Abstracts
The electronic nicotine delivery system, also known as the electronic cigarette, is generating considerable controversy, not only in the general population but also among health professionals. Smokers the world over have been increasingly using electronic cigarettes as an aid to smoking cessation and as a substitute for conventional cigarettes. There are few available data regarding the safety of electronic cigarettes. There is as yet no evidence that electronic cigarettes are effective in treating nicotine addiction. Some smokers have reported using electronic cigarettes for over a year, often combined with conventional cigarettes, thus prolonging nicotine addiction. In addition, the increasing use of electronic cigarettes by adolescents is a cause for concern. The objective of this study was to describe electronic cigarettes and their components, as well as to review the literature regarding their safety; their impact on smoking initiation and smoking cessation; and regulatory issues related to their use.
Smoking; Tobacco Products; Nicotine
O cigarro eletrônico é um sistema eletrônico de liberação de nicotina que está gerando controvérsias, tanto entre a população quanto entre profissionais da saúde. O uso crescente do cigarro eletrônico é observado em tabagistas de diversos países, tanto para auxiliar na cessação do tabagismo quanto como substituto do cigarro convencional. Dados sobre a segurança do uso do cigarro eletrônico são limitados. Do mesmo modo, até o momento, não há evidências de que o cigarro eletrônico seja efetivo para tratar a adição à nicotina. Usuários relataram usar o cigarro eletrônico por mais de um ano, frequentemente combinado com o cigarro convencional, prolongando assim a dependência de nicotina. Ainda, o uso crescente do cigarro eletrônico por adolescentes gera preocupação. Neste artigo é feita uma descrição do cigarro eletrônico e de seus constituintes, assim como são revistos os dados disponíveis sobre segurança, impacto na iniciação e na cessação do tabagismo, e questões relacionadas à regulação do uso do cigarro eletrônico.
Hábito de Fumar; Produtos do Tabaco; Nicotina
Introduction
Smoking is a major public health problem worldwide and is considered by the World Health
Organization (WHO) to be one of the leading causes of preventable death.(
11. World Health Organization [homepage on the Internet]. Geneva: WHO
[cited 2014 Jan 13]. WHO Report on the Global Tobacco Epidemic, 2011; [about 2
screens]. Available from:
http://www.who.int/tobacco/global_report/en/
http://www.who.int/tobacco/global_report...
) In Brazil, approximately 220,000 tobacco-related deaths occur each year.
(
22. Instituto Nacional de CâncerJosé Alencar Gomes da Silva [homepage on
the Internet]. Rio de Janeiro: INCA; c [cited 2014 Jan 13]. Available from:
www.inca.gov.br
www.inca.gov.br...
) Nevertheless, 16.1% of all Brazilian adults are smokers; of those, 17
million are male and 12.5 million are female.(
33. Malta DC, Moura EC, Silva SA, Oliveira PP, Silva VL. Prevalence of
smoking among adults residing in the Federal District of Brasília and in the state
capitals of Brazil, 2008. J Bras Pneumol. 2010;36(1):75-83.
http://dx.doi.org/10.1590/S1806-37132010000100013
http://dx.doi.org/10.1590/S1806-37132010...
) Concerns regarding the morbidity and mortality associated with smoking led
to the WHO Framework Convention on Tobacco Control (FCTC), which was implemented on
February 27, 2005 and was ratified by 177 countries, including Brazil. (
44. World Health Organization [homepage on the Internet]. Geneva: WHO
[cited 2014 Jan 13]. WHO Framework Convention on Tobacco Control. [Adobe Acrobat
document, 44p.]. Available from:
http://whqlibdoc.who.int/publications/2003/9241591013.pdf
http://whqlibdoc.who.int/publications/20...
) Among the guidelines for implementation of the WHO FCTC are the promotion
of smoke-free environments and the implementation of smoking cessation projects. In
accordance with the WHO FCTC, the Brazilian National Ministry of Health developed a
smoking cessation program based on cognitive-behavioral therapy and pharmacological
treatment, the program being implemented in the Brazilian Unified Health Care
System.(
55. Portal de Saúde [homepage on the internet]. Brasília: Ministério da
Saúde [cited 2012 Apr 20]. Portaria no. 1035/GM, de 31 de maio de 2004. Available
from:
http://dtr2001.saude.gov.br/sas/PORTARIAS/Port2004/GM/GM-1035.htm.
http://dtr2001.saude.gov.br/sas/PORTARIA...
)
Studies of smokers have shown that many would not smoke if they had their time
again(
66. Jarvis MJ, McIntiyre NC, Bates C, Foulds J. Effectiveness of smoking
cessation initiatives. Efforts must take into account smokers' disillusionment with
smoking and their delusions about stopping. BMJ. 2002;324(7337):608-9.
http://dx.doi.org/10.1136/bmj.324.7337.608
http://dx.doi.org/10.1136/bmj.324.7337.6...
) and that 60-70% wanted to quit smoking.(
77. Aveyard P, West R. Managing smoking cessation. BMJ.
2007;335(7609):37-41. http://dx.doi.org/10.1136/bmj.39252.591806.47
http://dx.doi.org/10.1136/bmj.39252.5918...
) However, without assistance, most of those who attempt to quit smoking
relapse, and only 4% remain abstinent at one year.(
88. Hughes JR, Keely J Naud S. Shape of the relapse curve and long-term
abstinence among untreated smokers. Addiction. 2004;99(1):29-38.
http://dx.doi.org/10.1111/j.1360-0443.2004.00540.x
http://dx.doi.org/10.1111/j.1360-0443.20...
) One of the most important factors that make smoking cessation more
difficult is nicotine dependence. In this context, the electronic cigarette (EC, also
known as e-cigarette) has emerged as a form of nicotine replacement therapy. The EC was
developed by Chinese pharmacist Hon Lik and was patented in 2003.(
99. Cahn Z, Siegel M. Electronic cigarettes as a harm reduction strategy
for tobacco control: a step forward or a repeat of past mistakes? J Public Health
Policy. 2011;32(1):16-31. http://dx.doi.org/10.1057/jphp.2010.41
http://dx.doi.org/10.1057/jphp.2010.41...
) Although there is a lack of data on their efficacy and safety, ECs are
widely available for purchase on the Internet, as well as being sold directly to
consumers in various countries.
Currently, more than 2,500 brands of ECs are sold worldwide.(
1010. Benowitz NL, Goniewicz ML. The regulatory challenge of electronic
cigarettes. JAMA. 2013;310(7):685-6.
http://dx.doi.org/10.1001/jama.2013.109501
http://dx.doi.org/10.1001/jama.2013.1095...
) Several of these brands have been acquired by the tobacco industry. In the
USA, the price of an EC ranges from U$ 29.95 to U$ 149.95, and the price of an EC
cartridge ranges from U$ 9.95 to U$ 19.95.(
1111. Odum LE, O'Dell KA, Schepers JS. Electronic cigarettes: do they have
a role in smoking cessation? J Pharm Pract. 2012;25(6):611-4.
http://dx.doi.org/10.1177/0897190012451909
http://dx.doi.org/10.1177/08971900124519...
) In Brazil, the National Health Surveillance Agency prohibited the
commercialization, importation, and advertising of ECs in 2009.(
1212. Brasil. Ministério da Saúde. Agência Nacional de Vigilância
Sanitária. Resolução de Diretoria Colegiada no. 46, de 28 de agosto de 2009. Proíbe a
comercialização, a importação e a propaganda de quaisquer dispositivos eletrônicos
para fumar, conhecidos como cigarro eletrônico. Diário Oficial da União; 29 Aug 2009;
Section 1. p. 45.
) Nevertheless, smokers have access to ECs and often seek advice from
pulmonologists regarding the recommendations for use and efficacy of ECs. The objective
of the present study was to describe ECs and their components, as well as to review the
available evidence regarding their role in smoking cessation; their impact on smoking
initiation; their safety; and ethical and regulatory issues related to their use.
Characteristics of ECs
The EC is an electronic device that provides users with an aerosol containing nicotine
and other additives. The three main components of an EC are a battery, an atomizer, and
a cartridge containing nicotine (Figure 1).
Nicotine-free ECs are commercialized in some countries.(
1313. Bullen C, Howe C, Laugesen M, McRobbie H, Parag V, Williman J, et
al. Electronic cigarettes for smoking cessation: a randomised controlled trial.
Lancet. 2013;382(9905):1629-37.
http://dx.doi.org/10.1016/S0140-6736(13)61842-5
http://dx.doi.org/10.1016/S0140-6736(13)...
) Some ECs have, on one end, a light-emitting diode that lights up when the
device is used, thus reminding users that the cigarette is lit. Most electronic nicotine
delivery systems mimic traditional forms of tobacco use, i.e., cigarettes, cigars, and
pipes; less commonly, electronic nicotine delivery systems resemble daily use objects
such as a pen or a USB flash drive, being primarily used by individuals who want to
smoke without attracting attention.(
1414. World Health Organization [homepage on the Internet]. Geneva: WHO
[cited 2014 Jan 13]. WHO Tobacco Free Initiative (TFI) - Questions and answers on
electronic cigarettes or electronic nicotine delivery systems (ENDS). Available from
http://www.who.int/tobacco/communications/statements/eletronic_cigarettes/en/index.html.
http://www.who.int/tobacco/communication...
