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Health effects

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Position of medical organizations

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Main article: Positions of medical organizations regarding electronic cigarettes

As of 2014 electronic cigarettes have not been approved for helping people quit smoking by any government.[1] In July 2014, a report produced by the World Health Organization (WHO) for the Conference of the Parties to the WHO Framework Convention on Tobacco Control, found there was not enough evidence to determine if electronic cigarettes can help people quit smoking. It suggested that smokers should be encouraged to use approved methods for help with quitting.[1] But the same report also mentioned expert opinions in scientific papers that suggested e-cigarettes may have a role helping people quit who have failed using other methods.[1] A previous WHO statement from July 2013 stated that e-cigarettes have not been shown to be effective helping people quit smoking.[2] It also recommended that "consumers should be strongly advised not to use" e-cigarettes unless a reputable national regulatory body has found them safe and effective.[2] The World Lung Foundation applauded the 2014 WHO report's recommendation for tighter regulation of e-cigarettes due to concerns about the safety of e-cigarettes and the possible increased nicotine or tobacco addiction among youth.[3]

The UK National Health Service has concluded, "While e-cigarettes may be safer than conventional cigarettes, we don't yet know the long-term effects of vaping on the body. There are clinical trials in progress to test the quality, safety and effectiveness of e-cigarettes, but until these are complete, the government can't give any advice on them or recommend their use."[4]

In 2014, the US Food and Drug Administration (FDA) concluded, "E-cigarettes have not been fully studied, so consumers currently don't know: the potential risks of e-cigarettes when used as intended, how much nicotine or other potentially harmful chemicals are being inhaled during use, or whether there are any benefits associated with using these products. Additionally, it is not known whether e-cigarettes may lead young people to try other tobacco products, including conventional cigarettes, which are known to cause disease and lead to premature death."[5]

Smoking cessation

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As of 2014, research on the safety and efficacy of e-cigarette use for smoking cessation is limited.[6][7] Their benefit in helping people quit smoking is uncertain.[8] The evidence suggests that e-cigarettes can supply nicotine at concentrations that are, at least partially, enough to substitute for traditional cigarettes.[9] While there are some reports of improved smoking cessation, especially with intensive e-cigarette users, there are also several studies showing a decline in cessation in dual users.[10] A 2014 Cochrane review found limited evidence of a benefit as a smoking cessation aid from a small number of studies.[11] A 2015 review found variable quality evidence that nicotine-containing e-cigarettes were associated with smoking cessation and reduction from a limited number of studies.[12] A 2015 review concluded that while they may have a benefit for decreasing cigarette use in smokers, they have a limited benefit in quitting smoking.[13] A 2014 review found e-cigarettes may have some potential for reducing smoking.[14]

Two 2014 reviews found no evidence that e-cigarettes are more effective than existing nicotine replacement treatments for smoking cessation.[11][15] Studies have not shown that e-cigarettes are superior to regulated medications for smoking cessation.[8] A 2014 review found four experimental studies and six cohort studies that indicated that electronic cigarettes reduced the desire to smoke and withdrawal symptoms.[16] This review also noted that two cohort studies found that electronic cigarettes led to a reduction in the number of cigarettes smoked per day.[16] Nicotine-containing e-cigarettes were associated with greater effectiveness for quitting smoking than e-cigarettes without nicotine.[12] A 2014 review concluded that the adverse public health effects resulting from the widespread use of e-cigarettes could be significant, in part due to the possibility that they could undermine smoking cessation.[17] This review therefore called for their use to be limited to smokers who are unwilling or unable to quit.[17] A 2014 review found that the research suggested that personal e-cigarette use may reduce overall health risk in comparison to traditional cigarettes.[18] However, e-cigarettes could have a broad adverse effect for a population by expanding initiation and lowering cessation of smoking.[18] A 2014 review found that the evidence suggests that "e-cigarettes are not associated with successful quitting in general population-based samples of smokers."[19]

Safety

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Main article: Safety of electronic cigarettes

