E-Cigarettes and Patients

Since the introduction of electronic cigarettes (dubbed “electronic nicotine delivery systems” or “ENDS” by the World Health Organization) in 2003 to the world marketplace, their use has exploded.  Currently, ENDS have a significant portion of the market.

The July/August 2014 of ASAM’s official journal, Journal of Addiction Medicine contains a superb review article, Science and Electronic Cigarettes: Current Data, Future Needs.
This article is comprehensive, covering the limited current research data, survey data on awareness and use, use of ENDS to assist with smoking cessation and highlights the arguments for and opposed to them. I urge all our readers to read this article.

The current model of the e-cigarette was invented and taken to market by Chinese pharmacist Hon Lik in 2003, entering the United States market in 2007 (Maron, 2014).

The FDA first attempted to regulate the e-cigarettes as drug-delivery devices, defined under federal law as items “intended to affect the structure or any function of the body.” However, e-cigarette company NJOY sued the agency, arguing that the nicotine-containing devices were similar to tobacco products- which had not been under FDA regulation. A federal appeals court ruled in December 2010 that the agency lacked authority over e-cigs, finding they offer only the recreational benefits of a regular cigarette.  That legal decision allowed sales of e-cigarettes to proceed but did not address the safety of the products (Maron, 2014). President Obama signed the Family Smoking Prevention and Tobacco Control Act in 2009. In the spring of this year, the FDA proposed extending the act to include e-cigarettes, pipe tobacco, cigars, hookah water pipes, nicotine gels, and dissolvable forms of nicotine. 

As of this date, the FDA does not regulate recreational nicotine products. Manufacturers have no requirement for consumer protection. Thus, there are no warning labels, no child resistant packaging and significant media advertising. Television advertisements for cigarettes have been banned in our country since 1971, but in the past few years supposedly healthier, battery-powered alternatives are seen in numerous prime-time programs. Electronic cigarettes had significant air time during the 2014 Super Bowl and are frequent products of late-night talk show advertising (Maron, 2014). 

While e-cigarettes are being marketed as healthy options for nicotine use, the scientific data, although limited, does not validate this position. Long-term consequences of electronic cigarette use have not been determined. “The increased use of e-cigarettes by teens is deeply troubling,” said CDC Director Tom Frieden, MD, in a press release. “Nicotine is a highly addictive drug. Many teens who start with e-cigarettes may be condemned to struggling with a lifelong addiction to nicotine and conventional cigarettes.” 

Concern has been raised about manufacturers catering to the teenage demographic in the hopes of snaring young users. Online kits provide flavors including cherry, vanilla, grape, cola and so on. Some states have gone about regulating e-cigarettes themselves, while awaiting further action by the FDA.

Proponents of e-cigarettes claim that the user is limiting the risks for harm by inhaling vapor, not smoke. “This illusive ‘safety’ of ENDS can be enticing to consumers; however, the chemicals used in electronic cigarettes have not been fully disclosed, and there are no adequate data on their emissions,” explains the WHO website. A study presented at the 2013 European Respiratory Annual Congress found significant airway resistance and decreased oxygen saturation among study subjects who used the e-cigarettes.

The electronic cigarette has four ingredients; nicotine, propylene glycol, vegetable glycerin and flavoring (Electronic Cigarette Consumer Reviews, 2014). Tobacco is not included. Some concerns have been raised not only about the potential effects of inhaling otherwise “safe” ingredients, but about the heating device itself and the solution in the e-cigarette. Several studies have suggested the vapors of e-cigarettes can contain microscopic particulate matter, tin, chromium, nickel and other heavy metals, which can cause pulmonary pathology (Kleinstreuer, 2013). 

With an e-cigarette, the user inhales vaporized liquid nicotine instead of the tobacco smoke that would be inhaled from a conventional cigarette.  This is the alternative that is touted as “healthy” or less harmful (Trimarchi, 2014).

The process of smoking an e-cigarette is called “vaping”. Nicotine addiction, as most other addictions, is cue driven.  The activity of using an e-cigarette is a powerful cue as it mimics the activity of regular smoking (Pepper, 2014). 

The unregulated and unrestricted availability of highly concentrated ENDS, has led to increased exposure and potentially significant nicotine toxicity. This is confirmed by the National Poison Data System, which has reported triple the number of childhood exposures to nicotine in 2013 compared with 2012. 

Nicotine is a plant derived parasympathomimetic alkaloid.  Nicotine is essentially a highly agonist of the nicotinic acetylcholine receptors.  Nicotine stimulates the reticular activating system in addition to stimulating a dopamine release.  Emerging research also links nicotine to impairment of the immune system (Bassett, 2014). 

With dosage increase of nicotine, cardiovascular effects can occur, including tachycardia and hypertension, gastrointestinal disturbance and at toxic levels neuromuscular blockade and CNS toxicity (Kuschner, 2011).  

As physicians and healthcare professionals, especially addiction medicine specialists, what are our reactions and responses to our patients, community members, colleagues, family when we are asked about electronic cigarettes? 

It seems reasonable that we continue to advise any current non-tobacco user to not start and not consider trying any of the currently available methods of using nicotine. As we also advise our patients regarding opiates, benzodiazepines, alcohol and other risk behaviors.

Considering a current patient that uses nicotine, who's considering cessation, how do we respond?  Is this an opportunity to discuss life change with our patient?  When a patient inquires about my opinion regarding e-cigarettes, it is an opportunity to begin discussing a goal of nicotine cessation and developing a treatment strategy.

A recent survey of North Carolina physicians published in PLOS ONE measured physicians’ attitudes toward e-cigarettes use by adult smokers.  

“Even in the absence of evidence regarding the health impact of e-cigarettes and other vaping devices, a third of physicians we surveyed are recommending e-cigarettes to their patients to help quit smoking”, said Leah Ranney, PhD, one of the authors of the survey. “Yet, e-cigarettes are not approved by the FDA for smoking cessation.”

Clinically, with each patient encounter, I remember, first do no harm…

Recently we added to our patient intake forms these questions-

1. Do you use electronic cigarettes? Yes/No

2. If yes, is it part of your plan to taper or quit smoking? Yes/No/Not Sure 

With any patient encounter I want to maintain the patient’s respect and trust in my providing guidance to healthy life choices.  One of my goals is to assist with the patient attaining their full potential.

Treat Addiction, Save Lives