)
Although the components of an EC cartridge vary according to the brand, EC cartridges
usually contain nicotine and a component aimed at producing an aerosol (e.g., propylene
glycol or glycerol diluted in water). The nicotine concentration in an EC cartridge can
vary and might not correspond to that described by the manufacturer.(
1515. Goniewicz ML, Knysak J, Gawron M, Kosmider L, Sobczak A, Kurek J, et
al. Levels of selected carcinogens and toxicants in vapour from electronic
cigarettes. Tob Control 2014;23(2):133-9.
http://dx.doi.org/10.1136/tobaccocontrol-2012-050859
http://dx.doi.org/10....
,
1616. World Health Organization Study Group on Tobacco Regulation. TobReg
scientific recommendation: devices designed for the purpose of nicotine to the
respiratory system in which tobacco is not necessary for their operation. In: WHO
Technical Report Series 955. Report on the scientific basis of tobacco regulation:
third report of a WHO study group. Geneva: World Health Organization; 2009. p.
3-22.
) Some brands of ECs contain flavorings such as fruit extract, vanilla, mint,
coffee, and chocolate, which make ECs more attractive, especially to adolescents.
Several potentially harmful substances, such as formaldehyde, acetaldehyde, acrolein,
volatile organic compounds, heavy metals, and tobacco-specific nitrosamines, have been
identified in nicotine cartridges.(
1515. Goniewicz ML, Knysak J, Gawron M, Kosmider L, Sobczak A, Kurek J, et
al. Levels of selected carcinogens and toxicants in vapour from electronic
cigarettes. Tob Control 2014;23(2):133-9.
http://dx.doi.org/10.1136/tobaccocontrol-2012-050859
http://dx.doi.org/10....
,
1717. Westenberger BJ. Evaluation of e-cigarettes. US Food and Drug
Administration; Center for Drug Evaluation and Research; Division of Pharmaceutical
Analysis. Rockville, MD: US Food and Drug Administration; 2009 [Adobe Acrobat
document, 8p.]. Available from:
http://www.fda.gov/downloads/Drugs/ScienceResearch/UCM173250.pdf
http://www.fda.gov/downloads/Drugs/Scien...
)
When users draw air through an EC, a sensor detects air flow and heats the liquid in the cartridge, which is vaporized. The aerosol delivers nicotine to EC users, and part of the EC aerosol is released into ambient air when users exhale. The temperature of the EC aerosol ranges from 40°C to 65°C. According to the manufacturers, a single EC cartridge can yield 10-250 puffs, corresponding to 5-30 conventional cigarettes (depending on the brand).( 1818. Bertholon JF, Becquemin MH, Annesi-Maesano I, Dautzenberg B. Electronic cigarettes: a short review. Respiration. 2013;86(5):433-8. ) Second- and third-generation ECs have recently been developed; they have batteries and atomizers that are more powerful and can deliver higher doses of nicotine, thus increasing the risk of addiction.( 1919. Farsalinos KE, Spyrou A, Tsimopoulou K, Stefopoulos C, Romagna G, Voudris V. Nicotine absorption from electronic cigarette use: comparison between first and new-generation devices. Sci Rep. 2014;26;4:4133. )
Prevalence of EC use in adults
Although there is a lack of evidence that the EC is effective in smoking cessation, the
interest in ECs is increasing, as is the number of EC users worldwide, most of whom are
adult smokers.(
2020. Yamin CK, Bitton A, Bates DW. E-cigarettes: a rapidly growing
Internet phenomenon. Ann Intern Med. 2010;153(9):607-9.
http://dx.doi.org/10.7326/0003-4819-153-9-201011020-00011
http://dx.doi.org/10.7326/0003-4819-153-...
21. Dockrell M, Indu SD, Lashkari HG, McNeill A. "It sounds like the
replacement I need to help me stop smoking": Use and acceptability of "e-cigarettes"
among UK smokers. Proceedings of the 12th annual meeting of the Society for Research
on Nicotine and Tobacco Europe; 2010 Sep 6-9; Bath, UK, 2010. London: SRNT and UK
Centre for Tobacco Control Studies; 2010. p.48.
-
2222. Pepper JK, Brewer NT. Electronic nicotine delivery system
(electronic cigarette) awareness, use, reactions and beliefs: a systematic review.
Tob Control. 2014;23(5):375-84.
http://dx.doi.org/10.1136/tobaccocontrol-2013-051122
http://dx.doi.org/10.1136/tobaccocontrol...
) Users of ECs identify themselves as "vapers". In the USA, a survey of more
than 10,000 adults showed that knowledge of the existence of ECs doubled between 2009
and 2010 (from 16.4% to 32.2%), and the use of ECs nearly quadrupled (from 0.6% in 2009
to 2.7% in 2010).(
2323. Regan AK, Promoff G, Dube SR, Arrazola R. Electronic nicotine
delivery systems: Adult use and awareness of the 'e-cigarette' in the USA. Tob
Control. 2013;22(1):19-23.
http://dx.doi.org/10.1136/tobaccocontrol-2011-050044
http://dx.doi.org/10.1136/tobaccocontrol...
) Among active smokers, 11.4% reported having used ECs, and 4.1% reported
having used ECs in the past 30 days.(
2424. Pearson JL, Richardson A, Niaura RS, Vallone DM, Abrams DB.
e-Cigarette awareness, use, and harm perceptions in US adults. Am J Public Health.
2012;102(9):1758-66. http://dx.doi.org/10.2105/AJPH.2011.300526.
http://dx.doi.org/10.2105/AJPH.2011.300...
) In Great Britain, the proportion of regular EC users increased from 2.7% in
2010 to 6.7% in 2012.(
2525. Dockrell M, Morrison R, Bauld L, McNeill A. E-cigarettes: prevalence
and attitudes in Great Britain. Nicotine Tob Res. 2013;15(10):1737-44.
http://dx.doi.org/10.1093/ntr/ntt057
http://dx.doi.org/10.1093/ntr/ntt057...
) Data collected between 2010 and 2011 from 5,939 individuals in four
countries (the USA, the UK, Canada, and Australia) showed that approximately half of the
interviewees (46.6%) were aware of the existence of ECs. However, the proportion of
individuals that were aware of the existence of ECs varied significantly among the
countries studied, being higher in the USA (73.4%) and the UK (54.4%), where EC use is
allowed, and lower in Canada (39.5%) and Australia (20.0%), where EC use has been
banned. The rate of experimentation was 7.6% (being 16.3% among those who were aware of
ECs), and the rate of current use was 3%; the proportion of current EC users did not
vary among the countries studied (p = 0.114).(
2626. Adkison SE, O'Connor RJ, Bansal-Travers M, Hyland A, Borland R, Yong
HH. Electronic nicotine delivery systems: international tobacco control four-country
survey. Am J Prev Med. 2013;44(3):207-15.
http://dx.doi.org/10.1016/j.amepre.2012.10.018
http://dx.doi.org/10.1016/j.amepre.2012....
)
An online forum on smoking cessation and ECs held in England and France in 2010 brought
together 3,587 participants (former smokers, 70%; males, 61%; mean age, 41 years).
Nicotine-containing ECs were used by 97% of the participants, being used for
approximately five months by former smokers. Most reported that ECs helped them quit or
reduce smoking (96%). Reasons for EC use included the perception that ECs were less
toxic than conventional cigarettes (87%), a reduction in tobacco craving (79%), a
reduction in withdrawal symptoms (77%), the fact that ECs were less expensive than
tobacco (57%), and control of situations in which smoking was prohibited
(39%).(
2727. Etter JF, Bullen C. Electronic cigarette: users profile,
utilization, satisfaction and perceived efficacy. Addiction. 2011;106(11):2017-28.
http://dx.doi.org/10.1111/j.1360-0443.2011.03505.x
http://dx.doi.org/10.1111/j.1360-0443.20...
) One limitation of the study was the selection of a convenience sample. An
online survey of 81 smokers showed the pattern of EC use among regular EC users. The
median duration of EC use was 100 days, and the median number of puffs/day was
175.(
2828. Etter JF. Electronic cigarettes: a survey of users. BMC Public
Health. 2010;10:231. http://dx.doi.org/10.1186/1471-2458-10-231
http://dx.doi.org/10.1186/1471-2458-10-2...
)
A recent systematic review of 49 studies showed that knowledge of the existence of ECs
increased from 16% in 2009 to 58% in 2011 and that the use of ECs increased from 1% to
6% in the same period.(
2222. Pepper JK, Brewer NT. Electronic nicotine delivery system
(electronic cigarette) awareness, use, reactions and beliefs: a systematic review.
Tob Control. 2014;23(5):375-84.
http://dx.doi.org/10.1136/tobaccocontrol-2013-051122
http://dx.doi.org/10.1136/tobaccocontrol...
)
Adolescent exposure to ECs
Children and adolescents in several countries are aware of and have access to ECs. An
online survey of 228 American male adolescents showed that 67% were aware of ECs,
although less than 1% reported having experimented with ECs.(
2929. Pepper JK, Reiter PL, McRee AL, Cameron LD, Gilkey MB, Brewer NT.
Adolescent males' awareness of and willingness to try electronic cigarettes. J
Adolesc Health. 2013;52(2):144-50.
http://dx.doi.org/10.1016/j.jadohealth.2012.09.014
http://dx.doi.org/10.1016/j.jadohealth.2...