The risks of electronic cigarette use are uncertain,[20][8] as there is little data regarding health effects,[21] and considerable variability between vaporizers and in the composition, concentration and quality of their liquid ingredients and thus the contents of the aerosol delivered to the user.[19][22][23] The limited evidence suggests that e-cigarettes are probably safer than traditional cigarettes.[22] Various methodological issues, conflicts of interest, and often inconsistent research has been identified in the research regarding e-cigarettes.[17] However, e-cigarettes cannot be regarded as simply harmless.[17] A 2014 review recommended that e-cigarettes should be regulated for consumer safety.[24]

One review found they appear to be similar in toxicity to other nicotine replacement products, but there is not enough data to draw conclusions.[25] Another found that the evidence suggests that the US Food and Drug Administration (FDA) accepted products such as a nicotine inhaler are probably a safer way to supply nicotine than e-cigarettes.[15] A July 2014 WHO report cautioned about potential risks of using electronic cigarettes. The report concluded that "the existing evidence shows that ENDS aerosol is not merely "water vapour" as is often claimed in the marketing for these products. ENDS use poses serious threats to adolescents and fetuses."[1] There are also risks from misuse or accidents (e.g., accidental fires caused by vaporizer malfunction, other vaporizer design issues, or accidental contact with liquid nicotine).[19][26][27] A 2014 systematic review concluded that the risks of e-cigarettes have been exaggerated by health authorities and stated that it is apparent that there may be some remaining risk accompanied with e-cigarette use, though the risk of e-cigarette use is likely small compared to smoking tobacco.[26] A 2014 Cochrane review found no serious adverse effects reported in trials.[11] Less serious adverse effects from e-cigarette use can include throat and mouth inflammation, vomiting, nausea, and cough.[19] As of 2015, the short and long term effects from using e-cigarettes remain unclear.[10] E-cigarette users are exposed to potentially harmful nicotine.[28]

Tobacco harm reduction has been a controversial area of tobacco control.[29] The health community have been reluctant to support harm reduction efforts, in part in response to tobacco industry deception.[29] A 2014 review found no long-term evidence on the efficacy of e-cigarettes in reducing harm from tobacco related disease or improving the health of the population as a whole and concluded promotion of e-cigarettes as a harm reduction product was premature.[15] A different review found e-cigarettes would likely be less harmful than tobacco cigarettes to users and bystanders, if at all.[30] The authors warned against the potential harm of excessive regulation and advised that health professionals may consider advising smokers who are reluctant to quit by other methods to switch to e-cigarettes as a safer alternative to smoking.[30] A 2014 review argued that regulations for electronic cigarettes should be similar to those for dietary supplements or cosmetic products to not limit their potential for harm reduction.[24] A 2012 review found electronic systems appear to generally deliver less nicotine than smoking, raising the question of whether they can effectively substitute for tobacco smoking over a long-term period.[22] A 2012 review found e-cigarettes could considerably reduce traditional cigarettes use and they likely could be used as a lower risk replacement for traditional cigarettes, but there is not enough data on the safety and efficacy to draw definite conclusions.[31] E-cigarette use for risk reduction in high-risk groups such as people with mental disorders is unavailable.[32]

Smoke from traditional tobacco products has 40 known carcinogens among the 10,000 chemicals it contains, none of which has been found in more than trace quantities in the cartridges or aerosol of e-cigarettes.[29] A 2011 review stated that while e-cigarettes can not be considered "safe" because there is no safe level for carcinogens, they are doubtless safer compared to tobacco cigarettes.[29] Any residual risk of e-cigarette use should be weighed relative to the risk of continuing or returning to smoking, taking account of the low success rate of currently-approved smoking cessation medications.[26] Adults most frequently use electronic cigarettes as a replacement for tobacco, but not always to quit.[33] Although some people have a desire to quit smoking by using e-cigarettes, another common explanation for the use of these products is to cut back on traditional cigarettes.[19]

