Electronic cigarettes: achieving a balanced perspective

FOR DEBATE
Electronic cigarettes: achieving a balanced perspective
Theodore L. Wagener1, Michael Siegel2 & Belinda Borrelli3
University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA1, Boston University School of Public Health, Boston, MA, USA2 and Alpert MedicalSchool of Brown University and the Miriam Hospital, Providence, RI, USA3 ABSTRACT
Concerns have been raised that the advent of electronic cigarettes (e-cigarettes) may be harmful to public health, and smokers have been advised by important agencies such as the US Food and Drug Administration not to use them. This paper argues that, while more research is needed on the cost–benefit equation of these products and the appropriate level and type of regulation for them, the harms have tended thus far to be overstated relative to the potential benefits.
In particular: concern over repeated inhalation of propylene glycol is not borne out by toxicity studies with this compound; risk of accidental poisoning is no different from many household devices and chemicals available in supermarkets; concern that e-cigarettes may promote continued smoking by allowing smokers to cope with no-smoking environments is countered by the observation that most smokers use these products to try to quit and their use appears to enhance quitting motivation; concerns over low nicotine delivery are countered by evidence that the products provide significant craving reduction despite this in some cases; and e-cigarettes may help reduce toxin Keywords
Electronic cigarette, harm reduction, nicotine.
Correspondence to: Theodore L. Wagener, General & Community Pediatrics, University of Oklahoma Health Sciences Center and the Oklahoma Tobacco Research Center, 1200 Children’s Ave., Suite 12400, Oklahoma City, OK 73117, USA. E-mail: [email protected] Submitted 2 November 2011; initial review completed 22 December 2011; final version accepted 24 January 2012 Electronic cigarettes, or ‘e-cigarettes’, look and feel like of e-cigarettes, but does little to examine the evidence of regular cigarettes but do not contain tobacco, require the potential promise of e-cigarettes.
combustion or produce smoke. To date, they have not The concerns of Cobb & Abrams focus on the limited been manufactured by tobacco or pharmaceutical evidence regarding both the safety and cessation benefit companies. e-Cigarettes are marketed to smokers as an e-cigarettes. They question the quality control alternative to regular cigarettes, offering the ‘freedom to standards of e-cigarette manufacturers, the impact of smoke anywhere’. e-Cigarettes are becoming increasingly repeated propylene glycol (a major chemical component popular, especially in locations with stronger tobacco of some e-cigarettes) inhalation by humans, and the pos- control regulations [1]. The e-cigarette has been the sibility of children (or adults) being harmed by inadvert- cause of significant debate both in the United States and ently consuming large refill bottles or cartridges of around the world. Although there are many staunch sup- e-cigarette liquid. Regarding quality control standards, porters of e-cigarettes, there appears to be even stronger Cobb & Abrams are correct, as the current standards and more powerful opposition from the US Food and of e-cigarette manufacturers have been quite variable, Drug Administration (FDA) and many individuals in the which could be a significant public safety concern.
tobacco control community who would prefer that However, the impact of repeated propylene glycol vapor e-cigarettes be regulated as drug-delivery devices or inhalation by humans, as it may be a throat irritant, banned entirely from the market. In recent months, though understandable, does not seem to be reason several commentaries on electronic cigarettes have been enough to remove these products from the market. Fur- presented [2,3]. One recent paper [4] by Cobb & Abrams thermore, animal studies on repeated propylene glycol in the New England Journal of Medicine reviews many of vapor exposure indicate no deleterious effects [5], and the the strongly held concerns of regulators and those in the nicotine inhaler has similar side effects [6]. Finally, their tobacco control community regarding the potential perils concern regarding the possibility of accidental child 2012 The Authors. Addiction 2012 Society for the Study of Addiction Addiction, 107, 1545–1548
poisonings is also something that should be investigated that they would start smoking again if they stopped using and monitored. Currently, e-cigarette companies label it [10]. Consequently, removing e-cigarettes from the their products with warnings to keep cartridges out of the market or discouraging their use could harm public reach of children. However, it is important to put this health by depriving smokers of a potentially important concern into context. Many household products are potentially dangerous to children if consumed, yet we do Although larger trials are needed to help answer ques- not ban these products. For example, if a child consumed tions regarding the possibility of dual use (i.e. smokers a large bottle of cherry-flavored liquid acetaminophen, maintain current smoking levels and add e-cigarettes), this too would be dangerous—if not deadly. Similar to the available evidence suggests that this is not the case.