) In a study of 444 Korean adolescents, 10.2% reported having seen or heard
of ECs and 0.5% reported having used ECs. Contact with ECs was through the Internet in
46% of cases; friends, in 27.9%; television, in 11.0%; books, in 9.3%; and others, in
5.4%. Male adolescents were 6.3 times more likely to use ECs than were female
adolescents, and adolescents with smokers in the family were 3.4 times more likely to
use ECs than were those without.(
3030. Cho JH, Shin E, Moon SS. Electronic-cigarette smoking experience
among adolescents. J Adolesc Health. 2011;49(5):542-6.
http://dx.doi.org/10.1016/j.jadohealth.2011.08.001
http://dx.doi.org/10.1016/j.jadohealth.2...
)
The prevalence of EC use and conventional cigarette smoking among US adolescents in
grades 6th-12th in the 2011-2012 period was assessed in a cross-sectional study
(National Youth Tobacco Survey).(
3131. Centers for Disease Control and Prevention[homepage on the Internet]
. Atlanta, GA: US Department of Health and Human Services, CDC; [cited 2014 Jan 13].
National Youth Tobacco Survey 2012. Available from:
http://www.cdc.gov/tobacco/data_statistics/surveys/nyts
http://www.cdc.gov/tobacco/data_statisti...
) The results showed that EC experimentation and recent EC use nearly doubled
in the study period. The use of ECs increased from 3.3% to 6.8% (p < 0.05), the use
of conventional cigarettes increased from 1.1% to 2.1% (p < 0.05), and the use of
both ECs and conventional cigarettes increased from 0.8% to 1.6% (p = 0.05) in the study
period. There were no differences between the adolescents in the 6th-8th grade and those
in the 9th-12th grade regarding the aforementioned increases. The study also showed
that, in 2012, 9.3% of all EC experimenters reported never smoking conventional
cigarettes and that 76% of all regular EC users reported smoking conventional cigarettes
regularly.(
3232. Centers for Disease Control and Prevention (CDC). Notes from the
field: electronic cigarette use among middle and high school students - United
States, 2011-2012. MMWR Morb Mortal Wkly Rep. 2013;62(35):729-30.
)
A study conducted in eight schools in North Carolina, USA, and involving 4,444
adolescents in the 11-19 year age bracket showed that 4.9% reported the use of ECs, 1.5%
having reported the use of ECs in the past month. Although EC use was more common among
conventional cigarette smokers, 12% of all EC users had never smoked conventional
cigarettes.(
3333. Sutfin EL, McCoy TP, Morrell HE, Hoeppner BB, Wolfson M. Electronic
cigarette use by college students. Drug Alcohol Depend. 2013;131(3):214-21.
http://dx.doi.org/10.1016/j.drugalcdep.2013.05.001
http://dx.doi.org/10.1016/j.drugalcdep.2...
)
The Internet advertising and online marketing of ECs, even in countries where ECs have
been banned, can encourage EC use and allow adolescents to have access to ECs. In
addition, data from the aforementioned studies(
2929. Pepper JK, Reiter PL, McRee AL, Cameron LD, Gilkey MB, Brewer NT.
Adolescent males' awareness of and willingness to try electronic cigarettes. J
Adolesc Health. 2013;52(2):144-50.
http://dx.doi.org/10.1016/j.jadohealth.2012.09.014
http://dx.doi.org/10.1016/j.jadohealth.2...
30. Cho JH, Shin E, Moon SS. Electronic-cigarette smoking experience
among adolescents. J Adolesc Health. 2011;49(5):542-6.
http://dx.doi.org/10.1016/j.jadohealth.2011.08.001
http://dx.doi.org/10.1016/j.jadohealth.2...
31. Centers for Disease Control and Prevention[homepage on the Internet]
. Atlanta, GA: US Department of Health and Human Services, CDC; [cited 2014 Jan 13].
National Youth Tobacco Survey 2012. Available from:
http://www.cdc.gov/tobacco/data_statistics/surveys/nyts
http://www.cdc.gov/tobacco/data_statisti...
32. Centers for Disease Control and Prevention (CDC). Notes from the
field: electronic cigarette use among middle and high school students - United
States, 2011-2012. MMWR Morb Mortal Wkly Rep. 2013;62(35):729-30.
-
3333. Sutfin EL, McCoy TP, Morrell HE, Hoeppner BB, Wolfson M. Electronic
cigarette use by college students. Drug Alcohol Depend. 2013;131(3):214-21.
http://dx.doi.org/10.1016/j.drugalcdep.2013.05.001
http://dx.doi.org/10.1016/j.drugalcdep.2...
) suggest that EC experimentation induces continued use of conventional
cigarettes during adolescence. Therefore, measures aimed at reducing the appeal of EC
use and prohibiting the sale of ECs to adolescents are essential to minimize the risk of
tobacco and EC use.
Safety of EC use
The safety of electronic nicotine delivery systems has yet to be scientifically
demonstrated, and health risks of EC use have yet to be determined. Most EC safety
issues are due to the lack of appropriate regulation and inconsistent quality control.
Because of the lack of regulation and surveillance, the quality of ECs, the amount of
nicotine delivered, and the components of EC cartridges vary widely across
brands.(
1515. Goniewicz ML, Knysak J, Gawron M, Kosmider L, Sobczak A, Kurek J, et
al. Levels of selected carcinogens and toxicants in vapour from electronic
cigarettes. Tob Control 2014;23(2):133-9.
http://dx.doi.org/10.1136/tobaccocontrol-2012-050859
http://dx.doi.org/10....
) Therefore, EC users cannot know the exact composition of the product that
they are using.
Adverse effects of EC use might be due to variations in the nicotine content of EC
cartridges. According to the manufacturers, the nicotine content of an EC cartridge can
range from 6 mg to 24 mg; however, nicotine concentrations as high as 100 mg per
cartridge have been detected. Therefore, the risk of poisoning should be taken into
consideration. When nicotine is inhaled, is ingested, or comes into contact with the
skin, it can be dangerous to the health of vulnerable individuals, such as children,
youth, pregnant women, lactating women, individuals with heart disease, and the elderly.
Large quantities of nicotine (i.e., 0.5-1.0 mg of nicotine per kg of body weight) can be
lethal, and it is therefore recommended that ECs, EC cartridges, and refills be kept out
of the reach of children.(
1414. World Health Organization [homepage on the Internet]. Geneva: WHO
[cited 2014 Jan 13]. WHO Tobacco Free Initiative (TFI) - Questions and answers on
electronic cigarettes or electronic nicotine delivery systems (ENDS). Available from
http://www.who.int/tobacco/communications/statements/eletronic_cigarettes/en/index.html.
http://www.who.int/tobacco/communication...
,
1616. World Health Organization Study Group on Tobacco Regulation. TobReg
scientific recommendation: devices designed for the purpose of nicotine to the
respiratory system in which tobacco is not necessary for their operation. In: WHO
Technical Report Series 955. Report on the scientific basis of tobacco regulation:
third report of a WHO study group. Geneva: World Health Organization; 2009. p.
3-22.
)
The health risks of EC use might also be associated with the various substances found in
EC refill cartridges. One such substance is propylene glycol, in which nicotine is
suspended and which is used in order to generate the EC aerosol. Data on the harmful
effects of inhaling propylene glycol are scarce. Eye irritation and upper airway
irritation, as well as cough and mild airway obstruction, have been reported to occur in
individuals without asthma after short-term exposure to the propylene glycol mist
created by an artificial smoke generator.(
3434. Wieslander G, Norbäck D, Lindgren T. Experimental exposure to
propylene glycol mist in aviation emergency training: acute ocular and respiratory
effects. Occup Environ Med. 2001;58(10):649-55.
http://dx.doi.org/10.1136/oem.58.10.649
http://dx.doi.org/10.1136/oem.58.10.649...
)
Other potentially harmful substances, including irritants and toxins such as diethylene
glycol, formaldehyde, acetaldehyde, and acrolein, were detected in some EC
brands.(
1717. Westenberger BJ. Evaluation of e-cigarettes. US Food and Drug
Administration; Center for Drug Evaluation and Research; Division of Pharmaceutical
Analysis. Rockville, MD: US Food and Drug Administration; 2009 [Adobe Acrobat
document, 8p.]. Available from:
http://www.fda.gov/downloads/Drugs/ScienceResearch/UCM173250.pdf
http://www.fda.gov/downloads/Drugs/Scien...
) Nitrosamines, which are well-recognized carcinogens,(
3535. World Health Organization [homepage on the Internet]. Geneva: WHO
[cited 2014 Jan 13]. Marketers of electronic cigarettes should halt unproved therapy
claims [about 2 screens]. Available from:
http://www.who.int/mediacentre/news/releases/2008/pr34/en/index.html
http://www.who.int/mediacentre/news/rele...
) as well as tobacco-specific impurities, were found in low concentrations in
two brands of ECs.(
1717. Westenberger BJ. Evaluation of e-cigarettes. US Food and Drug
Administration; Center for Drug Evaluation and Research; Division of Pharmaceutical
Analysis. Rockville, MD: US Food and Drug Administration; 2009 [Adobe Acrobat
document, 8p.]. Available from:
http://www.fda.gov/downloads/Drugs/ScienceResearch/UCM173250.pdf
http://www.fda.gov/downloads/Drugs/Scien...
