Dr. Nickels is a board-certified internist and pediatrician and is currently completing an allergy/immunology fellowship at Mayo Clinic. Dr. Nickels has completed a fellowship in clinical medical ethics at the MacLean Center at the University of Chicago a
Electronic cigarettes (e-cigarettes) are novel products that are changing the landscape of nicotine addiction. Also known as electronic nicotine delivery system, or ENDS, these products were developed in the early 2000s and by 2007 were available in the U.S. marketplace
Tobacco-related morbidity and mortality has significantly shaped the public health environment in the United States. According to a recent Surgeon General report on the health consequences of smoking, smoking is responsible for one in five deaths and has been responsible for over 20 million deaths since 1964.1 In regard to ocular health, smoking has been causally linked to age-related macular degeneration, cataracts, and ocular inflammation.2 As healthcare professionals, we are on the front lines of defense against the detrimental effects of tobacco and nicotine addiction.New look for nicotine addiction
Electronic cigarettes (e-cigarettes) are novel products that are changing the landscape of nicotine addiction. Also known as electronic nicotine delivery system, or ENDS, these products were developed in the early 2000s and by 2007 were available in the U.S. marketplace.3
E-cigarettes have three components: liquid (typically nicotine containing), an atomizer (to vaporize the liquid), and a battery. These elements are housed in a cylindrical container with some models looking very similar to traditional cigarettes, while others look like large pens with mouthpieces.
Both disposable and reusable models are available with entry-level kits starting around $40. Depending on the model of e-cigarette and length of each puff, an e-cigarette can last between 150 to greater than 400 puffs.
Since their debut in the U.S. in 2007, e-cigarettes have grown in popularity. In 2013, industry sales were projected at $1.7 billion.4 According to survey-based research, there is a large amount of optimism among current tobacco smokers about using electronic cigarettes to reduce and even quit smoking.5,6
E-cigarettes have been introduced to the marketplace as a “product,” not as a drug or drug delivery device; therefore, they have not been subject to the requirements of the FDA for efficacy and safety. As such, the medical science is racing to understand if there is any evidence to support the positive effects expected by e-cigarette users. The latest studies suggest that electronic cigarettes may be helpful in reducing the amount smoked but is not in helping the user quit smoking all together.7
Just as the benefits of e-cigarettes are not yet fully known, the risks of these products are uncertain as well. The FDA has underscored that the safety profile of these products has not been established.8 While short-term use is tolerated, the long-term effects of e-cigarette use are unclear including the pulmonary and ocular effects.
Beyond the direct user concerns, the phenomenon of e-cigarettes is raising concern among public health advocates. For decades, attempts have been made to push tobacco products and their consumption to the margins of American society.9
Anti-tobacco advocates have voiced strong concerns that e-cigarettes, which are not subject to the same laws, will cause a resurgence in nicotine addiction in our society and potentially spread tobacco use.3,4
Already, there is a striking increase in use of e-cigarettes among adolescents; the CDC reported that e-cigarettes use among high school students increased from 4.7 percent to 10 percent between 2011 to 2012.10
E-cigarettes are changing the face of nicotine addiction. We should continue to address nicotine addiction with all of our patients and respect the profound detrimental health effects of tobacco use. The 2008 U.S. Department of Health and Human Services guidelines, “Treating Tobacco Use and Dependence,” still holds important tenets of tobacco cessation such the fact that even brief tobacco cessation interventions (i.e. taking 10 minutes or less to address tobacco use) is effective.11
There is clear evidence that FDA-approved nicotine replacement tools (such as gum and patches) and smoking cessation medication (i.e. varenicline [Chantix, Pfizer]) are helpful for our patients.12 In instances of limited time or provider confidence regarding tobacco cessation, free resources such as 1-800-QUIT NOW should be provided to patients because these are resources that have proven helpful in assisting patient quit smoking.11
Medical Economics: E-cigarettes: What physicians need to know
There is currently a paucity of knowledge on the efficacy and safety profile of e-cigarettes.7,13 There is also compelling evidence that these products, which are not subject to the same restriction in advertising, sales, and use as other tobacco products, are being increasingly used by youth. This nebulous situation puts healthcare providers in a challenging situation when our patients inquire if they should use e-cigarettes.
