Be It Resolved: E-Cigarettes May Help Smokers Cut Back, but Quit Altogether? The Jury’s Out

Many veteran smokers resolving to butt out once and for all in 2017 are reaching for electronic cigarettes based on the belief that “vaping” can help them kick their smoking habit. What few smokers—and physicians—may realize is that while e-cigarettes appear to help people cut down on the number of tobacco cigarettes puffed per day, there’s little evidence to support their role as a quitting tool.

In fact, whether e-cigarettes can enable quitting is “a very important question, and it’s one that we have very little data on at this point,” said Douglas Jorenby, PhD (University of Wisconsin Center for Tobacco Research and Intervention, Madison). A full decade after the devices entered the US market in 2007, a firm answer to this question remains elusive.

While e-cigarettes may be less harmful than smoking tobacco, they are not harmless, stressed Samuel Wann, MD (Columbia St. Mary’s, Milwaukee, WI), who co-authored an editorial on the topic recently published in the American Journal of Cardiology. Then there’s also the question of whether normalizing the use of e-cigarettes might have larger public health implications by encouraging people, especially teens and young adults, to take up smoking.

E-cigarettes still contain nicotine, which is very addictive, Wann stressed to TCTMD. “More militant anti-e-cigarette people would say [they’ve] got all these other chemicals and stuff in [them],” he added, “but so does the air outside. Not to make light of it. There are some bad things, but they’re very, very low level. Smog in Beijing is probably worse than e-cigarettes for you. . . . But that doesn’t mean the smog in Beijing is particularly good for you either.”

What to Tell Patients

The lack of hard clinical data in this field is important to communicate to patients, experts say, in part because of the widespread believe that vaping is relatively “safe.”

“First and foremost, we tell them if they ask about e-cigarettes that there is just an awful lot that we don’t know at this point,” Jorenby told TCTMD in an interview. “And I think that anyone who’s practicing evidence-based treatment needs to be pretty open about that.”

Most of our knowledge, he said, is self-reported by smokers or stems from internet-based surveys. “While these are devices that are not without risk, what we do have suggests that they are almost certainly lower-risk than cigarette smoking,” Jorenby commented. “It’s kind of underwhelming how low that sets the bar, because with cigarettes you’re talking about a product that when used as directed is probably going to kill about 50% of people who are regular users.”

Last fall, a Cochrane review took a more systemic look, but overall the quality of evidence was low: randomized controlled trials accounted for only 3 of the 24 studies considered. Two of the randomized trials showed that people using e-cigarettes with nicotine were more likely to abstain for at least 6 months compared with those who received placebo e-cigarettes without nicotine (9% vs 4%; RR 2.29; 95% CI 1.05-4.96). The other pitted e-cigarettes against nicotine patches, finding no difference in abstinence rates at 6 months.

Yet “at the same time, a huge proportion of adults who smoke in the US perceive e-cigarettes as an effective and desirable cessation treatment,” Jorenby noted. “So those two things are kind of occupying the [same] space at the same time. Cognitive dissonance comes to mind.”

Harm Reduction vs Cold Turkey

Ultimately many who attempt to quit using the devices become what Jorenby calls “dual users.” When people buy an e-cigarette hoping it will help, he said, “what in actual reality happens is they reduce their cigarette smoking, but they don’t quit completely. So then they’re still being exposed to some degree of hazard from smoking and some degree of whatever risk e-cigarettes may present.”

A “strong harm reductionist,” Jorenby added, “would say, ‘Well, they’re reducing their exposure to combustible tobacco,’ and that’s a good thing because some of the [health risks], particularly cardiovascular effects, do seem to be dose dependent. So if you’re smoking 10 cigarettes a day you’re not at as high a risk as if you’re smoking a pack a day.

“On the other hand,” he continued, “if you look at dual users as people who had a good chance of quitting tobacco entirely if they had used an effective evidence-based treatment, that’s kind of a net public health loss.”

If you look at dual users as people who had a good chance of quitting tobacco entirely if they had used an effective evidence-based treatment, that’s kind of a net public health loss. Douglas Jorenby

Some of the patients he sees at his smoking cessation clinic find they can stop smoking tobacco and keep to just e-cigarettes, Jorenby reported. “They’re very proud and particularly online they’re almost like evangelists—they want to share their success and have other people succeed. They don’t perceive that as something that needs treatment.”

Others continue to vape but discontinue nicotine, he noted. “So they work themselves down to 0% nicotine e-juice and seem to enjoy the process, the experience of vaping, which is intriguing.”

In terms of specific advice for people who want to try e-cigarettes as a path to quitting, Wann said that he’d first sympathize with them that nicotine is very addictive and acknowledge that these devices are very efficient at delivering it.

“If you can cut back on tobacco, your lung cancer risk and all the other nasties go down,” he said. “But it’s still an addictive substance, and I wouldn’t hold my breath that you’re going to be able to quit smoking completely using e-cigarettes. It is less harmful and if you want to do it, that’s fine. I’m not condemning you to hell or anything but don’t fool yourself. It is very difficult to quit smoking, so the most effective thing is to not start, I suppose.”

