Seth Bilazarian, MD


June 30, 2014

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Editor's Note: On July 1, Dr. Bilazarian's practice will be acquired and he will become an employed physician. To reflect this change, his series will be renamed Practitioner's Corner.

E-Cigarettes on the Rise

Seth Bilazarian, MD: Hi. Seth Bilazarian on on Medscape, updating a blog I did 2 years ago on electronic cigarettes, or e-cigs. The reason for this is that there are some new things that have come about, some good reviews, and some changes in what our patients will be seeing, so I thought it was valuable for others to hear about it.

E-cigarette use has really grown pretty significantly. It does an estimated $1.7 billion in sales[1] and it's currently expected that it will exceed revenue from cigarettes in about 10 years. They're marketed as healthier, as potential quitting aids, and they allow smoking anywhere. The marketing is briefly summarized as "e-cigarettes are healthier, cleaner, and cheaper."

The reason for revisiting the topic is that on June 23, 2014, R.J. Reynolds (or Reynolds American) began a national campaign of the first American-made e-cigarette[2] and have reported that they will begin a broad national campaign to promote the sale of this new e-cigarette. It's expected that the other American companies will follow suit, and this will expand beyond what's been mostly retail Internet sites and billboards, mall kiosks, and gas station posters to a broader, more advanced marketing campaign.

The growth is also largely fueled by the fact that they cost less than cigarettes because there's no cigarette tax on e-cigarettes, and it's currently said that at least 1 in 5 smokers have tried e-cigarettes.[3] For us, the pertinent thing is that there are going to be more questions about their safety and utility and the value of potentially switching, so I thought it was valuable to review the status of this and what we might be seeing in our patients.

I've done a blog on this topic in the past, and I'll commend to the viewers a Circulation review[4] which does a really nice job on the status of e-cigarettes.

Smoking Cessation Aid?

The topic that often comes up is smoking cessation,[5] and I think that this is a really important topic because there's some reason why it makes sense to use these cigarettes as a smoking cessation tool. Of course, it combines both the nicotine and the behavioral aspects of smoking. Cigarette addiction is, of course, driven by smoking cues such as anytime patients eat or the phone rings. One patient told me that even years after quitting smoking, if the phone rings, they tap their breast pocket, looking for cigarettes. There are those smoking cues. Then there's the activity of actually smoking, which e-cigarettes mimic, as well as the chemical withdrawal aspect. E-cigarettes seem like a potentially valuable strategy that would address some of these issues in smoking addiction. Currently, smokers have a very high acceptability for e-cigarettes as a potential compared with nicotine replacement, so it's another potential avenue to access for patients.

Over half of smokers who have tried to quit have actually used these cigarettes already; 20% of smokers have used these cigarettes as well as about half of those trying to quit, but there's genuine uncertainty about the therapeutic merits of e-cigarettes, so I think it's really an issue that's uncertain for us and something to be mindful of. It's important for us as clinicians to be sensitive that when patients are asking [about e-cigarettes] they're actually asking for help to quit smoking, so it's an avenue for discussing this important issue with them.

What we know so far is that there's a single Chinese manufacturer for most of the e-cigarettes. They're not regulated by the FDA, and there are really variable engineering and quality issues.[4] A lot of the marketing says they're only harmless water vapor, which is completely incorrect and completely fallacious. What's happened is that there's a vaporized propylene glycol vehicle, or carrier, for the nicotine, as well as flavoring agents that are vaporized by a heating element which is powered by a battery, and it delivers this aerosols using ultrafine particles. There are about 400 vapors, or vapes, per cartridge, and there's a poor concordance between labeled and actual nicotine content. My patients have told me that sometimes the high-nicotine one seems low and the low-nicotine one seems high.

Each e-cigarette puff, with the highest nicotine content, has only about 20% of the nicotine of a puff from a cigarette.[6] So they're less potent, from a nicotine standpoint, and that may be why some patients have said they have tried them but don't really like e-cigarettes -- because they don't deliver the same level of nicotine that they would desire. That's the issue.

Those are the knowns. To take a page from former Secretary of Defense Donald Rumsfeld, who talked about known knowns and known unknowns, we have some things we definitely don't know that we'd like to know. Are e-cigarettes really safer over many years compared with smoking? Can we quantify the hazards of this propylene glycol, the battery vapor, the particulate matter? There are also some concerns from preclinical data in animal models that the solvents, flavorings, and preservatives have a variety of issues, such as immunocompromise and increased risk for pulmonary infections.[4] There are also concerns about inflammation from the nanoparticles, and concerns about the solvents potentially transforming into carcinogens like carbinols. There's also a concern that particularly the flavorings, preservatives, and additives may have a greater impact on stem cells, with a theoretically greater risk for a cancer.

There are so many known unknowns that there is actually a second list of known unknowns regarding their use as a cessation strategy: How do e-cigarettes really compare head-to-head with counseling or nicotine replacement, or bupropion (Wellbutrin®) or varenicline (Chantix®)? We don't have any data. There are now newer generations of e-cigarettes that heat to a higher level; are these safer or more hazardous? Other unknowns are the hazards of the battery vapor and the liquid leakage from the battery itself. Some patients have said that when they vape at the end of the 400, if they're not counting, there's really no way to know; there's no indicator that they're running out of nicotine. (Other patients say that they can clearly tell by the taste.) Is vaping the battery vapor at the end of a depleted cartridge hazardous?

