Maryland's Tobacco Resource Center - Linking Professionals to Best Practices

E-Cigarettes

For more than a decade, e-cigarettes have taken off as an alternative nicotine product to conventional cigarettes.  Since their entry to the market, debates among researchers and public health professionals have followed concerning their potential risks and possible benefits to global health.  At MD QUIT, we are keeping up with the latest research, and have summarized take-home points so that providers and consumers can best use this information to fit their smoking cessation needs. 

Are you new to the topic of e-cigarettes and other electronic nicotine delivery systems?  We welcome you to scroll down and read the important points in E-Cigarettes 101.

                                                                                                                                                                                                                                                 

Take-home point #1.  E-cigarettes contain nicotine, a hazardous chemical for many

Any product containing nicotine, including e-cigarettes, poses dangers to youth, young adults, pregnant women, and fetuses.  E-cigarettes harm brain development until the early to mid-20’s, and have become the most commonly used form of tobacco among youth today.   

For more information consider the 2016 Surgeon General’s Report1 for e-cigarette use among youth and young adults by clicking here.   

Take-home point #2:  E-cigarettes as harm reduction?

Based on the current understanding of the latest research, tobacco products that are noncombustible, including e-cigarettes, are less dangerous on most health measures than continued smoking with combustible, conventional cigarettes.

However, this does not mean that e-cigarettes are harmless.  A recent review of the literature has found that e-cigarettes containing nicotine have probable negative effects on cardiovascular and reproductive health, and possibly increased infectious disease risk3.  For more specific information please see the attached 2017 review

  • Current smokers concerned about their health are encouraged to make a quit attempt that includes FDA approved options, including 1) Nicotine Replacement Therapy:  NRT (e.g. patch and gum), 2) medications, and 3)  habit-reducing behavioral interventions such as counseling.          

Take-home point #3:  E – cigarettes to aid with smoking cessation?

Over the past years the research concerning e-cigarettes as a therapeutic quit aid have been mixed.  Some studies have found that e cigarettes have reduced urges and dependence-type symptoms4, while others have found that people tend to remain dual users of both5.    

  • However, a recent report from July 2017found that e-cigarette users were more likely than non-users to make a quit attempt in the past year, and more likely to succeed in quitting for at least 3 months.  These results may have also involved other factors related to e-cigarette use, such as an increased level of motivation, or increases in broader tobacco control initiatives, happening at the same time.
  • The clearest message we know today is that NRT and FDA-approved medications (Chantix and Zyban) are already evidence-based, and are suggested to be used before the use of e-cigarettes in a quit-attempt.     

 

E-Cigarettes 101:  

Electronic Cigarettes (E-Cigarettes or E-cigs) or Electronic Nicotine Delivery System (ENDS):

  • Are battery-powered devices designed to look similar to cigarettes in shape, size, and general appearance.
  • Operate by vaporizing a solution containing nicotine, creating a mist that is then inhaled.7
  • Are available in various flavors, such as vanilla,8 menthol,8 and pina colada8.
  • Nicotine cartridges contain various levels of nicotine, anywhere from 6-48 mg. This is significantly more nicotine compared to the typical range of 0.5-1.2 mg of nicotine in a single cigarette.7
  • The act of puffing an e-cigarette is often referred to as “vaping”.

 

E-Cigarette Components

Source: Tobacco-Free Partnership of Levy County. Frequently-Asked Questions About E-Cigarettes. 

Current awareness of e-cigarettes9:

  • Adult awareness of e-cigarettes has nearly doubled from 40.9% in 2010 to 79.7% in 2013 (awareness of e-cigarettes was assessed by asking, “Which, if any, of the following products have you heard of”? Those who selected e-cigarettes were considered to be aware)
  • Women are less likely to be aware than men
  • Non-Hispanic Blacks less likely to be aware than non-Hispanic Whites
  • Current smokers more likely to be aware than never smokers

Ever use of e-cigarettes10:

  • Nearly 1 in 10 adults have tried these products
  • Ever use of e-cigarettes has increased from 3.3% in 2010 to 8.5% in 2013
  • Ever use of e-cigarettes is higher among current smokers than former or never smokers

Current use of e-cigarettes11:

  • Despite controversy about their health effects11, e-cigarette use is on the rise
  • Current use of e-cigarettes has increased from 1% in 2010 to 2.6% in 2013
  • Among current cigarette smokers, current e-cigarette use increased from 4.9% in 2010 to 9.4% in 2013
    • ​Among ever e-cigarette smokers, 63.4% were current smokers in 2013
    • 76.8% of current e-cigarette users are current cigarette smokers compared to 72% in 2010

Are e-cigarettes regulated?12

  • Currently, only e-cigarettes marketed for therapeutic use are FDA-regulated. However, currently there are no e-cigarettes approved by FDA for therapeutic uses, therefore they cannot be recommended or marketed as a smoking cessation aid.13
  • FDA has recently proposed a rule to extend their regulatory authority to additional products, including e-cigarettes. This rule is still under the process of review and finalization.12  

Are e-cigarettes safe?

Currently, the research concerning the safety of electronic cigarettes is ambiguous.

  • E-cigarettes do not produce smoke like conventional cigarettes.14 Although the long-term effects of e-cigarette use are not known, current research indicates that e-cigarettes are likely safer than conventional cigarettes.10
  • Some toxins (e.g., nitrosamines, formaldehyde, and diethylene glycol) have been found in e-cigarettes indicating they may not be harmless.14-16
  • Other studies have found a correlation between conventional cigarette use and e-cigarette use.17-18 This suggests that some may not use e-cigarettes to quit conventional cigarette use, since the majority of e-cigarette users are also current smokers, which has a number of well-documented health risks.

