likely to have one that suits your needs.

Ironically if categorized as medicine the immediate effect will be a harm to public health in making smokers wait years til they are cleared. (Of course, if BAT is pushing for medicalization it is most likely because they now that would give them quite the edge since few other groups could pony up the funds to join the party).

There is also the distinct possibility that as medicines they will be allowed a greater latitude in harm than is allowed in consumer products. Champix would have never been considered safe enough as a consumer product but somehow as medicine having a shot at quitting smoking is worth the risk of suicide.

But perhaps there is a third way – a compromise. Two distinct products not unlike the relationship of the pharmaceutical inhalers and e-cigarettes.

Why not leave the recreational e-cigarette available while allowing a product that is similar but tested as a cessation device. Big Tobacco and Big Pharma could market their cessation e-cigarettes in competition with regular e-cigarettes.

Imagine all of us vapers as runners (I know at least a few of us must be). We have a choice between running the streets, out in the country, in the woods, changing our pace as it suits us, and then we have the option of a treadmill. Roughly the same but oh so different.

That’s the post.

On a separate note I would like to announce the publication of a collaboration between James Dunworth and myself on an ebook Electronic Cigarettes: What the Experts Say

This collection of interviews with scientists, activists and users, compiled over 4 years of writing for the Ashtray Blog, explores whether the electronic cigarette is really safe – and what is behind the campaign against them. (For more details on the contents)

All profits will be donated to The Consumer Advocates for Smoke-Free Alternatives Association (CASAA) and to the E-Cigarette Consumer Association of the UK (ECCA UK). You can download the book at either Amazon UK or Amazon USA.

Cheaper than a cup of coffee and all for the cause.

The trouble with dedicated nicotine-free e-cigarette producers

First of all there is nothing wrong with nicotine-free options for someone who wants them. The problem is that producers and marketers limited to nicotine-free options, particular in a distorted market (as in Canada where most people think there is a ban) tend to leverage the misperception of nicotine as not only harmful but as one of the main reasons smoking is bad for you.

One of these companies, Smoke NV, based in my home town of Edmonton, was featured on a recent CBC podcast discussing e-cigarettes in Canada.

If you happen onto their site, you will read the following on their Why not nicotine? page.

We simply don’t believe that there is any benefit to having Nicotine in our product, further to this, we believe that research shows that it is not needed for a smoker to enjoy this product.

What has been discussed and is growing momentum is the harm reduction view within research. This is an acknowledgement of the fact that the use of an electronic cigarette is simply safer than the use of a traditional cigarette. Essentially for each puff of an electronic cigarette containing no nicotine you avoid a puff from a traditional cigarette. Obviously traditional cigarettes have been shown to cause cancer, heart disease, pulmonary disease etc. (Harm Reduction, Dr Phillips

The one reference for the research being used to back their claims that smokers do not require nicotine for an effective substitution is quite a strange one out of the University of East London where smokers found that nicotine-free e-cigarettes did alleviate cravings as successfully as regular e-cigarettes. But here’s the kicker. The subjects were smokers (who typically smoked 10 or more cigarettes a day) who had been deprived of smoking for just one hour and then tested 5 minutes after vaping. Somehow I don’t think that reflects true life experience.

The second paragraph is much more insidious.

Leaving aside the issue that they are linking to writing from a resource I participated in creating – – the subtle move from saying that 1. e-cigarettes are safer than cigarettes to 2. because from our product you don’t get nicotine which 3. must have something to do with all those diseases you get from smoking. (This reminds me of the early days of e-cigarette marketing when the ad copy tended to mislead consumers by harping on about being safer because they tobacco free).

Smoke NV has positioned itself as firmly against nicotine and addiction. Sure, their product is better than smoking but if smokers really enjoy nicotine (and somehow I suspect that is the case) NV products are much more likely to have them scurrying back to cigarettes than a good old nicotine delivering e-cigarette would. So potentially nicotine-free e-cigarettes in competition with regular e-cigarettes could actually be harmful to public health.

On a more cynical note, on a recent vapecast discussing the CBC show, it was suggested that Smoke NV was inserting itself into the market and once Health Canada eased up would release nicotine versions. This might be more than likely. Following a link on a recent Siegel blogpost I found myself at the Tobacco Vapor Electronic Cigarette Association.

This is an American version of ECITA (UK) or ECTA (Canada) – an organizations that promote professionalism and compliance among its members. Oddly enough Smoke NV is one of those members. And though I have not looked through all of them, the ones I have are all your average nicotine delivering e-cigarette companies. Need I say more?

In summary, there is nothing wrong in supplying users who want nicotine-free e-cigarettes. They should be an option. But companies like this are insinuating that by virtue of their product containing no nicotine that it is healthier. And there is no real evidence for that.

Even professional harm reduction workers have issues with tobacco harm reduction

Ask any doctor what they would recommend if a patient of theirs who felt compelled to use a drug with proven health risks asked whether it would be better to take another drug which made them feel exactly the same but was a lot safer. Odds are the doctor would suggest switching.

