Can electronic cigarettes assist patients with smoking cessation?

Potential concerns

A Chinese company, Ruyan, is credited with the invention of the e-cigarette, released on the Asian market in 2004.⁵ “Vaping” (the act of using an e-cigarette) is healthier than smoking because the e-cigarette does not produce smoke or contain the toxic compounds present in a traditional cigarette, nor does it release second-hand smoke. However, there are potential concerns. In 2009, the US Food and Drug Administration conducted an analysis of 2 brands of e-cigarette cartridges. Trace levels of carcinogenic nitrosamines were present in more than half of the samples, and potentially harmful compounds, such as anabasine, myosmine, and β-nicotyrine, were present in most of the tested samples.⁶ These compounds are also present in tobacco smoke at concentrations that are 100 to 1000 times higher than in e-cigarettes! Propylene glycol, the main ingredient in most e-cigarette cartridges, has been approved for use in food products in Canada as a food preservative, in asthma inhalers and nebulizers, and in theatrical fog machines. Its effects on health are currently, at most, controversial.

Another concern is that public use of e-cigarettes could re-normalize the use of tobacco products.⁷ Flavoured nicotine cartridges appeal to youth, which could potentially serve as a gateway to developing a harmful nicotine addiction. That being said, all population-based studies of adults show the highest rate of e-cigarette use is among current smokers, followed by former smokers, with little use among non-smokers, although e-cigarette trial and use rose in all of these categories.⁸ In a sample of e-cigarette users recruited from websites dedicated to e-cigarettes and smoking cessation,⁹ most (72%) were former smokers at baseline.

In Canada, the only legal e-cigarettes have no nicotine added. We need to ensure that there is specific legislation to prevent smoking e-cigarettes in the same places regular cigarettes are prohibited. They also should not be flavoured or sold to minors.

Choice is needed

People smoke for various reasons and thus need a variety of choices to assist in cessation attempts. Nicotine addiction, habit, stress, and lifestyle are all factors that need to be dealt with. Reasons quoted for smoking include the following: “I light up when someone makes me angry,” “I am very aware of not smoking when I don’t have a cigarette in my hand,” and “I find a cigarette in my mouth and don’t remember putting it there.”¹⁰ Allowing patients to mimic smoking behaviour with an e-cigarette can be helpful. In the ECLAT (Efficiency and Safety of an Electronic Cigarette) study, 11% of the smokers who received e-cigarettes containing nicotine reported that they had abstained from smoking traditional cigarettes at the last follow-up visit.¹¹ Polosa et al followed 23 subjects not currently planning to quit who were given e-cigarettes containing nicotine; at the 24-month visit 18 continued to smoke and 11 had reduced cigarette consumption by 50% or more, with a statistically significant reduction from an average of 24 to 4 cigarettes per day (P = .003).¹² Five participants had quit tobacco cigarettes at 24 months.