With a fraction of the chemicals and carcinogens, e-cigarettes can be considered “safer” than traditional cigarettes, but a lack of research around long-term use of the devices, particularly newer versions, should prevent them from being considered “safe,” Brian King, PhD, MPH, said recently at an NCAD East panel in Baltimore. King is the deputy director for research translation in the Centers for Disease Control and Prevention’s Office on Smoking and Health.
“We know e-cigarettes are markedly safer than conventional cigarettes, but there’s a lot of debate on how much safer,” King said. “There is so much variation in products. We do know cigarette smoke has 7,000 chemicals and 70 carcinogens. E-cigarettes are nowhere near that. So, they’re safer, but not safe.
“We do know e-cigarettes contain an aerosol that contains potentially harmful ingredients, but not nearly as much as cigarettes. That being said, if an adult smoker were to transition completely, there could be a benefit to that individual because you’re not exposed to the same toxins.”
King said that based on existing research, it is unclear how many individuals using e-cigarettes are doing so for the purposes of smoking cessation. Overall, 60% of e-cigarette users are also currently smoking conventional cigarettes. Notably, 40% of e-cigarette users between the ages of 18 and 24 have never smoked traditional cigarettes compared to around 10% of e-cigarette users overall.
Studies shared by King and another panelist, Jessica Yingst, DrPH, research project manager at Penn State University, suggest that if e-cigarettes are used for smoking cessation, a higher dose of nicotine makes their usage more likely to be effective. A 2018 FDA report said there was moderate evidence that e-cigarettes with nicotine were more effective for smoking cessation than those without.
Yingst, meanwhile, shared data from a recently completed research trial she helped facilitate in which 520 smokers who were interested in reducing their smoking (but not quitting entirely) were divided into groups given one of four devices:
- A plastic cigarette substitute that produces no aerosol or vapor
- An e-cigarette with zero nicotine
- An e-cigarette with 8 milligrams of nicotine per milliliter
- An e-cigarette with 36 milligrams of nicotine per milliliter
After six months, 11% of those in 36 milligram group had quit smoking compared to 3% in the 8 milligram group and 1% in the 0 milligram group.
“That highlights that for smokers to switch completely over to e-cigarettes, they do have to deliver nicotine and serve as a replacement, or you will find they will just return to smoking,” Yingst said.
The newest generation of e-cigarettes, “pod mods,” the most widely known of which are manufactured by Juul, deliver nicotine significantly more efficiently than previous generations of e-cigarettes, King said. This is accomplished by using nicotine salts instead of freebase nicotine. This allows for higher levels of nicotine to go down easier, King said.
Still, King noted, the 2018 FDA report said there is insufficient evidence about the effectiveness of e-cigarettes as cessation aids compared with no treatment or cessation treatments approved by the U.S. Food and Drug Administration. Clinicians should continue to consider the seven FDA-approved medications for smoking cessation to be first-line recommendations and also continue to monitor science and research on emerging cessation strategies, King said.
In addiction treatment settings, beyond using FDA-approved medications, treatment centers should provide patients with “an overt structure” with a step-by-step approach instead of leaving patients to their own devices, said Jared P. Dempsey, chief science officer at NLW Partners.
“The biggest issue that we are seeing with treatment centers right now is that they’re not offering formal, structured treatment, some psychoeducation, some counseling,” Dempsey said. “There are many people that go into residential addiction treatment locations that do want to quit smoking and it’s not addressed. It’s not enough to ban smoking. You need to provide resources and tools for people.”