The Emerging Phenomenon of Electronic Cigarettes

Pasquale Caponnetto; Davide Campagna; Gabriella Papale; Cristina Russo; Riccardo Polosa

Disclosures

Expert Rev Resp Med. 2012;6(1):63-74. 

In This Article

The Subjective Experience of Using the Electronic Cigarette

The electronic cigarette is designed for the purpose of providing a flavor and physical sensation similar to that of inhaled tobacco smoke, while no smoke or combustion is actually involved in its operation. When a user sucks on the device, an electronic sensor detects air flow and automatically activates the heating element that heats the liquid in the cartridge so that it is vaporized. Upon inhalation, the same electronic sensor lights up a red LED indicator to signal activation of the device with each puff. Most replaceable cartridges contain nicotine suspended in propylene glycol (PG), glycerol and water, but they can also contain flavorings (e.g., fruit or mint). There are also cartridges containing no nicotine, created for those individuals who want to reproduce smoking habits without the use of nicotine. The heating element that vaporizes the liquid in the cartridge and generates the mist with each puff is the atomizer. This is powered by a lithium-ion rechargeable battery that is housed in the body of the electronic cigarette. The generated mist delivers nicotine into the bloodstream. The data from human laboratory studies are limited, but suggest that electronic cigarette use is unlikely to yield a high concentration of nicotine in the circulation of inexperienced users.[5,6] However, experienced users can extract as much nicotine from electronic cigarettes as smokers can from tobacco cigarettes.[7]

Electronic cigarettes look very similar to the conventional cigarette and are capable of emulating cigarette smoking, but there are differences. Probably the most immediate difference between the conventional cigarette and the electronic cigarette is tactile. The conventional cigarette is soft and light, whereas the electronic cigarette is hard, cold and a bit heavy. Hence, handling an electronic cigarette feels very different from a conventional cigarette. The smell and taste of the tobacco cigarette are characteristics difficult to reproduce. However, some nicotinized electronic cigarette cartridges may replicate the flavor of tobacco. The whole puffing experience is different and requires some degree of adaptation from smoking to vaping. Generally speaking, most electronic cigarettes require stronger suction to smoke than conventional cigarettes.[8] Also, the amount of aerosol produced by electronic cigarettes decreases with vaping, which requires increasing puff strength to produce the same amount of aerosol. It may take some time to master a satisfying technique. Thus, several caveats appear to limit the widespread adoption of electronic cigarettes by smokers, and it is important to assess the current level of satisfaction of users with these products.

Specifically designed surveys may be useful to identify the unmet needs of the typical electronic cigarette consumer. In a recent survey of users, 81 respondents reported more positive than negative effects with electronic cigarettes: many reported positive effects on the respiratory system (improved breathing and reduced cough and expectoration), which were probably associated with stopping smoking.[9] The fact that electronic cigarettes do not produce any unpleasant odors and are unlikely to generate environmental tobacco smoke was also appreciated. Most importantly, many respondents reported that the electronic cigarette helped them quit smoking, and several compared it favorably with either a nicotine patch or bupropion. Interestingly, dry mouth and throat was a frequent adverse effect of the electronic cigarette. Many respondents complained of the poor quality of electronic cigarettes, their frequent failures, the lack of durability of cartridges and batteries and, ocasionally, the liquid leaking from the product during usage. Although users' comments were generally positive, many were concerned about the safety and toxicity of electronic cigarettes, and questioned why no study has yet investigated these aspects. Several respondents were also concerned about the future legal status of electronic cigarettes and that they could be banned. In a second much larger survey of users, 3587 participants reported that they use electronic cigarettes as an aid to quit smoking, to avoid relapse and to deal with withdrawal symptoms, similar to individuals who use nicotine replacement therapy.[10] Many participants used them because they were perceived to be less toxic and cheaper than tobacco. Users of nicotine-containing electronic cigarettes reported only slightly superior effects on withdrawal than users of non-nicotine electronic cigarettes, suggesting that nicotine delivery explains only part of the effect of these devices on withdrawal, and that the sensory and behavioral components of the electronic cigarette are also important. Action on Smoking and Health UK surveyed 1380 smokers, of whom 486 had used electronic cigarettes.[11] In the national survey, 9% of smokers had tried them and 3% were still using them. In a focus group, those who had not tried electronic cigarettes pictured a device that looks and performs much like a real cigarette. Those who had tried electronic cigarettes put greater importance on an 'authentic smoking experience' and strength of nicotine.[11] These data demonstrate a widespread interest among smokers, particularly heavy smokers, for alternatives to smoking and highlight a variety of factors limiting the acceptability of products currently available.

In a recent prospective proof-of-concept study, we monitored possible modifications in smoking habits and product preference of 40 smokers (not willing to quit) experimenting a commercially available brand of electronic cigarette (Categoria™ electronic cigarette; Arbi Group Srl, Milan, Italy) with a 7.4 mg nicotine cartridge.[12] The electronic cigarette under study achieved high scores for satisfaction and for helpfulness (enabling individuals to refrain from smoking). Moreover, it was highly likely that participants would recommend it to friends or relatives who wanted to stop/reduce smoking. Although the overall participants' perception and acceptance of the product was good (most positive features included pleasure of inhalation and exhalation of the vapor, cleaner and fresher breath, and an absence of odors in clothing and hair), its ease of use could be improved and technical defects reduced. During the course of the study, five study participants could not use the product as recommended and had to be retrained within 72 h. Three participants reported that the device often failed to produce mist when puffed (three atomizers had to be substituted). Another two were given a faulty charger (chargers were immediately replaced). According to study participants, the perception and acceptance of the product could be improved by increasing manufacturing standards, by providing a recharge lasting at least 24 h, by reducing the weight of the device and by substituting the hard plastic mouthpiece. The latter two suggestions in particular would improve device acceptability for some common rituals of cigarette smoking (e.g., keeping the cigarette between lips).

Earlier electronic cigarettes models are hampered by inadequate manufacturing standards with leaky cartridges, an inadequate amount of vapor or nicotine and batteries lasting only a few hours. Manufacturers are doing their job in correcting design flaws in the hardware and have moved on to models with batteries that last 24 h, cartridges that do not leak, cartridges that do not contain filler material, models that produce a higher volume of visible vapor (many users consider this important) and stronger nicotine levels. Further improvements are in progress to improve users' satisfaction with the product.

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