Unknown Unknowns

Then again, from Secretary Rumsfeld, we have unknown unknowns, and those include the unanticipated long-term hazards to the lungs or other organs from this particulate matter. The manufacturers are continually adding flavorings or other additives -- how do those play in? And we don't know what they'll add in the future, with new technological iterations of these e-cigarettes.

One thing that's really an unknown unknown is the hazard associated with dual use. Some patients are picking these up to use them where they can't smoke: in a workplace or some other environment. Is the dual use a hazard other than the obvious increase in nicotine exposure, compared with being prohibited from smoking without access to e-cigarettes?

Finally, what is it going to mean for us? I anticipate that more patients are going to be aware of e-cigarettes. What are our responses? Very simply for nonsmokers, we would say, "Don't start." Clearly, this is not a safe alternative. Similar to what we say about alcohol, coffee, energy drinks, or marijuana we would say here: Don't start if you haven't been using these. For smokers, how can we succinctly and effectively convey these health concerns that exist in this really uncertain time when there is heavy promotion from a very well-funded industry?

I can think of 4 responses, and obviously there may be combinations of these, but the first one is to take the academic physician stance, which is, "There aren't enough data and therefore I can give no counseling." That's probably unsatisfying to our patients. It also leaves us at a disadvantage because patients are often seeking advice for smoking cessation.

A second one is to admit that there is frankly a harm reduction strategy here. It's not good to smoke e-cigarettes but they are safer than cigarettes, so therefore it's acceptable and reasonable for patients to use them. Our third piece of advice is that it might be reasonable as a cessation strategy. I've come to accept that if patients really want to use these e-cigarettes and are committed to trying to use them over 4-6 weeks to wean off cigarettes, it may be reasonable, but I can't comment on long-term safety.

The last one I think I already mentioned: It can't be considered a healthy choice, and really we have to do everything we can to dispel what was said by marketing to people that this is a harmless water vapor. We really need to make sure that [people know] that's not the case.

I realize that some patients may be coy with us when we ask them whether they smoke, and they say no when in fact they are using e-cigarettes. We may have to expand our social history questions to ask, "Do you vape (or do you use electronic cigarettes)?" rather than just asking, "Do you smoke?"

Policy Recommendations

The Circulation journal recently had another e-cigarettes summary paper[5]. This, along with the scientific review that I mentioned earlier, has a list of policy recommendations for those interested in healthcare policy. I won't go through all of the policy recommendations, but in short, I would summarize to say that they recommend that e-cigarettes be treated like conventional cigarettes in regard to the advertising, taxes, and other kinds of issues. There is no current tax on e-cigarettes. Governor Christie, in the state of New Jersey, has proposed a 75% wholesale tax on e-cigarettes to try to get them in line.[7] This would be a $2.70 tax on a pack of 20 e-cigarettes, which seems to me like a very appropriate and reasonable thing to do.

In summary, what are our responses? Is this similar to what we might say when we counsel patients on things where we don't have a lot of data? For vitamins, antioxidants, and fish oil, we might say that there's really no definite benefit but it's probably safe and not harmful. For moderate alcohol use, we'd say it's possibly useful and beneficial at 1-2 drinks per day for a man, and we'd say that it's probably safe and not harmful in most circumstances as long as it's kept at that low level. For smoking, we'd say it's clearly not useful or beneficial and we'd say it's definitely hazardous. For vaping e-cigarettes, we'd say it's clearly not useful or beneficial from any kind of health standpoint, but we should say it's probably less hazardous. I think that's probably a reasonable thing to continue to have patients think -- that we are being reasonable in our assessment of the uncertain data.

In Summary

Finally, what do you say to the patient who's sitting in front of you? I think I've tried to distill this by saying, "I can tell you that e-cigarette use will probably cause a lower disease burden than cigarettes." I say "probably" because we don't have long-term data; I can't say for sure. Second, there are no proven cessation benefits. It's a reasonable strategy if you commit to short-term use with a quit date. One thing that's dangerous with these e-cigarettes that I tell patients that I've discovered (as I've talked to them more about it with this knowledge) is that if you take up e-cigarettes and you're using them where you can't smoke to otherwise circumvent smoking prohibition laws, then you're probably increasing your nicotine use, and that's really not good in terms of a long-term reduction strategy. Clearly, e-cigarettes are not harmless water vapor, and we have to really think about that as an important thing in terms of long-term use.

The thing that I have learned that I most want to convey to my patients is that e-cigarettes have a lower level of toxicants but not particles, and these particles that lodge in the alveoli may have really long-term consequences, may increase a variety of long-term chronic diseases, and we have to be really careful about their use.

I'm interested in how other people plan to counsel as we see more and more advertising for e-cigarettes, and whether expanding our social history to "Do you vape?" is a valuable thing to do.

Until next time, thanks. I'm Seth Bilazarian on

To download the slides used in Dr. Bilazarian's presentation, click here.


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