) The EC might contain flavorings, which are added to EC cartridges in order
to make ECs more palatable. Although these substances are routinely used food
flavorings, the effects of inhaling them are unknown.
By the first quarter of 2012, the US Food and Drug Administration had received 49
reports of adverse events related to the use of ECs. Of those adverse events, 8 were
considered serious, including pneumonia and chest pain; the remaining events were
characterized as mild and included headache and cough.(
3636. Chen I. FDA summary of adverse events on electronic cigarettes.
Nicotine Tob Res. 2013;15(2):615-6.
http://dx.doi.org/10.1093/ntr/nts145
http://dx.doi.org/10.1093/ntr/nts145...
) Among other symptoms, headache, mouth and throat irritation, salivation,
sweating, weakness, palpitations, nausea, vomiting, and diarrhea were reported in a
study evaluating acute adverse effects 2.5 h after EC use. However, all of the
aforementioned effects were mild.(
3737. Dawkins L, Corcoran O. Acute electronic cigarette use: nicotine
delivery and subjective effects in regular users.2014;231(2):401-7.
) In three prospective studies in which smokers used ECs for 6 or 12 months,
no serious adverse events were observed, and the main complaints were cough, headache,
and mouth and throat irritation. The symptoms resolved or subsided with continued EC
use.(
3838. Polosa R, Caponnetto P, Morjaria JB, Papale G, Campagna D, Russo C.
Effect of an electronic nicotine delivery device (e-Cigarette) on smoking reduction
and cessation: a prospective 6-month pilot study. BMC Public Health. 2011;11:786.
http://dx.doi.org/10.1186/1471-2458-11-786
http://dx.doi.org/10.1186/1471-2458-11-7...
39. Caponnetto P, Auditore R, Russo C, Cappello GC, Polosa R. Impact of
an electronic cigarette on smoking reduction and cessation in schizophrenic smokers:
a prospective 12-month pilot study. Int J Environ Res Public Health.
2013;10(2):446-61. http://dx.doi.org/10.3390/ijerph10020446
http://dx.doi.org/10.3390/ijerph10020446...
40. Caponnetto P, Campagna D, Cibella F, Morjaria JB, Caruso M, Russo C,
Polosa R. EffiCiency and Safety of an eLectronic cigAreTte (ECLAT) as tobacco
cigarettes substitute: a prospective 12-month randomized control design study. PLoS
ONE. 2013;8(6):e66317.
http://dx.doi.org/10.1371/journal.pone.0066317
http://dx.doi.org/10.1371/journal.pone.0...
-
4141. Polosa R, Morjaria JB, Caponnetto P, Campagna D, Russo C, Alamo A,
et al. Effectiveness and tolerability of electronic cigarette in real-life: a
24-month prospective observational study. Intern Emerg Med. 2014;9(5):537-46.
http://dx.doi.org/10.1007/s11739-013-0977-z
http://dx.doi.org/10.1007/s11739-013-097...
)
In vivo and in vitro studies have evaluated the impact of EC aerosol on blood cells and
the cytotoxic effect of EC aerosol on myocardial cells. In an in vivo study, one group
of authors found that neither active EC use nor passive exposure to EC aerosol for 30
min affected leukocyte, lymphocyte, or granulocyte counts.(
4242. Flouris AD, Poulianiti KP, Chorti MS, Jamurtas AZ, Kouretas D,
Owolabi EO, et al. Acute effects of electronic and tobacco cigarette smoking on
complete blood count. Food Chem Toxicol. 2012;50(10):3600-3.
http://dx.doi.org/10.1016/j.fct.2012.07.025
http://dx.doi.org/10.1016/j.fct.2012.07....
) In an in vitro study, another group of authors evaluated the cytotoxic
effects that the aerosol produced by 20 EC brands had on myocardial cells in
culture.(
4343. Farsalinos KE, Romagna G, Allifranchini E, Ripamonti E, Bocchietto
E, Todeschi S, et al. Comparison of the cytotoxic potential of cigarette smoke and
electronic cigarette vapour extract on cultured myocardial cells. Int J Environ Res
Public Health. 2013; 10:5146-62.
http://dx.doi.org/10.3390/ijerph10105146
http://dx.doi.org/10.3390/ijerph10105146...
) Although some samples were found to have cytotoxic effects on myocardial
cells, the cytotoxicity of EC aerosol was found to be lower than was that of
conventional cigarette smoke.(
4343. Farsalinos KE, Romagna G, Allifranchini E, Ripamonti E, Bocchietto
E, Todeschi S, et al. Comparison of the cytotoxic potential of cigarette smoke and
electronic cigarette vapour extract on cultured myocardial cells. Int J Environ Res
Public Health. 2013; 10:5146-62.
http://dx.doi.org/10.3390/ijerph10105146
http://dx.doi.org/10.3390/ijerph10105146...
)
The effects of EC use on lung function have been studied, although only after acute
exposure. Neither active EC use for a few minutes (in smokers) nor passive exposure to
EC aerosol for 1 h (in nonsmokers) had any effect on FEV1.(
4444. Flouris AD, Chorti MS, Poulianiti KP, Jamurtas AZ, Kostikas K,
Tzatzarakis MN, et al. Acute impact of active and passive electronic cigarette
smoking on serum cotinine and lung function. Inhal Toxicol. 2013;25(2):91-101.
http://dx.doi.org/10.3109/08958378.2012.758197
http://dx.doi.org/10.3109/08958378.2012....
) In contrast, EC use for 5 min increased airway resistance and reduced the
fraction of exhaled nitric oxide in adult smokers without comorbidities.(
4545. Vardavas CI, Anagnostopoulos N, Kougias M, Evangelopoulou V,
Connolly GN, Behrakis PK. Short-term pulmonary effects of using an electronic
cigarette: impact on respiratory flow resistance, impedance, and exhaled nitric
oxide. Chest. 2012;141(6):1400-6.
http://dx.doi.org/10.1378/chest.11-2443
http://dx.doi.org/10.1378/chest.11-2443...
) Increased airway resistance can precede changes in PEF and FEV1
in experimentally induced airflow obstruction.(
4646. Vink GR, Arets HG, van der Laag J, van der Ent CK. Impulse
oscillometry: a measure for airway obstruction. Pediatr Pulmonol. 2003;35(3):214-19.
http://dx.doi.org/10.1002/ppul.10235
http://dx.doi.org/10....
) Nitric oxide is recognized to play a role in the pathophysiology of
smoking-related airway disease; in addition, nitric oxide is related to eosinophilic
inflammation and bronchial hyperreactivity, as well as being a marker of oxidative
stress.(
4747. American Thoracic Society Workshop. ATS Workshop Proceedings:
Exhaled nitric oxide and nitric oxide oxidative metabolism in exhaled breath
condensate: Executive summary. Am J Respir Crit Care Med. 2006;173(7):811-3.
http://dx.doi.org/10.1164/rccm.2601014
http://dx.doi.org/10.1164/rccm.2601014...
) Taken together, the aforementioned findings suggest that short-term EC use
induces pulmonary changes. Long-term effects of EC use on lung function have yet to be
studied.
Given that ECs do not generate the smoke that is associated with the combustion of
tobacco, EC use is generally considered safer than tobacco use. This "relative safety"
can be appealing to users; however, the chemicals used in ECs have yet to be fully
disclosed, and data on the environmental pollution generated by the use of ECs in
enclosed spaces are scarce. One study evaluated the air quality in a room in which 9
individuals used ECs. The results showed substantial quantities of 1,2-propanediol,
glycerin, and nicotine, as well as high concentrations of particulate matter of 2.5 mm
in diameter, together with a 20% increase in the levels of polycyclic aromatic
hydrocarbons and an increase in the levels of aluminum and total particulate matter. The
concentration of exhaled nitric oxide increased in 7 of the 9 individuals
studied.(
4848. Schober W, Szendrei K, Matzen W, Osiander-Fuchs H, Heitmann D,
Schettgen,T, et al. Use of electronic cigarettes (e cigarettes) impairs indoor air
quality and increases FeNO levels of e-cigarette consumers. Int J Hyg Environ Health.
2014;217(6):628-37 http://dx.doi.org/10.1016/j.ijheh.2013.11.003
http://dx.doi.org/10.1016/j.ijheh.2013.1...
) In addition, there are currently no data on the safety of long-term EC
use.(
1414. World Health Organization [homepage on the Internet]. Geneva: WHO
[cited 2014 Jan 13]. WHO Tobacco Free Initiative (TFI) - Questions and answers on
electronic cigarettes or electronic nicotine delivery systems (ENDS). Available from
http://www.who.int/tobacco/communications/statements/eletronic_cigarettes/en/index.html.
http://www.who.int/tobacco/communication...
)
Efficacy of ECs in smoking cessation
There are currently few available data on ECs. According to the WHO, there is no
scientific evidence for the use of ECs as a substitute for conventional cigarettes or as
an aid to smoking cessation. In addition, unlike approved nicotine replacement therapies
(e.g., nicotine patches, gum, and lozenges), ECs deliver nicotine directly to the lungs
and therefore must be further studied.(
1414. World Health Organization [homepage on the Internet]. Geneva: WHO
[cited 2014 Jan 13]. WHO Tobacco Free Initiative (TFI) - Questions and answers on
electronic cigarettes or electronic nicotine delivery systems (ENDS). Available from
http://www.who.int/tobacco/communications/statements/eletronic_cigarettes/en/index.html.
http://www.who.int/tobacco/communication...