Now ask them about smoking and e-cigarettes and the answer might change.

Though many doctors are coming around the health community as a whole is still experiencing a bizarre disconnect when it comes to nicotine. You can’t even call it cognitive dissonance because they don’t seem to experience any anxiety from endorsing harm reduction in general while rejecting it when it applies to smokers.

A few years ago at a small meeting held at one of the conferences of what used to be called the International Harm Reduction Association I witnessed a similar occurrence which given the context was even more disturbing. The meeting had arisen due to certain influential elements within the organization who wanted to eliminate tobacco harm reduction from their community.

It was very strange to see individuals who had supported safer sex, safer drug injection practices, and safe injection sites, practically foaming at the mouth at the thought of promoting tobacco harm reduction. One of the central objections was that one avenue of harm reduction, smokeless tobacco, was produced by tobacco companies, and these same people who would, if it improved the likelihood of safer practices, collaborate with drug producers and dealers, with difficult anti-democratic bureaucracies, and with pimps, would rather cut off their own hands than join with tobacco companies to find a solution.

When the people who are on the front lines of the battle reject what should be contiguous with their own goals (reducing the harm in risky practices) you have to be concerned about the average public health official.

I don’t want to be entirely negative here. I believe the tide is turning and to a great degree because e-cigarettes arose independently of the tobacco companies. However the companies are buying into the e-cigarette market and you can expect the objections to increase in number.

Most of these objections will be of the “just a way of maintaining nicotine addiction” nature. But guess what – along with the independent e-cigarette companies these “evil” folks are taking pretty well all the harm out of using nicotine. The addiction was never really the issue.

The anti-nicotine forces like to promote the idea that there is something special about smoking, nicotine and tobacco companies.

Not so.

Smoking is just another popular behavior with some safer satisfying alternatives available. Nicotine is just another drug like caffeine that feels good enough to make a difference but not so good that it disrupts the rest of your life. And tobacco companies are no different from any other large corporations that will do anything to keep customers.

Bad apple studies – pt 2 (and Josey Wales too)

Following from Part 1

There is something else that is special about the Winn and FDA studies.

Typically when one study becomes a standard citation it is an examplar of some sort. It either represents best some aspect of the ideas being expressed or it summarizes much of the knowledge acquired to date in the field. While these need not be perfect studies they should be of a fairly high caliber. They do not need to be universally accepted but disagreements will tend to centre on the interpretation of the results.

Just about anyone looking at the Winn and FDA studies conclude that they are methodologically unsound. And if you don’t trust the method how can you trust the results.

And yet they are presented as pillars of evidence.

Perhaps it is better to think of them as mantras.

They function quite well as articles of faith. Words repeated by believers.

Because these are so central to the ANTZ messages it feels as though we have to critically respond to them time and time again when in fact they are so poor that they should be ignored. Were it not for the timing, or their usefulness to anti-nicotine forces these studies would never have caused the slightest ripple.

And this is where we can easily claim the superior moral ground. We take these bad studies seriously enough to think about them, to accept them as possible evidence.

Both sides are guilty of assembling lists of references to support a particular position but one main difference is that pro-tobacco harm reduction researchers accept that studies not supporting their position exist. You won’t hear a pro-THR researcher denying that any study does not exist. On the other hand rather than doing the work and critically engaging opposing studies ANTZ will simply say they don’t exist.

One lesson we can all learn from this though is that as much as we like a particular conclusion or result we should remain critical.

I like both coffee and alcohol and will have an immediate reaction of “of course” to any popular report of either of them being beneficial and an “as if” to any report of them being harmful to health. I would like to think however that if I was professionally studying either that I would be critical of both pro and con studies.

And this is another reason these studies were taken up so quickly and became so persistent. They supported existing views.

While the health effects of chewing tobacco were not certain, the practice was seen as reprehensible as most people now see smoking. In films the dastardly villain might be a spitter, rarely the hero (though see anti-hero Josey Wales below).

If it is gross it must be bad for you. Winn played to popular sentiment. And the FDA study played to the folks who thought that anything that looked like smoking had to be bad for you (also the reason the exploding battery made such a news splash).

On some level we are all looking for substantial arguments against things we dislike but can’t really make a good case against. Its an understandable impulse but it is a luxury no one with any influence over public health should be allowed.

E-cigarettes are NOT banned in Canada

You know the old canard – if it walks like a duck, sounds like a duck and looks like a duck its probably a duck? Well, what we have here in Canada is the opposite. Though Health Canada acts as though there is a ban, suggests there is a ban, and though just about everybody in this country refers to the current situation as a ban, there really is no ban.

E-cigarettes are not a health product. They are a recreational consumer good and as such do not fall under the Food and Drugs Act. Nicotine replacement therapies (pharmaceutical nicotine products used for the purpose of quitting smoking) make therapeutic claims and therefore are covered under the act. E-cigarettes make no such claims.

