Taking a vape break…

e-cigarette

E-cigarette use is now more common than cigarette use among teens [1], and has become increasingly popular with adults who wish to quit smoking by using a safer alternative to cigarettes. In case you have been living under a rock, e-cigarettes are devices that allow you to heat and inhale nicotine, the main substance that makes cigarettes addictive, without getting the rest of the harmful chemicals.

But unlike cigarettes, e-cigarettes are relatively new and little research has been done on them. A PubMed search using the keyword “smoking” (of tobacco products) yields 124389 results. “Electronic cigarettes” yields a modest 328. And while long-term health outcomes will take some time to appear, many argue that whatever the results, e-cigarettes are bound to be the lesser of two evils.

But do e-cigarettes actually help people quit? One UK study found that daily e-cig use was associated with more attempts to quit and far fewer cigarettes smoked, but was not associated with having fully quit smoking at one-year follow-up [2]. However a larger study, also from the UK, found that compared to those who tried to quit with an over-the-counter nicotine replacement therapy like gum or the patch, e-cigarette users were more than twice as likely to have quit [3], perhaps because in addition to administering nicotine, e-cigarettes also replace the all-important physical habits of smoking: holding something in your hand and mouth, inhaling and exhaling.

As Farsalinos and colleagues (2015) recently argued:

“Most of the tobacco cigarette’s toxicity is related to the combustion process. Models of harm reduction applied to tobacco suggest that switching from inhalation of combustible products to a noncombustible nicotine delivery product would likely result in a vast reduction in tobacco-related death and illness. Currently available evidence raises no doubt that electronic cigarettes (e-cigs) are by far less harmful than smoking (although probably not absolutely safe) and have the potential to be the most effective tobacco harm reduction products due to their unique property of resembling smoking and providing satisfaction to the user” [4]. 

But it’s that little side note – probably not absolutely safe – that needs to be addressed.

What Farsalinos and colleagues argue is that regulation is necessary to ensure some level of quality control, but as e-cigs are neither tobacco nor medication, the regulatory process could instead follow the example of food standards by excluding chemicals known or suspected to be harmful and ensuring products aren’t contaminated. Impurities are a concern, however one analysis of 20 vials of e-cig liquid found that the nicotine level written on the labels nearly matched the detected levels, and while some impurities and nicotine degradation were found, these weren’t at levels high enough to likely cause harm [6].

There is a lot of debate in the research community about whether or not e-cigarettes represent a lower, similar, or higher risk of cancer as compared to cigarettes, with journal commentary sections running wild. Because they are quite new, studies can only look at the products and make toxicological inferences; unfortunately, for real-world outcomes we simply have to wait and see [7]. What the toxicological experiments reveal is mixed – some argue that e-cigs produce formaldehyde levels with 5 to 15 times the cancer-causing risk as cigarettes [8] while others argue this highly publicized experiment was fundamentally flawed because it used extreme coil-temperatures (creating a phenomenon known as ‘dry-puff’) that actual e-cigarette users would never tolerate [9]. In any case, potential harms are difficult to assess when constant modifications to the technology and the absence of regulatory measures allow for extensive variation in the content of e-cig liquids and the heating mechanisms of various e-cig models.

And those e-cigarette models keep getting fancier and fancier: besides smartphones, e-cigarettes may just be the closest we get to that slick, 1960s outer space-like version of the future that is so much more endearing than the actual future we wound up with (Tinder, bad loans, and melting sea ice): glowing chrome robot flutes emitting plumes of vapour that smell like cheesecake… it’s delightfully absurd and probably a minimal harm compared to the many other toxicities in our environment. [although full disclosure – as an ex-smoker, this writer’s gauge of what is acceptable risk might be different than someone who has never poisoned themselves so deliberately!]

Yet many others are concerned that the high-tech/seemingly low-risk appeal of e-cigs will renormalize smoking or act as a ‘gateway’ drug for youth is common. Some point out that smoking rates continue to decline, citing that only 1% of youth who have never smoked a cigarette use e-cigarettes, while others argue otherwise [10].

What are your thoughts about e-cigs? Is more research required to form an accurate opinion about them? Is the government right to ban e-cigarettes in addition to cigarettes in non-smoking areas? Or do e-cigarettes potentially offer another way to help tobacco smokers kick the habit? Do you see this as a growing industry or just another fad? Let us know in the comments.

[thanks to Armen Slikhanian for background research and the first draft of this post.]

[1] Miech, R. A., Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2014, December 16). National press release, “E-cigarettes surpass tobacco cigarettes among teens.” University of Michigan News Service, Ann Arbor, 16 pp.

[2] Brose, L.S.; Hitchman, S.C.; Brown, J.; West, R.; McNeill, A. (2015). Is the use of electronic cigarettes while smoking associated with smoking cessation attempts, cessation and reduced cigarette consumption? A survey with a 1-year follow-up. Addiction, 110(7), 1160-1168

[3] Jamie Brown, J.; Beard, E.; Kotz, D.; Michie, S.; West, R. (2014). Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study. Addiction 109(9), 1531-1540.

[4] Farsalinos, K. E., & Le Houezec, J. (2015). Regulation in the face of uncertainty: the evidence on electronic nicotine delivery systems (e-cigarettes).Risk Management and Healthcare Policy8, 157–167. http://doi.org/10.2147/RMHP.S62116

[6] Etter, J.F.; Zäther, E.; Svensson, S. (2013). Analysis of refill liquids for electronic cigarettes. Addiction, 108(9), 1671-1679.

 [7] West, R., & Brown, J. (2014). Electronic cigarettes: fact and faction. The British Journal of General Practice64(626), 442–443. http://doi.org/10.3399/bjgp14X681253

[8] Jensen RP, Luo W, Pankow JF, Strongin RM, Peyton DH. Hidden formaldehyde in e-cigarette aerosols. N Engl J Med 2015; 372:392–4. doi: 10.1056/NEJMc1413069.

[9] Bates, C.D.; Farsalinos, K.E (2015). Research letter on e-cigarette cancer risk was so misleading it should be retracted. Addiction 110(10), 1686–1687.

[10] Hall, W., Gartner, C., & Forlini, C. (2015). Ethical issues raised by a ban on the sale of electronic nicotine devices, Addiction, 110(7), 1061-1067.

[image source: http://www.engadget.com/2013/12/18/smokio-connected-e-cigarette/]

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