)
A comparison of different EC brands showed varying concentrations of nicotine in the
cartridges, as well as varying aerosol content and inconsistent nicotine delivery. After
EC use, plasma nicotine levels remained unchanged in all of the patients in two
studies(
4949. Vansickel AR, Cobb CO, Weaver MF, Eissenberg TE. A clinical
laboratory model for evaluating the acute effects of electronic "cigarettes":
nicotine delivery profile and cardiovascular and subjective effects. Cancer Epidemiol
Biomarkers Prev. 2010;19(8):1945-53.
http://dx.doi.org/10.1158/1055-9965.EPI-10-0288
http://dx.doi.org/10.1158/1055-9965.EPI-...
,
5050. Eissenberg T. Electronic nicotine delivery devices: ineffective
nicotine delivery and craving suppression after acute administration. Tob Control.
2010;19(1):87-8. http://dx.doi.org/10.1136/tc.2009.033498
http://dx.doi.org/10.1136/tc.2009.033498...
) and in approximately one third of the cases in another study.(
5151. Bullen C, McRobbie H, Thornley S, Glover M, Lin R, Laugesen M.
Effect of an electronic nicotine delivery device (e cigarette) on desire to smoke and
withdrawal, user preferences and nicotine delivery: randomised cross-over trial. Tob
Control. 2010;19(2):98-103. http://dx.doi.org/10.1136/tc.2009.031567
http://dx.doi.org/10.1136/tc.2009.031567...
) However, in regular EC users, plasma nicotine levels can
increase,(
5252. Vansickel A, Eissenberg T. Electronic cigarettes: effective nicotine
delivery after acute administration. Nicotine Tob Res. 2013;15(1):267-70.
http://dx.doi.org/10.1093/ntr/ntr316
http://dx.doi.org/10.1093/ntr/ntr316...
) although serum cotinine levels have been found to vary widely among
individuals.(
3737. Dawkins L, Corcoran O. Acute electronic cigarette use: nicotine
delivery and subjective effects in regular users.2014;231(2):401-7.
)
Several studies have evaluated the impact of ECs on the urge to smoke and on cravings.
In a randomized crossover study sponsored by an EC manufacturer, an electronic nicotine
delivery device containing 16 mg of nicotine was found to be more effective than placebo
in relieving morning withdrawal symptoms following overnight abstinence in 40 smokers.
The effects of the electronic nicotine delivery device on nicotine withdrawal symptoms
were comparable to those of a nicotine inhaler but lower than those of conventional
cigarettes.(
5151. Bullen C, McRobbie H, Thornley S, Glover M, Lin R, Laugesen M.
Effect of an electronic nicotine delivery device (e cigarette) on desire to smoke and
withdrawal, user preferences and nicotine delivery: randomised cross-over trial. Tob
Control. 2010;19(2):98-103. http://dx.doi.org/10.1136/tc.2009.031567
http://dx.doi.org/10.1136/tc.2009.031567...
) One group of authors(
5353. Dawkins L, Turner J, Hasna S, Soar K. The electronic-cigarette:
Effects on desire to smoke, withdrawal symptoms and cognition. Addict Behav.
2012;37(8):970-3. http://dx.doi.org/10.1016/j.addbeh.2012.03.004
http://dx.doi.org/10.1016/j.addbeh.2012....
) studied the effects of an EC on the urge to smoke, nicotine withdrawal
symptoms, and cognition in 86 patients randomly divided into three groups: a) 18-mg
nicotine EC (the nicotine group); b) nicotine-free EC (the placebo group); and c) just
hold the EC (the just hold group). Within 20 min after EC use, the urge to smoke and
nicotine withdrawal symptoms were significantly reduced in the nicotine and placebo
groups in comparison with the just hold group. Regarding the reduction in the urge to
smoke, the nicotine EC was significantly superior to placebo in males but not in
females. However, memory test results were significantly better in the nicotine group.
In another crossover study, an acute exposure protocol consisting of 10 sequential
puffs, 30 s apart, was used in order to compare four experimental conditions: an EC
brand with a 16-mg nicotine cartridge; another EC brand with a 16-mg nicotine cartridge;
own brand cigarettes; and an unlit cigarette (placebo). When compared with placebo, one
of the EC brands tested reduced craving; however, the effect was lower than was that of
conventional cigarettes.(
5050. Eissenberg T. Electronic nicotine delivery devices: ineffective
nicotine delivery and craving suppression after acute administration. Tob Control.
2010;19(1):87-8. http://dx.doi.org/10.1136/tc.2009.033498
http://dx.doi.org/10.1136/tc.2009.033498...
)
Few studies have evaluated the effects of EC use on smoking reduction and cessation
within 6-24 months. Two randomized controlled clinical trials and three prospective
before-and-after studies are described in Chart 1.
One of the clinical trials(
1313. Bullen C, Howe C, Laugesen M, McRobbie H, Parag V, Williman J, et
al. Electronic cigarettes for smoking cessation: a randomised controlled trial.
Lancet. 2013;382(9905):1629-37.
http://dx.doi.org/10.1016/S0140-6736(13)61842-5
http://dx.doi.org/10.1016/S0140-6736(13)...
) compared a 16-mg nicotine EC with 21-mg nicotine patches and a
nicotine-free EC, whereas the other(
4040. Caponnetto P, Campagna D, Cibella F, Morjaria JB, Caruso M, Russo C,
Polosa R. EffiCiency and Safety of an eLectronic cigAreTte (ECLAT) as tobacco
cigarettes substitute: a prospective 12-month randomized control design study. PLoS
ONE. 2013;8(6):e66317.
http://dx.doi.org/10.1371/journal.pone.0066317
http://dx.doi.org/10.1371/journal.pone.0...
) compared a 7.2-mg nicotine EC with a nicotine-free EC. Both trials lasted
12 weeks, and neither found significant differences between groups in terms of smoking
reduction or smoking cessation rates at 6 or 12 months. (
1313. Bullen C, Howe C, Laugesen M, McRobbie H, Parag V, Williman J, et
al. Electronic cigarettes for smoking cessation: a randomised controlled trial.
Lancet. 2013;382(9905):1629-37.
http://dx.doi.org/10.1016/S0140-6736(13)61842-5
http://dx.doi.org/10.1016/S0140-6736(13)...
,
4040. Caponnetto P, Campagna D, Cibella F, Morjaria JB, Caruso M, Russo C,
Polosa R. EffiCiency and Safety of an eLectronic cigAreTte (ECLAT) as tobacco
cigarettes substitute: a prospective 12-month randomized control design study. PLoS
ONE. 2013;8(6):e66317.
http://dx.doi.org/10.1371/journal.pone.0066317
http://dx.doi.org/10.1371/journal.pone.0...
) The three prospective uncontrolled studies involved a small number of
smokers unwilling to quit (one of the groups consisting of schizophrenic patients) and
found smoking cessation rates of 22.5%, 14.3%, and 12.5% at 6 months, 12 months, and 24
months, respectively.(
3838. Polosa R, Caponnetto P, Morjaria JB, Papale G, Campagna D, Russo C.
Effect of an electronic nicotine delivery device (e-Cigarette) on smoking reduction
and cessation: a prospective 6-month pilot study. BMC Public Health. 2011;11:786.
http://dx.doi.org/10.1186/1471-2458-11-786
http://dx.doi.org/10.1186/1471-2458-11-7...
,
3939. Caponnetto P, Auditore R, Russo C, Cappello GC, Polosa R. Impact of
an electronic cigarette on smoking reduction and cessation in schizophrenic smokers:
a prospective 12-month pilot study. Int J Environ Res Public Health.
2013;10(2):446-61. http://dx.doi.org/10.3390/ijerph10020446
http://dx.doi.org/10.3390/ijerph10020446...
,
4141. Polosa R, Morjaria JB, Caponnetto P, Campagna D, Russo C, Alamo A,
et al. Effectiveness and tolerability of electronic cigarette in real-life: a
24-month prospective observational study. Intern Emerg Med. 2014;9(5):537-46.
http://dx.doi.org/10.1007/s11739-013-0977-z
http://dx.doi.org/10.1007/s11739-013-097...
) In addition, an online survey of 5,000 individuals who had purchased a
particular brand of ECs was conducted 7 months after the purchase and showed high rates
of smoking reduction (66.8%) and smoking cessation (31.0%) at 6 months among the 222
questionnaire respondents.(
5454. Siegel MB, Tanwar KL, Wood KS. Electronic cigarettes as a smoking
cessation tool: Results from an online survey. Am J Prev Med. 2011;40(4):472-5.
http://dx.doi.org/10.1016/j.amepre.2010.12.006
http://dx.doi.org/10.1016/j.amepre.2010....
) However, one limitation of that study was that the survey response rate was
low, i.e., 4.5%; if the survey nonrespondents were to be considered smokers, the smoking
cessation rate would be 1.4%.(
5454. Siegel MB, Tanwar KL, Wood KS. Electronic cigarettes as a smoking
cessation tool: Results from an online survey. Am J Prev Med. 2011;40(4):472-5.
http://dx.doi.org/10.1016/j.amepre.2010.12.006
http://dx.doi.org/10.1016/j.amepre.2010....
