Score on electronic cigarettes
By Rafael Castillo
Philippine Daily Inquirer
January 31, 2015 at 12:52 am

Ronaldo Perez, a reader from Pasig City, is requesting for some updates on electronic cigarettes (e-cigs).

We’ve written previously in this column that we need more scientific data—aside from the obviously biased information from e-cig manufacturers—that would support their effectiveness and safety as a tool for smoking cessation.

The e-cigs work as a vaporizer which converts a liquid solution into an aerosol mist. There’s a small device inside the e-cig that heats up the liquid nicotine, turning it into a vapor that smokers inhale and exhale.

Peter Hajek, a consultant at Queen Mary University of London, published last month a commentary on e-cigs in the British journal BioMed. He has published several papers supporting e-cig use and has not received any funding for his research works on e-cigs.

He premised his commentary by stating that the apparent “hostility” to e-cigs could be related to a moral belief by many experts and health organizations that nicotine use should be “eradicated rather than allowed to morph into a relatively harmless activity” such as with the use of e-cigs.

“If electronic cigarettes are allowed to compete with cigarettes and develop further, smoking is likely to all but disappear,” he wrote. “Discouraging smokers from making the switch and reducing [e-cigs’] competitiveness with cigarettes by unwarranted regulation will delay this opportunity or squander it altogether,” he added.

Hajek believes that the tide has changed already and there is now sufficient evidence to recommend e-cigs to smokers who cannot stop smoking with existing treatments.

Efficacy, adverse effects

An Italian research group headed by Prof. Maria Rosaria Gualano of the University of Torino also published their review of the scientific literatures recently. The group wanted to evaluate all available data on the efficacy and the adverse effects through a systematic review of published studies on e-cigs.

They included a total of 12 published studies in their review. They reported that e-cigs helped significantly reduce the number of regular cigarettes use in studies ranging from 12 weeks to one year. Regarding the side effects of e-cigs, the most frequently reported ones are dry mouth and throat irritation, nausea, headache and dry cough.

Professor Gualano and her group are convinced that the use of e-cigs can reduce the number of cigarettes smoked including the withdrawal symptoms, but they cautioned that the side effects they reported were mainly related to a short period of use. Long-term studies of several years of use are needed to thoroughly evaluate the real impact of e-cigs—whether they’re beneficial or not, harmful or not.

This was the same conclusion and recommendation of Berg C.J. et al. in their paper published in the October 2014 issue of the Journal of Preventive Medicine.


Discouraging e-cig use

However, medical organizations and other health agencies, including the World Health Organization, have not yet revised their recommendation discouraging e-cig use, while at the same time lobbying for legislation and policies restricting or regulating e-cigs.

This was based on earlier studies showing that the vapors from e-cigs contain traces of toxic substances that can harm bystanders by “secondhand” smoke. On the other hand, the e-cig advocates argue that the levels of these chemicals are well within safe limits when measured in the air after lighting e-cigs.

The medical organizations are also concerned that e-cig use may serve as a “gateway” for nonsmokers, especially children, to progress to actual smoking. It can be an “introductory vice” that can subsequently lead to the real vice of smoking.

Last year, the Philippine Medical Association and other health experts have called for a ban on the sale of e-cigs to the public until such time that valid clinical trial data are already available. They pointed out that the sale of e-cigs is unregulated, making them accessible to children and adolescents, who look at them as cool devices to be seen with.

E-cigs are also promoted by some marketers as an “alternative lifestyle”, and many think they are safer and relatively “healthier” than actual smoking.

So what’s the score now for e-cigs? Most of the studies showed they help in reducing the number of cigarettes smoked, but not in making the smokers quit smoking completely. In my practice, I allow their use as “temporary” weaning devices to lick smoking, but I don’t encourage their prolonged use of more than six months. If one is really determined to quit smoking, six months should be more than enough to quit all forms of smoking once and for all.

A good number of patients achieve that, but some smokers are happy with simply reducing the number of cigarettes smoked, resorting to e-cigs from time to time to fill in the “nicotine gap.” I’m not too sure if this type of change in smoking behavior could really impact favorably on these smokers in the long term.

Temp smoking-cessation tool

I support the use of e-cigs as a temporary smoking-cessation tool since clinical studies show they’re helpful tools for this objective, but I think they also have an inherent behavioral downside. Quitting smoking requires a behavioral change that should also wean the smoker from the habit of lighting a cigarette, holding it with one’s forefinger and middle finger, and lifting it to one’s lips to suck in the smoke or vapor. Using e-cigs is still virtually smoking from the behavioral sense.

A smoker does not only have to be weaned off from the nicotine addiction, but from the behavioral aspect of being habituated to the act of holding a cigarette, or what looks like it, and gently inhaling the smoke or vapor.

So is it okay to quit cigarette smoking and shifting to e-cigs as an “alternative vice” presuming that it’s a lesser evil? Well, I don’t think we have enough long-term data proving it’s really a lesser evil than actual cigarette smoking. I hope it does not turn out to be the classical case of jumping from the frying pan into the fire.

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