Update on Electronic Cigarettes

Smoking cessation tools and techniques are a hot topic in today’s healthcare, with many providers and patients searching for the most effective individual approach to kicking the habit. The relatively new electronic cigarette, or “e-cig,” has quickly become perceived as one of the most desirable and effective smoking cessation aids available. Electronic cigarettes were developed in China in 2004 and public awareness of the devices continues to grow rapidly.[1] Of course, their recent popularity does not come without criticism or uncertainty regarding their safety profile, efficacy and effects on the general population.

What’s an Electronic Cigarette?

Electronic cigarettes, also called electronic nicotine delivery systems (ENDS), have a very similar appearance to traditional cigarettes, but they do not contain tobacco.[2] The device includes a metal casing that holds a battery-powered atomizer that reduces a liquid to a fine mist or vapor.[1] This vapor is then inhaled from cartridges inserted that may contain propylene glycol, glycerol, flavors, nicotine and sometimes medications.[2] The vapor is inhaled through the mouthpiece and does not contain smoke or carbon monoxide.[3] The tip of the ENDS lights up when inhaled, and some manufacturers have chosen the color blue (instead of red) to illustrate to surrounding individuals it is not a true cigarette.[3] However, because electronic cigarettes mimic the ergonomics and appearance of cigarettes, they are appealing to some smokers.[1]

Popularity of Electronic Cigarettes

Google searches with the search term “electronic cigarettes” have increased by 5,000% since 2009.[2] A small number of studies have evaluated the prevalence of use and satisfaction with the ENDS. Etter and Bullen conducted a survey that included questions on current or prior use of an ENDS (including dosages, puffs per day, costs, flavors and place of purchase), duration of use, effectiveness in abstaining from cigarettes and withdrawal symptoms, and use of other smoking cessation mechanisms.[2] Results showed that among current smokers, the daily users of an ENDS smoked fewer cigarettes than those participants that have never used one (13 vs. 16 cigarettes per day).[2] Before these same users began using an ENDS, they smoked more tobacco than the participants that had not used one (25 vs. 16 cigarettes per day).[2] The brands most used in the United States were Joye, Vapor4Life, Janty, Totally Wicked and PureSmoker.[2]

To individuals beginning the smoking cessation journey, an incentive to choose the ENDS may be the cost.[2] The monthly cost (approximately $33) is much lower than smoking a pack per day.2 It is also noted that electronic cigarettes are much cheaper than other smoking cessation aids like medications which are also equivalent to the cost of smoking one pack per day ($150 to $200 per month).[2]

Use and Satisfaction

The median duration of ENDS use among daily users in the Etter and Bullen study was 3 months, with 15% using electronic cigarettes for a year or more.[2] Almost all of the users surveyed (97%) reported use of electronic cigarettes with nicotine cartridges.[2] On average, daily users used two bottles of refill liquid per month with the average monthly expense (including cartridges, refill liquid, batteries and components) totaling $33.[2] The vast majority of users surveyed purchased their electronic cigarettes online (96%) and 45% reported they plan to continue using them for another year or more.[2] Electronic cigarettes are used mostly at home (98%) and in the car (90%), sometimes at work (70%), and less frequently in restaurants, cafes, bars (43%) and public transportation (15%).[2]

The majority of participants (92%) surveyed by Etter and Bullen reported that the ENDS helped them to cut down on their smoking and former smokers said it helped them to completely quit smoking.[2] Only 10% of electronic cigarette users still experienced the urge to smoke and 79% of users feared they would return to smoking if they stopped using the ENDS.[2] Reasons for choosing the ENDS included belief the system was less toxic than tobacco, to aid in quitting smoking or avoid returning to smoking, to deal with tobacco craving and withdrawal symptoms, and because they were more cost-efficient than cigarettes.[2] The most reported reasons for stopping use of the ENDS were because it was not needed anymore, the participants believed they would not relapse to smoking again, the product was of poor quality, the product didn’t reduce cravings and the participants returned to smoking.[2] The greatest symptom relief reported was a decreased craving to smoke.[2]

Clinical Trial Evidence of Effects

A prospective proof-of-concept study published in BMC Public Health in 2011 was conducted in Italy to assess possible modifications in smoking habits with use of electronic cigarettes in people not currently attempting to quit or wishing to do so in the next 30 days.[4] Participants were provided all material and training necessary to utilize the ENDS and were given a 4-week study diary to record their use, number of tobacco cigarettes smoked, and any adverse effects.[4] Participants returned at 4-week intervals to replenish ENDS supplies, to measure their exhaled carbon monoxide levels, and to return completed study diaries and unused supplies.[4] Results showed an overall 80% decrease in median cigarette per day use from 25 to 5 by the conclusion of the study and an overall quit rate of 22.5%.[4] These findings are quite significant because all participants were not interested in smoking cessation at the time of study enrollment.[4] It is also noted that the electronic cigarette may have a positive effect on quitting because replaces conditioned smoking movements (i.e. hand-to-mouth actions).[4] In light of this, the researchers conclude this study proves that electronic cigarettes only improve smoking cessation in smokers for whom the ritual of smoking is important.[4]