)
Clinical studies evaluating the effects of electronic cigarettes on smoking reduction and smoking cessation. CO: carbon monoxide; EC: electronic cigarette; and G1, G2, and G3: groups 1, 2, and 3.
The studies described above show a low rate of smoking cessation with the use of ECs in
a population relying on self-treatment and self-reporting smoking cessation. However, a
survey of EC users showed frequent and prolonged EC use (approximately 20 times per day
for more than 1 year), often in association with conventional cigarettes.(
5555. Foulds J, Veldheer S, Berg A. Electronic cigarettes (e-cigs): views
of aficionados and clinical/public health perspectives. Int J Clin Pract.
2011;65(10):1037-42.
http://dx.doi.org/10.1111/j.1742-1241.2011.02751.x
http://dx.doi.org/10.1111/j.1742-1241.20...
) In addition, some smokers with no intention to quit use ECs as a substitute
for conventional cigarettes in places where smoking is prohibited. Therefore, EC use
modulated by the need for nicotine can contribute to the maintenance of nicotine
dependence.
Advertisement, impact on public health, and regulatory issues
Manufacturers of ECs have used aggressive advertising to encourage EC use. The main
arguments used by the EC industry are the health benefits of ECs in comparison with
conventional cigarettes, smoking reduction, smoking cessation, minimal passive exposure,
and the possibility of using ECs in places where smoking is prohibited. (
5555. Foulds J, Veldheer S, Berg A. Electronic cigarettes (e-cigs): views
of aficionados and clinical/public health perspectives. Int J Clin Pract.
2011;65(10):1037-42.
http://dx.doi.org/10.1111/j.1742-1241.2011.02751.x
http://dx.doi.org/10.1111/j.1742-1241.20...
) In 2012, a large tobacco company (Lorillard Tobacco Company) acquired an EC
brand and began to run television and Internet advertisements starring celebrities and
suggesting that the EC is glamorous and modern.(
5656. Noel JK, Rees VW, Connolly GN. Electronic cigarettes: a new
"tobacco" industry? Tob Control. 2011;20(1):81.
http://dx.doi.org/10.1136/tc.2010.038562
http://dx.doi.org/10.1136/tc.2010.038562...
,
5757. YouTube. [homepage on the Internet]. San Bruno (CA) : YouTube [cited
2014 Jan 13]. BluCigs. blu Electronic Cigarette TV Commercial - blu e-cigs National
TV Commercial; 2012. Available from:
http://www.youtube.com/watch?v=9pxuBgfbid0
http://www.youtube.com/watch?v=9pxuBgfbi...
) These strategies have proven useful, given that EC use has increased.
Professionals working to reduce tobacco consumption are increasingly concerned about the
impact of ECs on public health. The reasons for this concern are as follows: the lack of
data on the efficacy of ECs in smoking cessation; the potential to induce nicotine
addiction in nonsmokers, especially children and adolescents; the simultaneous use of
conventional cigarettes and ECs, reducing smoking cessation attempts; the possibility
that ECs will undermine tobacco-free environments, making smoking acceptable; and
exposure to a new form of pollution in places where smoking has been banned.(
1010. Benowitz NL, Goniewicz ML. The regulatory challenge of electronic
cigarettes. JAMA. 2013;310(7):685-6.
http://dx.doi.org/10.1001/jama.2013.109501
http://dx.doi.org/10.1001/jama.2013.1095...
,
5858. Britton J. Electronic cigarretes. Thorax. 2013;68(10):904-5.
http://dx.doi.org/10.1136/thoraxjnl-2013-203973
http://dx.doi.org/10.1136/thoraxjnl-2013...
)
In the USA, ECs have yet to be regulated as drugs or tobacco products.(
1010. Benowitz NL, Goniewicz ML. The regulatory challenge of electronic
cigarettes. JAMA. 2013;310(7):685-6.
http://dx.doi.org/10.1001/jama.2013.109501
http://dx.doi.org/10.1001/jama.2013.1095...
) In the European Union and the UK, it has been proposed that ECs be
regulated as medicinal products.(
5959. Hajek P. Electronic cigarettes for smoking cessation. Lancet.
2013;382(9905):1614-6.
http://dx.doi.org/10.1016/S0140-6736(13)61534-2
http://dx.doi.org/10.1016/S0140-6736(13)...
) Through regulation, ECs have been banned in Australia, Canada, Singapore,
and Brazil because of the lack of data on their safety and efficacy.(
1212. Brasil. Ministério da Saúde. Agência Nacional de Vigilância
Sanitária. Resolução de Diretoria Colegiada no. 46, de 28 de agosto de 2009. Proíbe a
comercialização, a importação e a propaganda de quaisquer dispositivos eletrônicos
para fumar, conhecidos como cigarro eletrônico. Diário Oficial da União; 29 Aug 2009;
Section 1. p. 45.
,
1616. World Health Organization Study Group on Tobacco Regulation. TobReg
scientific recommendation: devices designed for the purpose of nicotine to the
respiratory system in which tobacco is not necessary for their operation. In: WHO
Technical Report Series 955. Report on the scientific basis of tobacco regulation:
third report of a WHO study group. Geneva: World Health Organization; 2009. p.
3-22.
)
How to counsel patients regarding EC use
On the basis of the aforementioned information, pulmonologists can and should counsel
patients seeking information on ECs. Chart 2 shows
EC issues that can be addressed. It is possible that patients seeking information on ECs
are motivated to quit smoking. Cognitive-behavioral therapy should be offered to all
smokers. Smoking cessation guidelines(
6060. Reichert J, Araújo AJ, Gonçalves CM, Godoy I, Chatkin JM, Sales MP,
et al. Smoking cessation guidelines--2008. J Bras Pneumol. 2008;34(10):845-80.
http://dx.doi.org/10.1590/S1806-37132008001000014
http://dx.doi.org/10.1590/S1806-37132008...
) contain scientifically proven information on how to help patients quit
smoking. Nicotine withdrawal treatment is available in the public health
system.(
55. Portal de Saúde [homepage on the internet]. Brasília: Ministério da
Saúde [cited 2012 Apr 20]. Portaria no. 1035/GM, de 31 de maio de 2004. Available
from:
http://dtr2001.saude.gov.br/sas/PORTARIAS/Port2004/GM/GM-1035.htm.
http://dtr2001.saude.gov.br/sas/PORTARIA...
) For smokers with a high level of dependence, the combined use of
medications to control withdrawal symptoms can increase treatment effectiveness.
Nicotine replacement therapy, bupropion, and varenicline are treatment options approved
by the Brazilian National Health Surveillance Agency.
Counseling patients on the use of electronic cigarettes EC: electronic cigarette; and ANVISA: Agência Nacional de Vigilância Sanitária (National Health Surveillance Agency).
Final considerations
The EC is an electronic nicotine delivery system that has gained popularity in recent years. However, EC sales are prohibited in Brazil. The dose of nicotine delivered and the contents of EC cartridges vary widely across EC brands. Short-term adverse health effects of EC use have been reported. The long-term toxicity of ECs has yet to be studied. Data on the efficacy of ECs in smoking cessation are scarce, and the role of ECs in inducing smoking cessation has yet to be confirmed. Prolonged use of ECs by smokers might perpetuate nicotine addiction, and EC use during adolescence might encourage smoking initiation. Therefore, a smoking cessation approach based on cognitive-behavioral therapy and the use of drugs approved by regulatory agencies in order to control nicotine withdrawal symptoms should be recommended for smokers who want to quit smoking.
References
-
1World Health Organization [homepage on the Internet]. Geneva: WHO [cited 2014 Jan 13]. WHO Report on the Global Tobacco Epidemic, 2011; [about 2 screens]. Available from: http://www.who.int/tobacco/global_report/en/
» http://www.who.int/tobacco/global_report/en/ -
2Instituto Nacional de CâncerJosé Alencar Gomes da Silva [homepage on the Internet]. Rio de Janeiro: INCA; c [cited 2014 Jan 13]. Available from: www.inca.gov.br
» www.inca.gov.br -
3Malta DC, Moura EC, Silva SA, Oliveira PP, Silva VL. Prevalence of smoking among adults residing in the Federal District of Brasília and in the state capitals of Brazil, 2008. J Bras Pneumol. 2010;36(1):75-83. http://dx.doi.org/10.1590/S1806-37132010000100013
» http://dx.doi.org/10.1590/S1806-37132010000100013 -
4World Health Organization [homepage on the Internet]. Geneva: WHO [cited 2014 Jan 13]. WHO Framework Convention on Tobacco Control. [Adobe Acrobat document, 44p.]. Available from: http://whqlibdoc.who.int/publications/2003/9241591013.pdf
» http://whqlibdoc.who.int/publications/2003/9241591013.pdf -
5Portal de Saúde [homepage on the internet]. Brasília: Ministério da Saúde [cited 2012 Apr 20]. Portaria no. 1035/GM, de 31 de maio de 2004. Available from: http://dtr2001.saude.gov.br/sas/PORTARIAS/Port2004/GM/GM-1035.htm.
