Return to Index
E-Cigarettes: A Safe Substitute for Smokers?
Electronic cigarette (e-cigarette) usage has surged since they were introduced in the US market in 2007. Many are excited that e-cigarettes may be a safer alternative to cigarette smoking with fewer obnoxious effects on those surrounding the smoker. While the news is exciting, these tools are still fairly new and not fully tested. It is important to confirm that these e-cigarettes are safer for the user and those around them, but this will take some time and research.
What Are E-Cigarettes?
E-cigarettes are battery-powered devices that are available in a range of sizes and shapes. Some look just like real cigarettes, while others are designed to look more like pens.
In general, the devices are made up of:
- A mouthpiece
- A replaceable (or refillable) cartridge, wich contains a liquid solution of different strengths of nicotine, flavoring, water, and chemicals.
- An atomizer, which transforms the liquid solution into a vapor.
- A rechargeable battery. Depending on the style, the battery end of the cigarette may have an LED light on the tip to look like the burning ember on a real cigarette. However, the LED light does not get hot, so it does not pose a fire hazard.
When the user inhales on the mouthpiece, this triggers the liquid to be heated, and the atomizer turns the liquid into a vapor. This vapor is then inhaled by the user, which feels like smoking a real cigarette. When the user exhales, the vapor quickly disappears. Smoking e-cigarettes is also known as vaping.
What Is the Controversy Surrounding E-Cigarettes?
There are over 250 e-cigarette brands available to consumers each with different combinations of nicotine and other chemicals. This variability causes controversy on how e-cigarettes should be regulated, if at all. Regulators, both in and out the US markets, are looking at e-cigarettes' potential benefits and harms.
The most obvious benefit to e-cigarettes is that it may help smokers stop smoking cigarettes. It is unique to all other current cessation programs because it allows people to continue "smoking" without inhaling thousands of harmful chemicals normally found in one burning cigarette. But, do e-cigarettes really help smokers quit?
In one controlled trial, a group of 300 smokers were split into three groups who received cartridges with either all the same amount of nicotine, a step-down amount of nicotine, or no nicotine. Half the smokers in each group had made past attempts to quit. The median daily smoked cigarettes was about 20 for each group. After 12 weeks, over 20% smoked less cigarettes per day from their baseline amount. Cessation was maintained by over 10% at a one-year follow-up. Nicotine content seemed to have no effect on the cessation rate among the groups. However, smokers did report big declines in smoking's side effects, such as dry cough, mouth and throat irritation, shortness of breath, and headache.
In 2014, a study with 949 current smokers was published. Participants used e-cigarettes for one year. The study found that using e-cigarettes did not help smokers quit or reduce cigarette consumption. Conversely, a review of two studies showed the six-month quit rate for e-cigarettes was higher than a non-nicotine placebo. In one of the studies, e-cigarettes were as effective as nicotine patches after six months. Though these studies are promising, more research needs to be done before they replace other nicotine replacement therapies.
Currently, the US Food and Drug Administration (FDA), along with several major anti-smoking organizations, have determined that there has not been enough research on e-cigarettes to make any claims about their safety or effectiveness in helping people quit smoking.
E-cigarette smoking is not without its concerns. The biggest challenge facing e-cigarettes is regulation. In the United States, that falls on the FDA's doorstep. Some of their concerns are:
- Safety and effectiveness of e-cigarettes if used to quit smoking.
- Wide variation of the amount of nicotine in each e-cigarette.
- How e-cigarettes impact younger people's views on smoking. Will it make smoking "cool" again?
- How liquid nicotine is handled, distributed, or stored. Small amounts that are ingested or absorbed through the skin can be toxic or deadly, especially to children.
One of the bigger issues for the FDA is the chemical make-up of the inhaled vapors. The agency analyzed different e-cigarette brands. They found diethylene glycol (a chemical used in antifreeze) and other cancer-causing agents in some of the samples. The agency is also concerned that the cartridges are not consistent in the amount of nicotine they provide. For example, you may use a low-strength nicotine cartridge, but actually receive a higher dose (or vice versa).
