The recent publications in CHEST regarding the widely discordant views on e-cigarettes (also known as electronic nicotine delivery systems) are reflective of the lack of good data we have on the benefits and risks of these new devices.
Opinions among public health experts and physicians have basically divided into two camps: what I'll call the realists and the idealists. The realists believe that anything is better than smoking actual cigarettes; e-cigarettes don't produce side-stream smoke so are less harmful for second-hand (i.e., passive) smoke inhalation in bystanders, and that e-cigarettes will ultimately be beneficial in reducing tobacco-associated morbidity and mortality. The idealists, on the other hand, believe that there is no good data demonstrating that e-cigarettes help people quit smoking, there are possible harms from the chemicals/carrier compounds in e-cigarettes, and that the tobacco companies are simply creating another addictive product for a wider, younger audience.
So, what is the answer to this dilemma? Unfortunately, no one knows for sure but I think that we need to take a cautious approach for now, especially as the data accumulate that e-cigarettes may not be as safe as we think.
To some extent, one's approach depends on our perspective: as pulmonologists, we have to treat the patient in front of us. For example, if a patient is smoking and has chronic obstructive pulmonary disease or asthma, it seems intuitive that continuing to smoke cigarettes would be worse than an alternative nicotine delivery system that avoids the combustible particulates and gases created by lighting up that scientists feel are responsible for the adverse pulmonary health effects of cigarettes. Studies have been done, and more are ongoing, but those will take a while and may not be conclusive. I recall when varenicline (Chantix) had some negative publicity surrounding FDA warnings on potential worsening of depression and other neuropsychiatric side effects. When I discussed these possible side effects with my patients, many would tell me they were afraid of taking it. I would think to myself: continuing to smoke will do irreparably more damage than varenicline, so why not try it? You can always stop it if side effects occur. This is an example of the realist approach.
The downside of e-cigarettes is that several studies have clearly shown that it is a "gateway" to getting some people, especially young adult nonsmokers, to start smoking. Although this is a desirable attribute for tobacco companies, this would be an unmitigated public health disaster, hence the strong desire to keep e-cigarettes out of the hands of teenagers and other nonsmokers.
This can't be easily regulated, though, and the marketing of e-cigarettes with their array of flavors (reminding me of the candy-flavored gum shaped like cigarettes) and playing up their edginess (vaping is way cooler than smoking, many ads targeting young adults suggest) leaves a great deal to be desired. In addition, many tobacco control advocates would argue that any product manufactured and marketed by tobacco companies is inherently tainted, and therefore the medical community would be making a huge mistake trusting an industry that has lied repeatedly and covered up the hazards of their product for decades. This is an example of the idealist view.
So, there is no right answer. Idealists will stay away from recommending e-cigarettes as a quit aid unless more studies confirm their benefit and safety, whereas the practical among us will recommend e-cigarettes as a way to help keep their patients from smoking actual cigarettes. My approach is to recommend nicotine replacement therapy (e.g., nicotine patch and gum which we know help some people abstain from cigarettes) in conjunction with other techniques (including varenicline and counseling) prior to grabbing an e-cigarette and vaping away. Time will tell if we've done any good.
Robert M. Jasmer, MD, practices at Pulmonary Associates in Burlingame, Calif., and is Associate Professor of Medicine at the University of California San Francisco. He serves as a clinical research reviewer for MedPage Today.
- Point: Does the Risk of E-Cigarettes Exceed Potential Benefits? Yes
- Counterpoint: Does the Risk of E-Cigarettes Exceed Potential Benefits? No