Is vaping a healthier alternative to smoking or is it just another gateway to tobacco and future lung diseases? Research is beginning to help clear up the cloud that surrounds electronic cigarettes.
Health issues, increased risk of cancer, COPD, cardiovascular disease, asthma, and a host of other issues related to smoking have been clearly proven, yet many people begin smoking, continue to smoke, or quit then restart the habit. Now the debate has shifted due to electronic cigarettes and many questions are being asked regarding this issue:
- Can you still smoke but avoid the health problems, provided you use electronic cigarettes?
- Can the use of e-cigarettes help one stop smoking? And, in contrast, do e-cigarettes encourage some to start smoking?
- Is it possible that the gains that have been made in changing the society norms related to smoking can be lost?
- Are the conceptions true that e-cigarettes are safe, that it’s acceptable to use e-cigarettes instead of tobacco cigarettes, and that “vaping” is not the same as smoking?
- Are non-smokers and particularly adolescents and teenagers starting to smoke as e-cigarettes become more accepted (or as target marketing takes hold in these groups)?
- And finally, what about the underlying concerns about accidental poisoning in children?
These issues are under scrutiny and published research is beginning to help make sense of what we are experiencing with e-cigarettes. This article will examine the research and explore the question: What about e-cigarettes?
E-cigarettes: Safe to Smoke?
E-cigarettes, or electronic nicotine delivery systems (ENDS) consist of a battery, a reservoir of liquid, and an atomizer that, when heated by the battery’s energy, produces an aerosol that is inhaled by the user. The liquid contains nicotine, propylene glycol or glycerol, some type of flavorings (tobacco, mint, fruit, coffee, chocolate, etc), and sometime other components. (In rare instances the liquid may claim or may actually be nicotine-free). People who use these products may claim that they are not smoking; instead they use the term ‘vape’ or ‘vaping.’
E-cigarettes first appeared on the world market in 2003-2004 after being developed in China and became available in the US and Europe in 2006-2007.1-2 The devices have gone through three generations: First-generation devices mimicked the size, shape, and feel of conventional cigarettes and were either disposable units that were discarded after the vapor stopped, or reusable units that had rechargeable lithium batteries and refillable or replaceable cartridges containing the liquid. Second-generation devices look more like a pen or contain a larger tank and have a larger battery plus electronic circuitry that can alter the frequency and length of “puff” or the energy send to the atomizer (thus creating more vapor). Third-generation devices are even more customizable and produce even more vapor (and deliver even more nicotine).1
Some 460 brands of e-cigarettes and over 7,600 flavors were counted from online sources for e-cigarettes at the beginning of 2014.2-3 Nicotine delivery through smoking the e-cigarette is widely variable—ranging between zero and 34 mg/mL—but it has been almost impossible to test e-cigarettes with the standard, conventional laboratory testing systems used to test conventional cigarettes due to the inability to produce the vapor from the e-cigarette (however modifications allowed for testing to go forward).
Some of the products labeled as nicotine-free actually contained some nicotine and the labeling of nicotine content is unreliable, and as smokers become more experienced, they can alter the nicotine delivered by changing their smoking technique. In an article by Schroeder and Hoffman published in Tobacco Control in 2014, the authors concluded that e-cigarette nicotine exposure is dependent on the smoker’s experience using these devices and dependent on their use behaviors, and that this population is likely exposed to “substantial amounts” of nicotine.4 The shift to third generation vaping devices and the technique used by an experienced smoker have shown that nicotine absorption is similar to what is found with conventional cigarettes.5 When examining the toxins produced from cigarettes versus e-cigarettes, this same article from 2014 has been frequently cited; the e-cigarettes produced less toxins in the range of some nine- to 450-fold, compared to conventional cigarettes.4 Tobacco cigarettes produce over 4,000 chemicals and studies have shown that as many as 55 of these are carcinogens.6
E-cigarettes don’t produce anywhere near the chemicals in comparison to combustable cigarettes, so the general assumption is that the e-cigarettes must be safer than tobacco cigarettes. However, the evidence has not been produced to prove this and there are issues with the other components not found in tobacco cigarettes, or that are present in less amounts. Heating the liquid to produce a vapor involves heating propylene glycol can result in producing propylene oxide—a class 2B carcinogen, according to the International Agency for Research on Cancer. Both conventional and electronic cigarettes produce formaldehyde, acetaldehyde, acrolein, toluene, xylene, benzene, and butadiene. The e-cigarettes produce much less of these substances but the health effects of this exposure are unknown.5
“Are e-cigarettes safe to smoke?” The answer is not clear. Nicotine addiction is likely to continue when using e-cigarettes and its effect on the cardiovascular system is of some concern. E-cigarettes have a greatly reduced exposure to toxins but the long-term health effects have not been proven. The chemicals produced by heating the liquid are being examined but no conclusions have been reached. The final word on safety regarding e-cigarettes has not been established, and as Denise B. Kandel, PhD, professor of Sociomedical Sciences in Psychiatry at Columbia University in New York expressed it, “Behavior is outpacing science. There is a tremendous increase in the use of these cigarettes, and there’s very little research carried out to address the basic questions that we need answers for. Could it possibly undo 50 years of public health work to reduce nicotine addiction? I think so.”7
Can E-cigarettes Help Smokers Quit?