In 2014 a report commissioned by Public Health England concluded that there is large potential for health benefits when switching from tobacco use to other nicotine delivery devices such as electronic cigarettes, but realizing their full potential requires regulation and monitoring to minimize possible risks.[34] They found that the evidence suggests that a considerable number of smokers want to reduce harm from smoking by using these products.[34] The British Medical Association encourages health professionals to recommend conventional nicotine replacement therapies, but for patients unwilling to use or continue using such methods, health professionals may present e-cigarettes as a lower-risk option than tobacco smoking.[35] The American Association of Public Health Physicians (AAPHP) suggests those who are unwilling to quit tobacco smoking or unable to quit with medical advice and pharmaceutical methods should consider other nicotine containing products such as electronic cigarettes and smokeless tobacco for long term use instead of smoking.[36] In an interview, the director of the Office on Smoking and Health for the U.S. federal agency Centers for Disease Control and Prevention (CDC) believes that there is enough evidence to say that using e-cigarettes is likely less harmful than smoking a pack of conventional cigarettes. However, due to the lack of regulation of the contents of the numerous different brands of electronic cigarettes and the presence of nicotine, which is not a benign substance, the CDC has issued warnings.[37] A 2014 WHO report concluded that some smokers will switch completely to e-cigarettes from traditional tobacco but a "sizeable" number will use both tobacco cigarettes and electronic cigarettes. This report found that such "dual use" of e-cigarettes and tobacco "will have much smaller beneficial effects on overall survival compared with quitting smoking completely."[1]

Addiction

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A number of organizations have concerns that e-cigarettes might increase addiction to and use of nicotine and tobacco products in the young.[38][39][40] These include the Centers for Disease Control and Prevention, the International Union Against Tuberculosis and Lung Disease, the American Academy of Pediatrics and the Food and Drug Administration.[37][41][42][43] The World Health Organization raised concern of addiction for nonsmokers from their use in July 2013.[2] The National Institute on Drug Abuse stated that there is a possibility that they could promote continuation of addiction to nicotine in those who are attempting to quit.[39]

The nicotine molecule.

It is not clear whether using e-cigarettes will decrease or increase overall nicotine addiction.[21] The information concerning the drug action of the nicotine in e-cigarettes is limited.[9] The evidence suggests that the nicotine in e-cigarettes is adequate to sustain nicotine dependence.[9] The limited data suggests that the likelihood of abuse from e-cigarettes could be smaller compared to traditional cigarettes.[44] A 2014 systematic review found that the concerns that e-cigarettes could cause non-smokers to begin smoking are unsubstantiated.[26] A 2014 review found no evidence that they are used regularly by those who have never smoked,[30] while another 2014 review has found that in some populations nearly up to a third of youth who have ever used electronic cigarettes have never smoked traditional cigarettes.[19] No long-term studies have been done on the effectiveness of e-cigarettes in treating tobacco addiction.[15] The degree to which teens are using e-cigarettes in ways it is not intended to be used, such as increasing the nicotine delivery, is unknown.[27] The extent to which e-cigarette use will lead to abuse in youth is unknown.[27] The impact of e-cigarette use by children in respect to substance dependence is unknown.[27] Some evidence suggests that dual use of e-cigarettes and traditional cigarettes may be associated with greater nicotine dependence.[10]

