By Mark Gold, MD
Smoking cigarettes can be very dangerous to a person’s health— each year smoking kills more Americans than alcohol, car accidents, HIV, guns, and illicit drugs combined. In addition to harming the person smoking, combustible cigarettes can also put non-smokers at risk: those who inhale someone else’s smoke (second hand smoke) or come into contact with smoke residue (third hand smoke exposure). Smoking is related to 30% of all cancer cases as well as emphysema, chronic bronchitis, higher risk of stroke, heart failure, and other heart diseases. Smoking traditional cigarettes can shorten a person’s lifespan by over 11 years.1 Since the Surgeon General’s pivotal report on the harms of tobacco was published in 1964, the US has launched major cessation programs using educational campaigns and improved access to medications like varenicline and nicotine-replacement therapies. While cigarette smoking has decreased substantially in the US since the report was released (45% in 1965 vs. 15.5% in 2016), it is still a major health concern. Despite the decrease in the use of traditional cigarettes, the use of e-cigarettes has gained popularity since their approval for use in 2006. E-cigarettes heat nicotine, flavorings, and other chemicals to create an aerosol that is inhaled. While e-cigarette manufacturers claim to have developed a safer nicotine delivery system, nicotine is the central chemical that causes addiction among cigarette smokers and worryingly, some research has associated higher nicotine levels with e-cigarette use. Given this information, we know that both cigarettes and e-cigarettes can be addicting on the basis of both smoke- and vapor-related release of nicotine into the blood and brain. Experts also caution against the potential harms associated with “vaping” and demand more research be conducted. Unlike other tobacco products, e-cigarettes have not yet been subject to a government health and safety review.
Recent attention has also been paid to the alarming rise in e-cigarette use by teens and young adults, especially due to the high variability of nicotine content and delivery speed across devices. Teen vaping has become an epidemic in the last few years: between 2017 and 2018, the share of high-school students using e-cigarettes rose by 78% (one in five). E-cigarettes have also gained some popularity among adults as an alternative to combustible cigarettes and a way to help adults quit smoking. E-cigarette use have been shown to reduce some of the health risks caused by smoking cigarettes, although some experts are skeptical.2 A recent study compares the effectiveness of using e-cigarettes versus existing nicotine-replacement therapies to help adults quit smoking.
The Study:
886 patients attending the National Health Service stop-smoking services in the U.K. were randomly assigned to either nicotine-replacement product(s) of their choice, including a combination of products, or an e-cigarette. Treatment included behavioral health support every week for a month.
Outcomes:
The goal was to help patients maintain abstinence for one year. At the final visit, the researchers used biochemical testing and qualitative interviews to collect the following results:
Abstinence at one year was 18% in the e-cigarette group, as compared with 9.9% in the nicotine-replacement group
Among those abstinent for the full year, those in the e-cigarette group were more likely than those in the nicotine-replacement group to still be using their assigned product— 80% of e-cigarette users and 9% of nicotine-replacement users.
Throat and/or mouth irritation was reported by more patients in the e-cigarette group (65.3% of e-cigarette users vs. vs. 51.2% of nicotine-replacement users) and;
Nausea was reported by more patients in the nicotine-replacement group (37.9% for users of nicotine-replacement, vs. 31.3% in the e-cigarette group).
A lower incidence of cough and phlegm production from baseline to 52 weeks than was reported by the nicotine-replacement group - a higher rate was reported by e-cigarette users.
Both groups reported a similar rate of wheezing or shortness of breath.
Because e-cigarettes are a newer technology, there is little data about the long-term health effects of using e-cigarettes as a short- or long-term alternative to traditional cigarettes.
Looking to the Future:
The study showed that in combination with behavioral support, e-cigarettes were found to be doubly as effective at helping people stop smoking than nicotine-replacement therapies. Nicotine-replacement therapies themselves have been found to be less effective than other medications, like varenicline, for smoking cessation. There is ongoing research that indicates e-cigarette use may cause higher rates of cardiovascular side effects and health events long-term. There is also very little research that tells us how the use of e-cigarettes to stop smoking is correlated with other chronic illnesses, like cancer, or asthma. These potential and currently unexplored health consequences could render e-cigarettes unsuitable as an aid for stopping smoking despite their high comparative effectiveness to other nicotine-replacement therapies. In short, more research is needed to understand the long-term primary, secondary, and tertiary effects of vaping nicotine, the initiation of other drug use, and concurrent cigarette and vaping prevalence. For example, some tobacco cigarette users may be initiating e-cigarette use to decrease their use of traditional cigarettes, but a recent study found that most were using the product infrequently and concurrently with cigarettes and other products. E-cigarettes could prove to be a viable acute option for helping to reduce the harm associated with traditional cigarette smoking, but the data is lacking, presently, to be able to suggest e-cigarettes as the most viable approach to smoking cessation.
References
The American Cancer Society medical and editorial content team. (2018, November 15). Health Risks of Smoking Tobacco. Retrieved from https://www.cancer.org/cancer/cancer-causes/tobacco-and-cancer/health-risks-of-smoking-tobacco.html.
McNeill, A., Brose, L.S., Calder, R., Bauld, L., Robson, D., (2018) Evidence review of e-cigarettes and heated tobacco products 2018: a report commissioned by Public Health England. Public Health England.
Citation:
Hajek, P., Phillips-Waller, A., Przulj, D., et al. (2019) A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy. New England Journal of Medicine.
Dr. Mark S. Gold is a teacher of the year, translational researcher, author, mentor and inventor best known for his work on the brain systems underlying the effects of opiate drugs, cocaine and food. Read more by Dr. Gold here.