Going “cold turkey” is appealing though also very difficult, Wann added, suggesting that counseling, support groups, and pharmacologic treatment may prove helpful.

Health Impact

Nicotine is the prime culprit when it comes to addiction but not the main source of the uptick in cancer and cardiovascular disease seen with smoking. “Burning tobacco produces a complex mixture of more than 7,000 compounds, many of which affect virtually every organ in the body, causing disease which result in premature death,” Wann writes with his colleague Joshua Liberman, MD (Columbia St. Mary’s), in their editorial.

It stands to reason that e-cigarettes, which heat but do not burn a liquid solution containing nicotine in order to create a vapor that can be inhaled, would carry fewer health risks. Whether derived from smoking or vaping, “nicotine has a relative short half-life,” Wann and Liberman say. Even so, “it causes catecholamine release with acute hemodynamic consequences and adverse effects on lipids, endothelial function, and insulin resistance, and could increase risk for acute cardiovascular events including dysrhythmia or rupture of atherosclerotic plaques.”

The vapor released by e-cigarettes itself “contains many potentially harmful degradation products released by heating the liquid propylene glycol or glycerol, used to dissolve the active nicotine ingredient,” they note. “These include low levels of propylene oxide, acrolein, formaldehyde, acetaldehyde, toluene, xylene, benzene, and butadiene, and ultrafine nanoparticles, all of which can contribute to cardiovascular, cancer, and lung disease. While the concentration of these noxious substances is far lower than those found in conventional tobacco smoke, the long-term adverse health effects of e-cigarette vapor are unknown, warranting further study.”

If you can cut back on tobacco, your lung cancer risk and all the other nasties go down. But it’s still an addictive substance, and I wouldn’t hold my breath that you’re going to be able to quit smoking completely using e-cigarettes. Samuel Wann

There also is the question of secondhand e-cigarette vapor. “Analyses of environmental emissions have found concerning levels of formaldehyde, acetaldehyde, and acrolein, along with low levels of toluene, xylene, benzene, and butadiene, though these concentrations are many-fold lower than those found from cigarette smoke,” the editorialists report. “While use of e-cigarettes in public spaces is not yet regulated and the danger to the environment from e-cigarette vapor may be negligible, normalizing the public use of e-cigarettes could erode gains in establishing smoke-free environments in offices, restaurants, airplanes, and other public spaces.”

Additionally, the long-term risks of e-cigarettes in comparison to tobacco cigarettes are unknown.

Public Health at Risk?

Admittedly, the public health conversation doesn’t come up much in the doctor’s office, but it is worth considering, Jorenby and Wann agreed.

The concerns are twofold, according to Jorenby. First, there’s the “idea that dual users may be missed cessation opportunities,” he said. Then there’s the possibility that young people may be more willing to first try e-cigarettes before smoking tobacco but then want to smoke the real thing.

In December, US Surgeon General Vivek Murthy, MD, released a report to raise awareness about this potential. “E-cigarette use among both youth and young adults has increased considerably in recent years. In 2015, more than a quarter of students in grades 6 through 12 and more than a third of young adults had ever tried e-cigarettes,” the report states.

Murthy’s report wasn’t shy about sounding alarm bells, either. A section on risks says: “E-cigarette use poses a significant—and avoidable—health risk to young people in the United States. Besides increasing the possibility of addiction and long-term harm to brain development and respiratory health, e-cigarette use is associated with the use of other tobacco products that can do even more damage to the body. Even breathing e-cigarette aerosol that someone else has exhaled poses potential health risks.”

Some had hoped that newer-generation vaporizers, or vape pens, might not trigger the desire to smoke. However, a study published January 12, 2017, in Nicotine & Tobacco Research found this not to be the case in a sample of 108 young adult smokers; exposure to newer vape pens, their more clunky predecessors, and tobacco cigarettes all inspired a similar urge.

Recent changes in US Food and Drug Administration oversight may augment these trends. In August 2016, the agency widened its purview to cover “all tobacco products, including e-cigarettes—which are also called electronic cigarettes or electronic nicotine delivery systems (ENDS)—all cigars (including premium ones), hookah (also called waterpipe tobacco), pipe tobacco, nicotine gels, and dissolvables that did not previously fall under the FDA’s authority.” Now, none of those products may be sold to people under the age of 18 in the United States.

In terms of trends, Wann observed that “it seems to me that e-cigarettes have had a wave of intense popularity and it’s somewhat waxing a little bit. I haven’t seen numbers to support that, but just looking around the community I don’t think it’s as popular as it once was.

“On the other hand, big tobacco seems to be getting involved, particularly in other countries. That’s a bad omen in general,” he concluded. “I think they will use every effort to market and promote smoking and obey the letter of the law and not [go] one step further.”

The prevalence of smoking has dropped from 43% in the mid-1960s to less than 18% today, though 42 million Americans continue to smoke, Wann and Liberman note in their paper, urging, “[W]e must not allow e-cigarettes to reverse our progress in reducing tobacco smoking, the leading cause of preventable death in the USA.”