  1. ^ a b c d e WHO. "Electronic nicotine delivery systems" (PDF). Retrieved 28 August 2014.
  2. ^ a b c "Tobacco Free Initiative (TFI)". World Health Organization. 9 July 2013.
  3. ^ "WHO Right to Call for E-Cigarette Regulation". World Lung Federation. Retrieved 6 November 2014.
  4. ^ "Stop smoking treatments". UK National Health Service. Retrieved 6 November 2014.
  5. ^ "Electronic Cigarettes (e-Cigarettes)". US Food and Drug Administration. Retrieved 6 November 2014.
  6. ^ Franck, C.; Budlovsky, T.; Windle, S. B.; Filion, K. B.; Eisenberg, M. J. (2014). "Electronic Cigarettes in North America: History, Use, and Implications for Smoking Cessation". Circulation. 129 (19): 1945–1952. doi:10.1161/CIRCULATIONAHA.113.006416. ISSN 0009-7322. PMID 24821825.
  7. ^ Orr, KK; Asal, NJ (November 2014). "Efficacy of electronic cigarettes for smoking cessation". The Annals of pharmacotherapy. 48 (11): 1502–6. doi:10.1177/1060028014547076. PMID 25136064.
  8. ^ a b c Harrell, PT; Simmons, VN; Correa, JB; Padhya, TA; Brandon, TH (4 June 2014). "Electronic Nicotine Delivery Systems ("E-cigarettes"): Review of Safety and Smoking Cessation Efficacy". Otolaryngology—head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. doi:10.1177/0194599814536847. PMID 24898072. These devices are unregulated, of unknown safety, and of uncertain benefit in quitting smoking.
  9. ^ a b c Schroeder, M. J.; Hoffman, A. C. (2014). "Electronic cigarettes and nicotine clinical pharmacology". Tobacco Control. 23 (Supplement 2): ii30–ii35. doi:10.1136/tobaccocontrol-2013-051469. ISSN 0964-4563. PMID 24732160.
  10. ^ a b c Orellana-Barrios, Menfil A.; Payne, Drew; Mulkey, Zachary; Nugent, Kenneth (2015). "Electronic cigarettes-a narrative review for clinicians". The American Journal of Medicine. doi:10.1016/j.amjmed.2015.01.033. ISSN 0002-9343. PMID 25731134.
  11. ^ a b c Cite error: The named reference Cochrane2014 was invoked but never defined (see the help page).
  12. ^ a b Rahman, Muhammad Aziz (30 March 2015). "E-Cigarettes and Smoking Cessation: Evidence from a Systematic Review and Meta-Analysis". PLoS One. doi:10.1371/journal.pone.0122544. PMID 25822251.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  13. ^ "Electronic Cigarettes: Vulnerability of Youth". Pediatr Allergy Immunol Pulmonol. 28 (1): 2–6. 2015. doi:10.1089/ped.2015.0490. PMID 25830075. {{cite journal}}: Unknown parameter |authors= ignored (help)
  14. ^ "Electronic cigarettes: patterns of use, health effects, use in smoking cessation and regulatory issues". Tob Induc Dis. 12 (1): 21. 2014. doi:10.1186/1617-9625-12-21. PMC 4350653. PMID 25745382. {{cite journal}}: Unknown parameter |authors= ignored (help)CS1 maint: unflagged free DOI (link)
  15. ^ a b c d Drummond, MB; Upson, D (February 2014). "Electronic cigarettes. Potential harms and benefits". Annals of the American Thoracic Society. 11 (2): 236–42. doi:10.1513/annalsats.201311-391fr. PMID 24575993.
  16. ^ a b Gualano, M. R.; Passi, S.; Bert, F.; La Torre, G.; Scaioli, G.; Siliquini, R. (9 August 2014). "Electronic cigarettes: assessing the efficacy and the adverse effects through a systematic review of published studies". Journal of Public Health. doi:10.1093/pubmed/fdu055. PMID 25108741.
  17. ^ a b c d Pisinger, Charlotta; Døssing, Martin (December 2014). "A systematic review of health effects of electronic cigarettes". Preventive Medicine. 69: 248–260. doi:10.1016/j.ypmed.2014.10.009. PMID 25456810.
  18. ^ a b Cite error: The named reference Rom2014 was invoked but never defined (see the help page).
  19. ^ a b c d e f Grana, R; Benowitz, N; Glantz, SA (13 May 2014). "E-cigarettes: a scientific review". Circulation. 129 (19): 1972–86. doi:10.1161/circulationaha.114.007667. PMC 4018182. PMID 24821826.
  20. ^ Cite error: The named reference EbbertAgunwamba2015 was invoked but never defined (see the help page).
  21. ^ a b Palazzolo, Dominic L. (Nov 2013), "Electronic cigarettes and vaping: a new challenge in clinical medicine and public health. A literature review.", Frontiers in Public Health, 1 (56), doi:10.3389/fpubh.2013.00056, PMC 3859972, PMID 24350225{{citation}}: CS1 maint: unflagged free DOI (link)
  22. ^ a b c O'Connor, RJ (March 2012). "Non-cigarette tobacco products: what have we learnt and where are we headed?". Tobacco control. 21 (2): 181–90. doi:10.1136/tobaccocontrol-2011-050281. PMC 3716250. PMID 22345243.