» http://dtr2001.saude.gov.br/sas/PORTARIAS/Port2004/GM/GM-1035.htm -
6Jarvis MJ, McIntiyre NC, Bates C, Foulds J. Effectiveness of smoking cessation initiatives. Efforts must take into account smokers' disillusionment with smoking and their delusions about stopping. BMJ. 2002;324(7337):608-9. http://dx.doi.org/10.1136/bmj.324.7337.608
» http://dx.doi.org/10.1136/bmj.324.7337.608 -
7Aveyard P, West R. Managing smoking cessation. BMJ. 2007;335(7609):37-41. http://dx.doi.org/10.1136/bmj.39252.591806.47
» http://dx.doi.org/10.1136/bmj.39252.591806.47 -
8Hughes JR, Keely J Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction. 2004;99(1):29-38. http://dx.doi.org/10.1111/j.1360-0443.2004.00540.x
» http://dx.doi.org/10.1111/j.1360-0443.2004.00540.x -
9Cahn Z, Siegel M. Electronic cigarettes as a harm reduction strategy for tobacco control: a step forward or a repeat of past mistakes? J Public Health Policy. 2011;32(1):16-31. http://dx.doi.org/10.1057/jphp.2010.41
» http://dx.doi.org/10.1057/jphp.2010.41 -
10Benowitz NL, Goniewicz ML. The regulatory challenge of electronic cigarettes. JAMA. 2013;310(7):685-6. http://dx.doi.org/10.1001/jama.2013.109501
» http://dx.doi.org/10.1001/jama.2013.109501 -
11Odum LE, O'Dell KA, Schepers JS. Electronic cigarettes: do they have a role in smoking cessation? J Pharm Pract. 2012;25(6):611-4. http://dx.doi.org/10.1177/0897190012451909
» http://dx.doi.org/10.1177/0897190012451909 -
12Brasil. Ministério da Saúde. Agência Nacional de Vigilância Sanitária. Resolução de Diretoria Colegiada no. 46, de 28 de agosto de 2009. Proíbe a comercialização, a importação e a propaganda de quaisquer dispositivos eletrônicos para fumar, conhecidos como cigarro eletrônico. Diário Oficial da União; 29 Aug 2009; Section 1. p. 45.
-
13Bullen C, Howe C, Laugesen M, McRobbie H, Parag V, Williman J, et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet. 2013;382(9905):1629-37. http://dx.doi.org/10.1016/S0140-6736(13)61842-5
» http://dx.doi.org/10.1016/S0140-6736(13)61842-5 -
14World Health Organization [homepage on the Internet]. Geneva: WHO [cited 2014 Jan 13]. WHO Tobacco Free Initiative (TFI) - Questions and answers on electronic cigarettes or electronic nicotine delivery systems (ENDS). Available from http://www.who.int/tobacco/communications/statements/eletronic_cigarettes/en/index.html.
» http://www.who.int/tobacco/communications/statements/eletronic_cigarettes/en/index.html -
15Goniewicz ML, Knysak J, Gawron M, Kosmider L, Sobczak A, Kurek J, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control 2014;23(2):133-9. http://dx.doi.org/10.1136/tobaccocontrol-2012-050859
» http://dx.doi.org/10.1136/tobaccocontrol-2012-050859 -
16World Health Organization Study Group on Tobacco Regulation. TobReg scientific recommendation: devices designed for the purpose of nicotine to the respiratory system in which tobacco is not necessary for their operation. In: WHO Technical Report Series 955. Report on the scientific basis of tobacco regulation: third report of a WHO study group. Geneva: World Health Organization; 2009. p. 3-22.
-
17.Westenberger BJ. Evaluation of e-cigarettes. US Food and Drug Administration; Center for Drug Evaluation and Research; Division of Pharmaceutical Analysis. Rockville, MD: US Food and Drug Administration; 2009 [Adobe Acrobat document, 8p.]. Available from: http://www.fda.gov/downloads/Drugs/ScienceResearch/UCM173250.pdf
» http://www.fda.gov/downloads/Drugs/ScienceResearch/UCM173250.pdf -
18Bertholon JF, Becquemin MH, Annesi-Maesano I, Dautzenberg B. Electronic cigarettes: a short review. Respiration. 2013;86(5):433-8.
-
19Farsalinos KE, Spyrou A, Tsimopoulou K, Stefopoulos C, Romagna G, Voudris V. Nicotine absorption from electronic cigarette use: comparison between first and new-generation devices. Sci Rep. 2014;26;4:4133.
-
20Yamin CK, Bitton A, Bates DW. E-cigarettes: a rapidly growing Internet phenomenon. Ann Intern Med. 2010;153(9):607-9. http://dx.doi.org/10.7326/0003-4819-153-9-201011020-00011
» http://dx.doi.org/10.7326/0003-4819-153-9-201011020-00011 -
21Dockrell M, Indu SD, Lashkari HG, McNeill A. "It sounds like the replacement I need to help me stop smoking": Use and acceptability of "e-cigarettes" among UK smokers. Proceedings of the 12th annual meeting of the Society for Research on Nicotine and Tobacco Europe; 2010 Sep 6-9; Bath, UK, 2010. London: SRNT and UK Centre for Tobacco Control Studies; 2010. p.48.
-
22Pepper JK, Brewer NT. Electronic nicotine delivery system (electronic cigarette) awareness, use, reactions and beliefs: a systematic review. Tob Control. 2014;23(5):375-84. http://dx.doi.org/10.1136/tobaccocontrol-2013-051122
» http://dx.doi.org/10.1136/tobaccocontrol-2013-051122 -
23Regan AK, Promoff G, Dube SR, Arrazola R. Electronic nicotine delivery systems: Adult use and awareness of the 'e-cigarette' in the USA. Tob Control. 2013;22(1):19-23. http://dx.doi.org/10.1136/tobaccocontrol-2011-050044
» http://dx.doi.org/10.1136/tobaccocontrol-2011-050044 -
24Pearson JL, Richardson A, Niaura RS, Vallone DM, Abrams DB. e-Cigarette awareness, use, and harm perceptions in US adults. Am J Public Health. 2012;102(9):1758-66. http://dx.doi.org/10.2105/AJPH.2011.300526.
» http://dx.doi.org/10.2105/AJPH.2011.300526 -
25Dockrell M, Morrison R, Bauld L, McNeill A. E-cigarettes: prevalence and attitudes in Great Britain. Nicotine Tob Res. 2013;15(10):1737-44. http://dx.doi.org/10.1093/ntr/ntt057
» http://dx.doi.org/10.1093/ntr/ntt057 -
26Adkison SE, O'Connor RJ, Bansal-Travers M, Hyland A, Borland R, Yong HH. Electronic nicotine delivery systems: international tobacco control four-country survey. Am J Prev Med. 2013;44(3):207-15. http://dx.doi.org/10.1016/j.amepre.2012.10.018
» http://dx.doi.org/10.1016/j.amepre.2012.10.018 -
27Etter JF, Bullen C. Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy. Addiction. 2011;106(11):2017-28. http://dx.doi.org/10.1111/j.1360-0443.2011.03505.x
» http://dx.doi.org/10.1111/j.1360-0443.2011.03505.x -
28Etter JF. Electronic cigarettes: a survey of users. BMC Public Health. 2010;10:231. http://dx.doi.org/10.1186/1471-2458-10-231
» http://dx.doi.org/10.1186/1471-2458-10-231 -
29Pepper JK, Reiter PL, McRee AL, Cameron LD, Gilkey MB, Brewer NT. Adolescent males' awareness of and willingness to try electronic cigarettes. J Adolesc Health. 2013;52(2):144-50. http://dx.doi.org/10.1016/j.jadohealth.2012.09.014
» http://dx.doi.org/10.1016/j.jadohealth.2012.09.014 -
30Cho JH, Shin E, Moon SS. Electronic-cigarette smoking experience among adolescents. J Adolesc Health. 2011;49(5):542-6. http://dx.doi.org/10.1016/j.jadohealth.2011.08.001
» http://dx.doi.org/10.1016/j.jadohealth.2011.08.001 -
31Centers for Disease Control and Prevention[homepage on the Internet] . Atlanta, GA: US Department of Health and Human Services, CDC; [cited 2014 Jan 13]. National Youth Tobacco Survey 2012. Available from: http://www.cdc.gov/tobacco/data_statistics/surveys/nyts
» http://www.cdc.gov/tobacco/data_statistics/surveys/nyts -
32Centers for Disease Control and Prevention (CDC). Notes from the field: electronic cigarette use among middle and high school students - United States, 2011-2012. MMWR Morb Mortal Wkly Rep. 2013;62(35):729-30.
-
33Sutfin EL, McCoy TP, Morrell HE, Hoeppner BB, Wolfson M. Electronic cigarette use by college students. Drug Alcohol Depend. 2013;131(3):214-21. http://dx.doi.org/10.1016/j.drugalcdep.2013.05.001
» http://dx.doi.org/10.1016/j.drugalcdep.2013.05.001 -
34Wieslander G, Norbäck D, Lindgren T. Experimental exposure to propylene glycol mist in aviation emergency training: acute ocular and respiratory effects. Occup Environ Med. 2001;58(10):649-55. http://dx.doi.org/10.1136/oem.58.10.649
» http://dx.doi.org/10.1136/oem.58.10.649 -
35World Health Organization [homepage on the Internet]. Geneva: WHO [cited 2014 Jan 13]. Marketers of electronic cigarettes should halt unproved therapy claims [about 2 screens]. Available from: http://www.who.int/mediacentre/news/releases/2008/pr34/en/index.html
» http://www.who.int/mediacentre/news/releases/2008/pr34/en/index.html -
36Chen I. FDA summary of adverse events on electronic cigarettes. Nicotine Tob Res. 2013;15(2):615-6. http://dx.doi.org/10.1093/ntr/nts145
» http://dx.doi.org/10.1093/ntr/nts145 -
37Dawkins L, Corcoran O. Acute electronic cigarette use: nicotine delivery and subjective effects in regular users.2014;231(2):401-7.