Adverse events reported included throat irritation, mouth irritation and dry cough, which seemed to spontaneously wane by the last study visit.[4] Typical side effects related to smoking cessation drugs for nicotine dependence were not reported in this study, including anxiety, depression, insomnia, hunger, irritability and constipation.[4] There were no serious adverse events reported throughout the duration of this study.[4]

Safety and Environmental Concerns
Although the ENDS is considered the next big thing in smoking cessation, the product is not without skeptics in the healthcare professions.[1] It is hypothesized that inhalation of nicotine without smoke should be of less risk to smokers and bystanders.[1] However, because of the limited research available on the safety and efficacy of electronic cigarettes, they remain a subject of debate for use and have even been banned in some nations.[1] It is possible that nicotine plays a role in the destruction of connective tissue, changes in immune function, apoptosis prevention, and substance or alcohol abuse.[1] Research does suggest that it is unlikely the harmful effects of inhaled nicotine would be comparable of those of smoking.[5] Electronic cigarette consumers should be aware that in addition to the nicotine added during production, they will also be exposed to any potential hazardous chemicals in the solution created during use.[1] The FDA did report that they found trace levels of harmful chemicals and inaccurate labeling of nicotine content in electronic cigarette cartridges.[1]

A study published in Nicotine & Tobacco Research in 2010 examined the relationship between the vacuum (i.e. suction) required to smoke conventional cigarettes compared to electronic cigarettes.[6] The researchers found that electronic cigarettes required a greater amount of suction to smoke than conventional cigarettes, and suggest this can cause adverse effects on health.[6] They conclude that the decreased efficiency of aerosol production during electronic cigarette smoking makes dosing nonuniform over time and calls into question their usefulness as nicotine delivery devices.[6]

Electronic cigarettes have received scrutiny regarding their poor quality control in production.[7] Investigation has uncovered incorrect labeling, incorrect dosing of nicotine, defective parts, leaky nicotine cartridges, and highly toxic substances in the electronic cigarette fluid that are associated with severe adverse effects when ingested.[7] However, two of the posed health dangers of electronic cigarettes (nicotine and low amounts of carcinogens) are also present in FDA-approved nicotine replacement therapy products.[7]

There is hope for the future that electronic cigarettes can substitute tobacco smoking as a “harm reduction strategy.”[7] Still, there is not enough known about the physiologic effects or consequences of the electronic cigarette, and there is a great need for improved quality control in the manufacturing of these products.[7] Also an area of concern is the potential for electronic cigarettes to become a gateway path to cigarettes, or traditional tobacco use, particularly in the younger population.[7] Further debate and decisions are warranted on how to regulate the use and availability of electronic cigarettes in the United States.[7]

Implications for Practice
It appears there is great potential for the future of electronic cigarettes in their use as a smoking cessation product, most importantly in the population of smokers who respond well to the physical maneuvers of holding a cigarette. However, based on the research and reports currently available, it is clear we are not yet able to advocate for electronic cigarettes as a possible option for our patients. Consumer satisfaction and ability to quit or decrease tobacco intake with use of the electronic cigarette is promising, and these preliminary research findings could paved the way for further clinical trials on this product. Equally important is the electronic cigarette manufacturers’ ability to provide better quality control and cooperate with the FDA and regulatory agencies’ requests regarding the process of approval for electronic cigarettes as a smoking cessation device.

1. McQueen A, et al. Interviews with “vapers”: implications for future research with electronic cigarettes. Nicotine Tob Res. September 2011;13(9):860-867.
2. Etter JF, Bullen C. Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy. Addiction. 2011;106(11):2017-2028.
3. Foulds J, et al. Electronic cigarettes (e-cigs): views of aficionados and clinical/public health perspectives. Int J Clin Pract. 2011;65(10):1037-1042.
4. Polosa R, et al. Effect of an electronic nicotine delivery device (e-Cigarette) on smoking reduction and cessation: a prospective 6-month pilot study. BMC Public Health. 2011;11:786.
5. Sumner W. Permissive nicotine regulation as a complement to traditional tobacco control. BMC Public Health. 2005;24(5):18.
6. Trtchounian A, et al. Conventional and electronic cigarettes (e-cigarettes) have different smoking characteristics. Nicotine Tob Res. 2010;12(9):905-912.
7. Hardin DF. Blowing electronic smoke: electronic cigarettes, regulation, and protecting the public health. U Illinois J Law Technol Policy. 2011(2):433-462.

Bethany Bell is a nurse practitioner student at University of North Florida, Jacksonville.

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