  23. ^ Odum, L. E.; O'Dell, K. A.; Schepers, J. S. (December 2012). "Electronic cigarettes: do they have a role in smoking cessation?". Journal of pharmacy practice. 25 (6): 611–4. doi:10.1177/0897190012451909. PMID 22797832.
  24. ^ a b Saitta, D; Ferro, GA; Polosa, R (Mar 2014). "Achieving appropriate regulations for electronic cigarettes". Therapeutic advances in chronic disease. 5 (2): 50–61. doi:10.1177/2040622314521271. PMC 3926346. PMID 24587890.
  25. ^ Cite error: The named reference Caponnetto2013 was invoked but never defined (see the help page).
  26. ^ a b c d Farsalinos, K. E.; Polosa, R. (2014). "Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review". Therapeutic Advances in Drug Safety. 5 (2): 67–86. doi:10.1177/2042098614524430. ISSN 2042-0986. PMC 4110871. PMID 25083263.
  27. ^ a b c d Durmowicz, E. L. (2014). "The impact of electronic cigarettes on the paediatric population". Tobacco Control. 23 (Supplement 2): ii41–ii46. doi:10.1136/tobaccocontrol-2013-051468. ISSN 0964-4563. PMID 24732163.
  28. ^ Cite error: The named reference Cheng2014 was invoked but never defined (see the help page).
  29. ^ a b c d M., Z.; Siegel, M (February 2011). "Electronic cigarettes as a harm reduction strategy for tobacco control: a step forward or a repeat of past mistakes?". Journal of public health policy. 32 (1): 16–31. doi:10.1057/jphp.2010.41. PMID 21150942.
  30. ^ a b c Hajek, P; Etter, JF; Benowitz, N; Eissenberg, T; McRobbie, H (31 July 2014). "Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit" (PDF). Addiction (Abingdon, England). 109 (11): 1801–10. doi:10.1111/add.12659. PMID 25078252.
  31. ^ Cite error: The named reference Caponnetto2012 was invoked but never defined (see the help page).
  32. ^ "E-cigarettes--prevention, pulmonary health, and addiction". Dtsch Arztebl Int. 111 (20): 349–55. 2014. doi:10.3238/arztebl.2014.0349. PMC 4047602. PMID 24882626. {{cite journal}}: Unknown parameter |authors= ignored (help)
  33. ^ Cite error: The named reference Car2014 was invoked but never defined (see the help page).
  34. ^ a b Britton, John; Bogdanovica, Ilze (15 May 2014). "Electronic cigarettes – A report commissioned by Public Health England" (PDF). Public Health England.
  35. ^ "BMA calls for stronger regulation of e-cigarettes" (PDF). British Medical Association. Retrieved 18 November 2013.
  36. ^ "Principles to Guide AAPHP Tobacco Policy". American Association of Public Health Physicians. Retrieved 31 July 2013.
  37. ^ a b Edgar, Julie. "E-Cigarettes: Expert Q&A With the CDC". WebMD. Retrieved 17 November 2013.
  38. ^ Centers for Disease Control and Prevention, (CDC) (6 September 2013). "Notes from the field: electronic cigarette use among middle and high school students – United States, 2011–2012". MMWR. Morbidity and mortality weekly report. 62 (35): 729–30. PMID 24005229.
  39. ^ a b "DrugFacts: Electronic Cigarettes (e-Cigarettes)". National Institute on Drug Abuse. September 2014. Retrieved 15 October 2014. There is also the possibility that they could perpetuate the nicotine addiction and thus interfere with quitting.
  40. ^ "Citing Health Concerns the American Cancer Society Calls for Action". American Cancer Society. Retrieved 12 November 2013. Government agencies and medical organizations, such as the FDA, the Centers for Disease Control and Prevention, and the American Academy of Pediatrics have also expressed concern that electronic cigarettes could increase nicotine addiction and tobacco use in young people.
  41. ^ "Position Statement on Electronic Cigarettes [ECs] or Electronic Nicotine Delivery Systems [ENDS]" (PDF). The International Union against Tuberculosis and Lung Disease. October 2013.
  42. ^ Korioth, Trisha. "E-cigarettes easy to buy, can hook kids on nicotine". The American Academy of Pediatrics. Retrieved 17 November 2013.
  43. ^ "FDA Warns of Health Risks Posed by E-Cigarettes". FDA. 23 July 2009. Retrieved 17 November 2013—Reviewed 17 September 2013{{cite web}}: CS1 maint: postscript (link)
  44. ^ Evans, S. E.; Hoffman, A. C. (2014). "Electronic cigarettes: abuse liability, topography and subjective effects". Tobacco Control. 23 (Supplement 2): ii23–ii29. doi:10.1136/tobaccocontrol-2013-051489. ISSN 0964-4563. PMID 24732159.
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