The makers of e-cigarettes have marketed their products to be useful for smoking cessation but quality scientific proof for this claim is not present. A Cochrane review published in 2014 looked at the use of e-cigarettes for smoking cessation and reduction.8 The review concluded that the trials that seem to show some effect in these areas are of low or very low quality but the results from two randomized controlled trials seem to indicate that e-cigarettes may be helpful in smoking cessation or reduction.8 One study that is frequently cited describes the results of a trial performed in New Zealand involving 657 smokers who wanted to quit. The participants were divided into three groups: group one was given e-cigarettes containing 16 mg of nicotine, group two was given patches containing 21 mg of nicotine, and group three was given placebo e-cigarettes. Low-intensity behavioral support was provided via voluntary telephone counseling and smoking abstinence was confirmed by measuring exhaled carbon monoxide levels. At six months, smoking abstinence was 7.3% with nicotine e-cigarettes, 5.8% with nicotine patches, and 4.1% with placebo e-cigarettes. No significant differences were observed in the study groups.8
Quit rates in this study were comparable to quit rates observed in studies of over-the-counter nicotine replacement therapy when minimal or no behavioral support is provided.9 Without further evidence it is hard to support the assumption that e-cigarettes can help smokers quit smoking tobacco cigarettes.
Another aspect of this discussion is dual-use, in which the smoker uses both conventional cigarettes and e-cigarettes. This may lead to a reduction in use of the tobacco products but even small amounts of exposure to tobacco smoke can still carry an increased risk for coronary artery disease.1
Are E-cigarettes Influencing Society’s Attitudes About Smoking?
The number of adults in the US who have tried e-cigarettes was estimated to be about 2.7% in 2010, some three to four years after these devices came on the market. By 2013, estimated use in adults had grown to 8% and the number is rapidly rising.3 The proliferation of e-cigarette use is even greater in adolescents, and this use seems to link to increased use of combustible tobacco products (CTP) as well. Between 2011 and 2014, high school students’ use of e-cigarettes jumped from 1.5% to 13.4% while in middle school students the use climbed from 0.6% to 3.9%.1 Ninth-graders from 10 public high schools in Los Angeles formed the basis for a longitudinal repeated assessment of e-cigarette use to see if there was an influence to also use or continue to use CTP (tobacco cigarettes, cigars, and hookah) over the course of a year. Among a group of ninth-graders who had never smoked CTP at baseline but were smoking e-cigarettes, they had a 30.7% incidence of smoking CTP at the six-month follow-up, compared with 8.1% of the never-smoked group.10 In the discussion of this study, the authors proposed that:
- Teens held the belief that e-cigarettes were not harmful or addictive;
- Marketing aimed at this group influenced their behavior to smoke;
- The availability of e-cigarette flavors attracted them to use e-cigarettes;
- The absence or lack of enforcement of restrictions against e-cigarette sales to minors influenced the movement from non-user to user of e-cigarettes, and e-cigarettes influenced the move to start smoking CTP.10
Adolescents are not the only group adopting the e-cigarette habit. For tobacco smokers who have been diagnosed with cancer, researchers found a jump in use of e-cigarettes, from 10.6% in 2010 to 38.5% in 2013.11 In addition, these e-cigarette users were more dependent on nicotine, had more attempts to quit, and had more diagnoses of thoracic and head or neck cancers than those who were not using e-cigarettes.11
In their conclusion, the authors state: “The current longitudinal findings raise doubts concerning the usefulness of e-cigarettes for facilitating smoking cessation among patients with cancer. Further research is needed to evaluate the safety and efficacy of e-cigarettes as a cessation treatment for patients with cancer.”11
What About Risks to Small Children?