e-cigarette labels, for consumer products that are hazard- Research indicates that the vast majority of e-cigarette ous to children we simply warn adults to keep them out users use e-cigarettes for either complete (79%) or partial replacement (17%) of tobacco cigarettes [10]. In addi- On the topic of cessation benefit, Cobb & Abrams tion, fears that smokers will forego traditional cessation argue that there is no evidence that e-cigarettes are ben- methods in favor of e-cigarettes has not been substanti- eficial for cessation, and that there may be a risk that ated. A substantial number of current e-cigarette users e-cigarettes will be used only in places where smoking report having tried to quit previously using nicotine is prohibited by current smokers (i.e. ‘bridge products’) replacement therapies (70%), bupropion (29%) and/or or function as attractive starter products for young varenicline (18.6%) [10]. This finding, taken together non-smokers. We agree that these concerns need to be with the Bullen et al. [8] finding that placebo e-cigarettes addressed through continued thoughtful, rigorous scien- also reduced craving, withdrawal symptoms and number tific investigations. Current research investigating these of cigarettes per day, suggests that e-cigarettes address an concerns is limited, although not non-existent. Moreover, additional behavioral component (e.g. hand to mouth the research indicates some promising effects. For gesture, ‘throat hit’ of the vapor, exhaling visible vapor) example, Cobb & Abrams argue that e-cigarettes are beyond the pharmacological effect of nicotine provided unlikely to be useful for smoking cessation because of by current FDA-approved therapies. As a result, for ineffective nicotine delivery, as evidenced by low plasma smokers who have failed to quit with current approved levels of nicotine by the smokers who used them.
therapies, e-cigarettes offer an alternative method of However, the study [7] that they cite to support this argu- quitting, or a method of supplementing these currently ment actually showed that one e-cigarette brand was able approved therapies. Moreover, withdrawing e-cigarettes to significantly reduce subjective craving for cigarettes from the market or discouraging ex-smokers who have despite low plasma levels of nicotine. Another study [8], quit by using these devices to discontinue their use and not mentioned by Cobb & Abrams, found that e-cigarettes switch to approved forms of therapy is unlikely to be a not only deliver nicotine effectively (more rapidly than a boon for public health, as the current evidence suggests nicotine inhaler), but that they significantly reduce ciga- that e-cigarette users often have high levels of nicotine rette craving and number of cigarettes smoked at a level dependence and have tried and failed to quit smoking similar to that of nicotine replacement products. Further- with multiple forms of approved cessation therapies more, a recent clinical trial [9] published after the Cobb & [10]. It seems misguided to ask people to discontinue an Abrams article showed that e-cigarette use may motivate approach that is working in favor of an approach that has quitting. Among 40 smokers who were initially not inter- ested in quitting but who were asked to use the e-cigarette ad libitum, 22.5% achieved sustained smoking absti- e-cigarettes is that they do not require combustion and nence (biochemically verified) at 6-month follow-up [9].
therefore produce no second-hand smoke exposure Furthermore, an additional 12.5% and 32.5% reduced (SHSe) to the user or to individuals in the smoker’s envi- their smoking by Ն80% and Ն50%, respectively [9].
ronment. Second-hand smoke, especially in homes with Several survey studies support these findings. In a large children, poses a serious public health risk increasing the international survey of current, former or never users incidence of sudden infant death syndrome, respiratory of e-cigarettes, 72% of users reported that e-cigarettes illness, middle-ear disease and asthma [11,12]. Children helped them to deal with cravings and withdrawal symp- aged between 3 and 11 years have the highest levels toms, 92% reported reductions in their smoking when of SHSe, probably because they spend a majority of using e-cigarettes, and only 10% reported that they expe- their time in close proximity to a caregiver who smokes rienced the urge to smoke tobacco cigarettes when using [13–15]. Despite the strong national effort of introduc- the e-cigarette [10]. Moreover, of more than 2000 former ing smoking bans in public spaces, children living smokers in this survey, 96% reported that the e-cigarette with smokers have not experienced any reduction in helped them to stop smoking, and 79% reported fearing their SHSe, as evidenced by serum cotinine levels [16].
2012 The Authors. Addiction 2012 Society for the Study of Addiction Addiction, 107, 1545–1548
E-cigarettes: balanced perspective Furthermore, clinical interventions aimed at reducing Declarations of interest
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