-
38Polosa R, Caponnetto P, Morjaria JB, Papale G, Campagna D, Russo C. Effect of an electronic nicotine delivery device (e-Cigarette) on smoking reduction and cessation: a prospective 6-month pilot study. BMC Public Health. 2011;11:786. http://dx.doi.org/10.1186/1471-2458-11-786
» http://dx.doi.org/10.1186/1471-2458-11-786 -
39Caponnetto P, Auditore R, Russo C, Cappello GC, Polosa R. Impact of an electronic cigarette on smoking reduction and cessation in schizophrenic smokers: a prospective 12-month pilot study. Int J Environ Res Public Health. 2013;10(2):446-61. http://dx.doi.org/10.3390/ijerph10020446
» http://dx.doi.org/10.3390/ijerph10020446 -
40Caponnetto P, Campagna D, Cibella F, Morjaria JB, Caruso M, Russo C, Polosa R. EffiCiency and Safety of an eLectronic cigAreTte (ECLAT) as tobacco cigarettes substitute: a prospective 12-month randomized control design study. PLoS ONE. 2013;8(6):e66317. http://dx.doi.org/10.1371/journal.pone.0066317
» http://dx.doi.org/10.1371/journal.pone.0066317 -
41Polosa R, Morjaria JB, Caponnetto P, Campagna D, Russo C, Alamo A, et al. Effectiveness and tolerability of electronic cigarette in real-life: a 24-month prospective observational study. Intern Emerg Med. 2014;9(5):537-46. http://dx.doi.org/10.1007/s11739-013-0977-z
» http://dx.doi.org/10.1007/s11739-013-0977-z -
42Flouris AD, Poulianiti KP, Chorti MS, Jamurtas AZ, Kouretas D, Owolabi EO, et al. Acute effects of electronic and tobacco cigarette smoking on complete blood count. Food Chem Toxicol. 2012;50(10):3600-3. http://dx.doi.org/10.1016/j.fct.2012.07.025
» http://dx.doi.org/10.1016/j.fct.2012.07.025 -
43Farsalinos KE, Romagna G, Allifranchini E, Ripamonti E, Bocchietto E, Todeschi S, et al. Comparison of the cytotoxic potential of cigarette smoke and electronic cigarette vapour extract on cultured myocardial cells. Int J Environ Res Public Health. 2013; 10:5146-62. http://dx.doi.org/10.3390/ijerph10105146
» http://dx.doi.org/10.3390/ijerph10105146 -
44Flouris AD, Chorti MS, Poulianiti KP, Jamurtas AZ, Kostikas K, Tzatzarakis MN, et al. Acute impact of active and passive electronic cigarette smoking on serum cotinine and lung function. Inhal Toxicol. 2013;25(2):91-101. http://dx.doi.org/10.3109/08958378.2012.758197
» http://dx.doi.org/10.3109/08958378.2012.758197 -
45Vardavas CI, Anagnostopoulos N, Kougias M, Evangelopoulou V, Connolly GN, Behrakis PK. Short-term pulmonary effects of using an electronic cigarette: impact on respiratory flow resistance, impedance, and exhaled nitric oxide. Chest. 2012;141(6):1400-6. http://dx.doi.org/10.1378/chest.11-2443
» http://dx.doi.org/10.1378/chest.11-2443 -
46Vink GR, Arets HG, van der Laag J, van der Ent CK. Impulse oscillometry: a measure for airway obstruction. Pediatr Pulmonol. 2003;35(3):214-19. http://dx.doi.org/10.1002/ppul.10235
» http://dx.doi.org/10.1002/ppul.10235 -
47American Thoracic Society Workshop. ATS Workshop Proceedings: Exhaled nitric oxide and nitric oxide oxidative metabolism in exhaled breath condensate: Executive summary. Am J Respir Crit Care Med. 2006;173(7):811-3. http://dx.doi.org/10.1164/rccm.2601014
» http://dx.doi.org/10.1164/rccm.2601014 -
48Schober W, Szendrei K, Matzen W, Osiander-Fuchs H, Heitmann D, Schettgen,T, et al. Use of electronic cigarettes (e cigarettes) impairs indoor air quality and increases FeNO levels of e-cigarette consumers. Int J Hyg Environ Health. 2014;217(6):628-37 http://dx.doi.org/10.1016/j.ijheh.2013.11.003
» http://dx.doi.org/10.1016/j.ijheh.2013.11.003 -
49Vansickel AR, Cobb CO, Weaver MF, Eissenberg TE. A clinical laboratory model for evaluating the acute effects of electronic "cigarettes": nicotine delivery profile and cardiovascular and subjective effects. Cancer Epidemiol Biomarkers Prev. 2010;19(8):1945-53. http://dx.doi.org/10.1158/1055-9965.EPI-10-0288
» http://dx.doi.org/10.1158/1055-9965.EPI-10-0288 -
50Eissenberg T. Electronic nicotine delivery devices: ineffective nicotine delivery and craving suppression after acute administration. Tob Control. 2010;19(1):87-8. http://dx.doi.org/10.1136/tc.2009.033498
» http://dx.doi.org/10.1136/tc.2009.033498 -
51Bullen C, McRobbie H, Thornley S, Glover M, Lin R, Laugesen M. Effect of an electronic nicotine delivery device (e cigarette) on desire to smoke and withdrawal, user preferences and nicotine delivery: randomised cross-over trial. Tob Control. 2010;19(2):98-103. http://dx.doi.org/10.1136/tc.2009.031567
» http://dx.doi.org/10.1136/tc.2009.031567 -
52Vansickel A, Eissenberg T. Electronic cigarettes: effective nicotine delivery after acute administration. Nicotine Tob Res. 2013;15(1):267-70. http://dx.doi.org/10.1093/ntr/ntr316
» http://dx.doi.org/10.1093/ntr/ntr316 -
53Dawkins L, Turner J, Hasna S, Soar K. The electronic-cigarette: Effects on desire to smoke, withdrawal symptoms and cognition. Addict Behav. 2012;37(8):970-3. http://dx.doi.org/10.1016/j.addbeh.2012.03.004
» http://dx.doi.org/10.1016/j.addbeh.2012.03.004 -
54Siegel MB, Tanwar KL, Wood KS. Electronic cigarettes as a smoking cessation tool: Results from an online survey. Am J Prev Med. 2011;40(4):472-5. http://dx.doi.org/10.1016/j.amepre.2010.12.006
» http://dx.doi.org/10.1016/j.amepre.2010.12.006 -
55Foulds J, Veldheer S, Berg A. Electronic cigarettes (e-cigs): views of aficionados and clinical/public health perspectives. Int J Clin Pract. 2011;65(10):1037-42. http://dx.doi.org/10.1111/j.1742-1241.2011.02751.x
» http://dx.doi.org/10.1111/j.1742-1241.2011.02751.x -
56Noel JK, Rees VW, Connolly GN. Electronic cigarettes: a new "tobacco" industry? Tob Control. 2011;20(1):81. http://dx.doi.org/10.1136/tc.2010.038562
» http://dx.doi.org/10.1136/tc.2010.038562 -
57YouTube. [homepage on the Internet]. San Bruno (CA) : YouTube [cited 2014 Jan 13]. BluCigs. blu Electronic Cigarette TV Commercial - blu e-cigs National TV Commercial; 2012. Available from: http://www.youtube.com/watch?v=9pxuBgfbid0
» http://www.youtube.com/watch?v=9pxuBgfbid0 -
58Britton J. Electronic cigarretes. Thorax. 2013;68(10):904-5. http://dx.doi.org/10.1136/thoraxjnl-2013-203973
» http://dx.doi.org/10.1136/thoraxjnl-2013-203973 -
59Hajek P. Electronic cigarettes for smoking cessation. Lancet. 2013;382(9905):1614-6. http://dx.doi.org/10.1016/S0140-6736(13)61534-2
» http://dx.doi.org/10.1016/S0140-6736(13)61534-2 -
60Reichert J, Araújo AJ, Gonçalves CM, Godoy I, Chatkin JM, Sales MP, et al. Smoking cessation guidelines--2008. J Bras Pneumol. 2008;34(10):845-80. http://dx.doi.org/10.1590/S1806-37132008001000014
» http://dx.doi.org/10.1590/S1806-37132008001000014
-
Financial support: None
-
*
Study carried out under the auspices of the Graduate Program in Pulmonology, Federal University of Rio Grande do Sul, and at the Porto Alegre Hospital de Clínicas, Porto Alegre, Brazil
Publication Dates
-
Publication in this collection
Sep-Oct 2014
History
-
Received
13 Jan 2014 -
Accepted
27 June 2014