Read Healthy Debate’s analysis on Regulating the ‘wild west’ of e-cigarettes.
As respirologists, we are frequently asked for our opinion on e-cigarettes. At first glance there appears to be some potential positives. While one study suggested that there could be a role for these devices in helping active smokers quit tobacco, a more recent small study questions this claim. Certainly when you consider the countless harmful chemicals in tobacco smoke, a nicotine delivery option without the tar and other combustion by-products seems like a healthier way to satisfy a nicotine addiction. However, we have concerns about e-cigarettes, including the absence of long-term data on their safety and efficacy as smoking cessation aids as well as the lack of regulation regarding their production, sale and use.
The safety concerns are not insignificant. In 2009, the Food and Drug Association released a warning that a cartridge from a leading brand of e-cigarettes was found to contain a small amount of diethylene glycol, a chemical used in antifreeze, as well as detectable levels of known carcinogens and toxic chemicals to which users could be exposed. Propylene glycol, in which the nicotine in e-cigarettes is suspended, has been linked to adverse changes in lung function. While the short term effects of using e-cigarettes on lung health may be comparable or less than conventional cigarettes, there are no studies looking at longer term effects on lung or cardiovascular health.
Furthermore, in the current climate of unregulated products, individuals can select from over 400 devices and compounds, delivering as much as 10- to 15-fold more nicotine compared to a cigarette. It is difficult to base a clinical recommendation on a series of products that are so highly variable.
More concerning is that the high concentration of nicotine in the substances used to fill these devices can be profoundly toxic when taken orally. The exotic flavours are attractive to children and the manufacturers are not required to have child-proof caps. As use becomes more prevalent, we will likely see cases of serious toxicity or possibly death due to nicotine overdose. Independent of the debate around whether e-cigarettes are effective smoking cessation aids, immediate attention must be paid to regulating these products to mitigate this important public health risk.
The lack of high quality evidence to support the use of e-cigarettes as smoking cessation aids presents another barrier for the clinician. Some smokers view e-cigarettes as a risk-free alternative to available smoking cessation aids. But we do not actually know how e-cigarettes compare in terms of effectiveness and safety to pharmacologic smoking cessation aids. In the absence of high quality clinical trials to address these and other important questions about e-cigarettes as smoking cessation aids, at the present time we are not able to provide our patients with advice concerning the true efficacy or safety of e-cigarettes.
Much of the popular debate regarding e-cigarettes is policy related, but from a clinical perspective, there are far more questions than answers. We see many parallels between e-cigarettes and herbal medications: their use is becoming more common, they are not regulated and they are often considered to be harmless by the people who take them. Perhaps when the dust settles, like herbal medications, we will find that e-cigarettes may be useful in the right context and with the right oversight, but also are not without risk.
There is much more work to be done before we can comfortably recommend e-cigarettes as smoking cessation aids, including clear and comprehensive regulation to prevent immediate public safety risks and a well designed randomized control trial assessing the safety and effectiveness of e-cigarette devices compared to commonly used smoking cessation aids.