The chemicals in e-cigarette vapor are not the only area of potential risk. Accidental exposure to the liquid in e-cigarettes has caused calls to poison control centers increase from a single call in September 2010 to 215 calls in February 2014.12 Even more alarming is that fact that more than half of these calls involved children under five-years-old.12 The number of accidental poisonings from the liquid used in e-cigarettes in children increased by 300% from 2012 to 2013 and is expected to continue climbing rapidly.13 Currently, few states in the US require child-resistant packaging for e-cigarette liquids, which means it is up to users to prevent their children from being exposed.
E-cigarettes are continuing to grow in popularity and it has been assumed that they are much safer than conventional cigarettes. Another assumption is that they can reduce use of tobacco products and may be effective in helping smokers quit altogether. Marketing to American youth has been strong and the popularity in this group has caused concerns as children and teenagers experiment with this habit.
Nicotine addiction and the reinforcement of hand-to-mouth habits continue to be present in the e-cigarette smoker which runs counter to the idea that e-cigarettes will help in reduction or cessation from smoking. The issue of poisoning is another concern for public health. But a lack of high-level research leaves many questions unanswered. RTs need to be vigilant in staying up with the research and be honest with their patients about what is known and what is not. As new recommendations and guidelines come out, the “smoke may clear” as to how to answer the questions and what to tell others about using e-cigarettes. But for now, we just don’t have enough evidence to condemn or condone these devices. RT
Bill Pruitt, MBA, RRT, CPFT, AE-C, FAARC, is a senior instructor and director of clinical education in the department of Cardiorespiratory Sciences, College of Allied Health Sciences, at the University of South Alabama in Mobile. For further information, contact [email protected].
Rogotti NA. E-Cigarettes. In UpToDate, Park L (Ed), UpToDate, Waltham, MA. Accessed 3/8/16.
Rom, O., Pecorelli, A., Valacchi, G., & Reznick, A. Z. (2015). Are E?cigarettes a safe and good alternative to cigarette smoking?. Annals of the New York Academy of Sciences, 1340(1), 65-74.
Born, H., Persky, M., Kraus, D. H., Peng, R., Amin, M. R., & Branski, R. C. (2015). Electronic Cigarettes A Primer for Clinicians. Otolaryngology–Head and Neck Surgery, 153(1), 5-14.
Schroeder, M. J., & Hoffman, A. C. (2014). Electronic cigarettes and nicotine clinical pharmacology. Tobacco control, 23(suppl 2), ii30-ii35.
Morris, P. B., Ference, B. A., Jahangir, E., Feldman, D. N., Ryan, J. J., Bahrami, H., … & Shields, M. S. (2015). Cardiovascular effects of exposure to cigarette smoke and electronic cigarettes: clinical perspectives from the prevention of cardiovascular disease section leadership council and early career councils of the American College of Cardiology. Journal of the American College of Cardiology, 66(12), 1378-1391.
Suter, M. A., Mastrobattista, J., Sachs, M., & Aagaard, K. (2015). Is there evidence for potential harm of electronic cigarette use in pregnancy?. Birth Defects Research Part A: Clinical and Molecular Teratology, 103(3), 186-195.
Fillon, M. (2015). Electronic Cigarettes May Lead to Nicotine Addiction. Journal of the National Cancer Institute, 107(3), djv070.
McRobbie, H., Bullen, C., Hartmann-Boyce, J., & Hajek, P. (2014). Electronic cigarettes for smoking cessation and reduction. Cochrane Database Syst Rev, 12.
Bullen, C., Howe, C., Laugesen, M., McRobbie, H., Parag, V., Williman, J., & Walker, N. (2013). Electronic cigarettes for smoking cessation: a randomised controlled trial. The Lancet, 382(9905), 1629-1637.
Leventhal, A. M., Strong, D. R., Kirkpatrick, M. G., Unger, J. B., Sussman, S., Riggs, N. R., … & Audrain-McGovern, J. (2015). Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence. JAMA, 314(7), 700-707.
Borderud, S. P., Li, Y., Burkhalter, J. E., Sheffer, C. E., & Ostroff, J. S. (2014). Electronic cigarette use among patients with cancer: characteristics of electronic cigarette users and their smoking cessation outcomes. Cancer, 120(22), 3527-3535.
From the CDC website and the Morbidity and Mortality Weekly Report (MMWR) April 4, 2014 / 63(13);292-29. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6313a4.htm. Accessed 3/10/16.
Smith, J. E. (2014). Electronic cigarettes: a safer alternative or potential poison?. Home Healthcare Now, 32(9), 532-535.