Possible Benefits:

  • Some research indicates that e-cigarettes can help individuals cut down or quit smoking conventional cigarettes.19-20
  • In 2010, an online survey was conducted to determine possible electronic cigarette use patterns and the effectiveness of electronic cigarettes as a smoking-cessation tooll.
  • Results of the study indicated that more frequent use of e-cigarettes was associated with a number of positive outcomes:
    • ​Less cigarette smoking (66.8% of participants)
    • Longer periods of abstinence from cigarette smoking (48.8% of participants)
    • Increased likelihood of quitting cigarettes if e-cigarette use was >20 times per day (70% of participants)

Possible Disadvantages and Concerns11:

  • Potential initiation of nicotine addiction in adolescents
  • Potential progression to combusted tobacco use among non-tobacco users
  • May lead to long-term co-morbid use of e-cigarettes and conventional cigarettes among current smokers
  • May lead to relapse to cigarette smoking among current cigarette smokers

Conclusions:

  • More research is needed on electronic cigarettes.
  • The field of tobacco research has begun to examine the utility and health effects of these products, but is only at the beginning.
  • To date, research has not shown consistent findings that these products are safe and able to reduce cigarette consumption. 
References: 

1.  U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General—Executive Summary. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2016.

2. Royal College of Physicians. Nicotine without smoke: Tobacco harm reduction. London: RCP, 2016. 

3. Benowitz, N. L., & Fraiman, J. B. (2017). Cardiovascular effects of electronic cigarettes. Nature Reviews Cardiology14(8), 447-456. doi:10.1038/nrcardio.2017.36 

4. Malas, M., van der Tempel, J., Schwartz, R., Minichiello, A., Lightfoot, C., Noormohamed, A., ... & Ferrence, R. (2016). Electronic Cigarettes for Smoking Cessation: A Systematic Review. Nicotine & Tobacco Research, ntw119.

5. Shahab, L., Goniewicz, M. L., Blount, B. C., Brown, J., McNeill, A., Alwis, K. U., & ... West, R. (2017). Nicotine, Carcinogen, and Toxin Exposure in Long-Term E-Cigarette and Nicotine Replacement Therapy Users: A Cross-sectional Study. Annals Of Internal Medicine166(6), 390-400. doi:10.7326/M16-1107

6.  Zhu, S. H., Zhuang, Y. L., Wong, S., Cummins, S. E., & Tedeschi, G. J. (2017). E-cigarette use and associated changes in population smoking cessation: evidence from US current population surveys.  British Medical Journal358, j3262.   

7. Kuschner, W.G., Reddy, S., Mehrotra, N., & Paintal, H.S. (2011). Electronic cigarettes and thirdhand tobacco smoke: Two emerging health care challenges for the primary care provider. International Journal of General Medicine, 4, 115-120. doi: 10.2147/IJGM.S16908.

8.  blu Cigs (2014). blu Rechargeable Pack, Original and Premium Electronic Cigarette Flavor Cartridges. Retrieved from: http://www.blucigs.com/cartridges.

9.  King, B.A. et al. (2014). Trends in Awareness and Use of E-Cigarettes Among Adults, 2010-2013. Nicotine and Tobacco Research. Advance online publication.  doi: 10.1093/ntr/ntu191

10.  Sutfin, E.L., et al. (2013).  Electronic cigarette use by college students. Drug & Alcohol Dependence, 131, 214-221.

11.  U.S. Food and Drug Administration (2014). Electronic Cigarettes. Retrieved from: http://www.fda.gov/newsevents/publichealthfocus/ucm172906.htm

12.  Goniewicz, M.L., et al. (2014).  Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tobacco Control, 23, 133-139.

13. U.S. Department of Health and Human Services (2014). Electronic Cigarettes. Retrieved from http://betobaccofree.hhs.gov/about-tobacco/Electronic-Cigarettes/

14. Burstyn, I. (2013).  Peering through the mist: systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks. BMC Public Health, 14: 18. doi:10.1186/1471-2458-14-18 

15. U.S. Food and Drug Administration (2014). Summary of results: Laboratory analysis of electronic cigarettes conducted by FDA. Retrieved from http://www.fda.gov/newsevents/publichealthfocus/ucm173146.htm

16. Lee, S., Grana, R.A., & Glantz, S.A. (2013). Electronic-cigarette use among Korean adolescents: A cross-sectional study of market penetration, dual use, and relationship to quit attempts and former smoking. Journal of Adolescent Health, 54, 684-90. 

17. Regan, A.K., Promoff, G., Dube, S.R. & Arrazola, R. (2011). Electronic nicotine delivery systems: Adult use and awareness of the 'e-cigarette' in the USA. Tobacco Control, 22, 19-23. doi:10.1136/tobaccocontrol-2011-050044 

18. Bullen, C., et al. (2013).  Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet, 382, 1629 – 1637.

19. Siegel, M.B., Tanwar, K.L., & Wood, K.S. (2011). Electronic Cigarettes As a Smoking-Cessation Tool. American Journal of Preventive Medicine, 40, 472-475.

20. Etter, J.-F. &Bullen, C. (2014).  A longitudinal study of electronic cigarette users. Addictive Behaviors, 2, 491-494.