The American Heart Association has recently released a policy statement that seems to be a reasonable approach to e-cigarettes use.13 The AHA recommends (adapted):
• Electronic cigarettes should be included in tobacco screening questionnaires that are given at every health examination
• Clinicians should be educated about e-cigarettes and be prepared to counsel on the subject
• There is not enough evidence to suggest clinicians should recommend e-cigarettes as a first-line tobacco cessation tool and FDA-approved aids (nicotine replacement and pharmacotherapy) should be recommended
• For patients who have tried and were unsuccessful with or refuse FDA-approved methods and wish to try e-cigarettes, it is reasonable to support this approach after ensuring the patient understands the lack of evidence of efficacy and unknown safety profile.
E-cigarettes are a growing part of the U.S. public health landscape. Healthcare providers hold a privileged place in society to help shape public discourse in important health-related matters.
As e-cigarettes change the landscape of nicotine addiction, we should continue to passionately and compassionately address nicotine and tobacco addition with our patients.
In regard to e-cigarettes, more science is needed, and we should advocate for prudent regulations and increased funding for sound research. Please consider contacting your state and national medical societies to see how you can contribute to a brighter, tobacco-free future for your patients.
1. U.S. Dept. of Health and Human Services. "The Health Consequences of Smoking-50 Years of Progress. A Report of the Surgeon General." http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf. Accessed 12/10/14.
2. Galor A, Lee DJ. Effects of smoking on ocular health. Curr Opin Ophthalmol. Nov 2011;22(6):477-482.
3. Nickels AS, Joshi AY, Dinakar C. Electronic cigarettes: navigating the vapor. Ann Allergy Asthma Immunol. Jun 2014;112(6):481-3.
4. Fairchild AL, Bayer R, Colgrove J. The renormalization of smoking? E-cigarettes and the tobacco "endgame." N Engl J Med. 2014;370(4):293-295.
5. Palazzolo DL. Electronic cigarettes and vaping: a new challenge in clinical medicine and public health. A literature review. Front Public Health. 2013 Nov 18;1:56.
6. Dawkins L, Turner J, Roberts A, Soar K. 'Vaping' profiles and preferences: an online survey of electronic cigarette users. Addiction. Jun 2013;108(6):1115-1125.
7. Grana R, Benowitz N, Glantz SA. E-cigarettes: a scientific review. Circulation. 2014 May 13;129(19):1972-86.
8. Electronic Cigarettes (e-Cigarettes). United States Food and Drug Administration. http://www.fda.gov/newsevents/publichealthfocus/ucm172906.htm Published April 25, 2103. Accessed 12/30/14.
9. Paradise J. No sisyphean task: how the FDA can regulate electronic cigarettes. Yale J Health Policy Law Ethics. 2013 Summer;13(2):326-374.
10. Centers for Disease C, Prevention. Notes from the field: electronic cigarette use among middle and high school students - United States, 2011-2012. MMWR Morb Mortal Wkly Rep. Sep 6 2013;62(35):729-730.
11. Fiore MC JC, Baker TB, Bailey WC, Benowitz NL, Curry SJ, Dorfman SF, Froelicher ES, Goldstein MG, Froelicher ES, Healton CG, et al. Treating Tobacco Use and Dependence: 2008 Update-Clinical Practice Guidelines. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, Agency for Healthcare Research and Quality, 2008 [accessed 2014 December 29].
12. Quitting Smoking. United States Center for Disease Control. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/index.htm Accessed 12/20/14.
13. Bhatnagar A, Whitsel LP, Ribisl KM, et al. Electronic cigarettes: a policy statement from the American Heart Association. Circulation. 2014 Oct 14;130(16):1418-36.