Despite the fact that many smokers have switched to e-cigarettes, vendors do not claim that their products aid cessation. They also do not claim their product, or nicotine, has any health benefits.

Users do make those claims but policy is based on what producers claim and how the product behaves rather than what people say it does for them. For example I could be a smoker who took up scuba diving. The more time I spent underwater the less I smoked. After a while the desire to smoke lessened more and more and I eventually quit. I could tell you that I quit smoking through scuba diving but it does not make scuba diving a quit smoking therapy.

Granted that interpreting where e-cigarettes should be categorized can be a little confusing since they are rather unique in that they are both like and unlike cigarettes, smokeless nicotine products and nicotine inhalers. What makes them really unique is that they deliver enough nicotine to satisfy smokers who are not trying to quit.

There is a strong advisory on the Health Canada website that has been interpreted as a ban.

There is also an additional document aimed at potential vendors in which you see that though they claim e-cigarettes fall under their jurisdiction they refer to them as “health products”.

Market authorization is granted by Health Canada following successful review of scientific evidence demonstrating safety, quality and efficacy with respect to the intended purpose of the health product.
In addition, the delivery system within an electronic smoking kit that contains nicotine must meet the requirements of the Medical Devices Regulations.

Apart from the point that you require a therapeutic claim to be made to be classified as a “health product”, I think many vapers though they certainly believe their e-cig is healthier than smoking still do not consider it a “health product” nor would they think of it as a “medical device”. E-cigarettes are a consumer product and as such are governed by guidelines of consumer protection (safety standards, product labelling, quality control). In many ways consumers are more fully protected there than under Health Canada guidelines. In fact, in the UK, US and in Canada too (see the ECTA site), e-cigarette vendors have banded together to create standards of excellence for the product and marketing guidelines (no selling to minors, no health claims).(See this ECITA post on how nicotine replacement therapies would not pass the standards required of consumer products – it is a British context but roughly similar to the Canadian).

The wording of the advisory is harsh but the strongest evidence for this not being a real ban is the behavior of Health Canada when someone appeals one of their cease and desist letters.

One courageous vendor has stood up to Health Canada (HC) and remains in business. On a recent VapeCast this vendor, who openly sells e-cigarettes via a website, reported on their experience with threats from HC. They received cease and desist letters and said that when they asked HC for the specific law that was being broken HC would not furnish that information. A little time would pass and then HC would send another letter with another argument. These actions ran the gamut from cease and desist to getting customs to seize product.

If there was a legitimate ban in place all they would have had to do was cite the law and take the vendor down. It appears that while they are saying there is a ban there really isn’t.

The problem is that if you think there is a ban then you start acting as though there is. Many vendors have switched to selling non nicotine e-cigarettes (Health Canada does not seem to have a problem with those as “medical devices”) or have simply closed their doors. And though it is easy enough to say that everyone should stand up for the cause, in Canada, almost of these companies are too small to muster the resources that they think might be required.

There is a lot more to say about this. Stay tuned. This will be a recurring topic on the site. Bullying by Health Canada is depriving smokers of a safer alternative to using nicotine – it is saying in no uncertain terms that smoking is the preferable route.

If you have a story about an experience dealing with Health Canada on this issue leave a comment or send me an email describing it and I will report it (I am happy to keep it as anonymous as you wish).

New Four Country E-cigarette Survey Published

I’ll get back to the Bad Apple post but this is worth publicizing (noticed it on Michael Siegel’s Rest of the Story).

The citation is Adkison SE, et al. Electronic Nicotine Delivery Systems: International Tobacco Control Four-Country Survey. Am J Prev Med. March, 2013 (article here).

If you go to the article and take a look at Table 1 (awareness and use of e-cigarettes among smokers) you will see how smokers are faring in countries where e-cigarettes are essentially banned (Canada and Australia). While the awareness of e-cigarettes was substantially lower in Canada, the real difference comes in how many smokers actually tried them (roughly half compared to America). The real killer (and it is unfortunate that that does really describe the end result) is that the percentage of Canadians who tried vaping and then became users is about the same as the percentage of Americans.

In other words, it is equally attractive and effective for users in both countries but in Canada the current restrictions (not surprisingly) lessen the number of how many smokers know about e-cigarettes and thus how many try them and how many will switch from smoking. Thus current policy serves to maintain higher national smoking numbers than would naturally occur.

And by naturally I mean if e-cigarettes were as available as cigarettes.

There is a lot more meat to chew over in the article and I do encourage everyone to read it over. The one sour note I find on a cursory first scan through is the final line of the conclusion: “If credible evidence can be provided that ENDS reduces the number of cigarette smokers and does not attract use among nonsmokers, then the net public health effect is likely to be positive”.

Its been quite clear for some time that the level of risk associated with vaping is so much lower than that with smoking that if everyone vaped rather than anyone smoke the net public health effect would be overwhelmingly positive.