Another issue is the chemical make-up of exhaled vapors. Like cigarette smoke, not all of the chemicals in e-cigarettes remain in the lungs of the smoker. Some of these elements are exhaled into the air where others can breathe in these chemicals. The particles can also land on surfaces, like clothes, furniture, and carpets. Studies on these effects will need to be taken into account during the regulatory process. E-cigarettes are also not included in current public smoking bans, which is causing some states to scramble to put e-cigarettes in the same class as tobacco products, but it may not be that easy.
In recent surveys, perception exists that e-cigarettes are safer and can be used as a tool to stop smoking, especially among young adult smokers. Currently, there is too much conflicting information among agencies and manufacturers to make such a broad statement. The bottom line is that e-cigarette users still inhale nicotine and other potentially-hazardous chemicals, but the types and amounts of these chemicals are varied and usually unknown. That's where regulation may help.
Making an Informed Decision
If you are thinking about kicking the habit, your best option would be to weigh out all your options. Some smoking cessation strategies, like nicotine replacement products, prescription medications, organized programs, and support groups, have a proven track record. If you are considering e-cigarettes, discuss the pros and cons with your doctor. It may also make a difference if you are using this as a tool to quit, or a potentially safer substitute for smoking that you plan to continue indefinitely. Making an informed decision is an important step in taking control of your health.
US Food and Drug Administration
Canadian Lung Association
Adkison SE, O'Connor RJ, et al. Electronic nicotine delivery systems: International tobacco control four-country survey. Am J Prev Med. 2013;44(3):207-215.
Benowitz NL, Goniewicz ML. The regulatory challenge of electronic cigarettes. JAMA. 2013;310(7):685-686.
E-cigarettes: Questions and answers. US Food and Drug Administration website. Available at: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm225210.htm. Updated January 21, 2015. Accessed March 19, 2015.
Kim, S. Study: Smokers using e-cigarettes to quit are younger, more motivated. Public Health Newswire. American Public Health Association website. Available at: http://www.publichealthnewswire.org/?p=8171. Accessed March 19, 2015.
Kuschner WG, Reddy S, et al. Electronic cigarettes and thirdhand tobacco smoke: two emerging health care challenges for the primary care provider. Int J Gen Med. 2011;4:115-120.
Nicotine. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed. Updated January 18, 2013. Accessed March 19, 2015.
Pokhrel P, Fagan P, et al. Smokers who try e-cigarettes to quit smoking: findings from a multiethnic study in Hawaii. Am J Public Health. 2013;103(9):e57-e62.
Policy guidance document regarding cigarettes. American Heart Association website. Available at: http://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm%5F315097.pdf. Accessed March 19, 2015.
Rankin KV. E-cigarettes: What's known, what's unknown. Tex Dent J. 2013;130;(5):446-452.
Questions and answers on electronic cigarettes or electronic nicotine delivery systems (ENDS). World Health Organization website. Available at: http://www.who.int/tobacco/communications/statements/eletronic%5Fcigarettes/en. Updated June 3, 2014. Accessed March 19, 2015.
What's in a cigarette? American Lung Association website. Available at: http://www.lung.org/stop-smoking/about-smoking/facts-figures/whats-in-a-cigarette.html. Accessed March 19, 2015.
6/24/2014 DynaMed's Systematic Literature Surveillance http://www.ebscohost.com/dynamed: Grana RA, Popova L, et al. A longitudinal analysis of electronic cigarette use and smoking cessation. JAMA Intern Med. 2014;174(5):812-813.
3/19/2015 DynaMed's Systematic Literature Surveillance http://www.ebscohost.com/dynamed: McRobbie H, Bullen C, et al. Electronic cigarettes for smoking cessation and reduction. Cochrane Database Syst Rev. 2014;12:CD010216.
- Reviewer: Michael Woods, MD
- Review Date: 08/2013