Some say e-cigarettes are the smokers’ salvation, others say they are the next agents of addiction. In our first in-depth feature we explore the public health versus personal health argument and what the experts, including the TSANZ, have to say on the matter.
Richard, 53, is very successful, a lifelong heavy smoker, and loves his habit. He knows he is a nicotine addict. He was a 60-a-day man, until a couple of years ago, when his son, who was working in London, persuaded him to convert to e-cigarettes.
“My motivation was my health,” says Richard (not his real name). Given my age of 53, I knew smoking was going to have a significantly negative effect on that, so I switched to e-cigarettes.”
“I now smoke about 10 tobacco cigarettes a day,” he says, “and that’s mainly out of habit – usually when I’m with other smokers.”
The bulk of his nicotine consumption now comes from e-cigarettes – or ‘vaping’ – as it is known. He says it’s hard to quantify how many e-cigarettes he has because he uses them in a completely different way to traditional cigarettes.
“I can sit at my desk, take a quick puff, and then put it down (he works from home). I don’t have to finish that cigarette. With a normal cigarette you are compelled to finish it.”
“The convenience side of it is underestimated. I can work with my e-cigarette by me and I don’t have to keep going outside. It doesn’t burn – there’s a safety aspect to it as well – and a litter aspect – you are not throwing cigarettes out of car windows.”
To purchase an empty e-cigarette on the internet costs about $45, he says, and he fills it with nicotine e-liquid for around $65 per month. This is a fraction of the cost of cigarettes, he says. Another advantage is that his clothing no longer smells of smoke, he adds.
“I travel a lot. In Australia it’s virtually impossible to get a smoking hotel room, but now I can simply go to my room and puff away on my e-cigarette and it doesn’t make the room smell or trigger the alarms because it is not smoke – it is a vapour. For me, the benefits are dramatic.”
He found filling the cartridge with nicotine a little difficult at first but soon got used to it. The puffing technique is easy, he says.
“You get an instant hit of nicotine – I think it is equivalent to smoking a cigarette – if not even more powerful.”
He used to get sore throats from smoking conventional cigarettes but says this doesn’t happen with e-cigarettes. “I actually prefer the flavour of e-cigarettes now. Smokers don’t enjoy the noxious chemicals and tar in cigarettes: they smoke for the nicotine.”
“I think the advent of e-cigarettes is absolutely revolutionary for all those of us who were hopelessly addicted to cigarettes. It’s obviously going to make us healthier and I personally believe the health authorities around the world should welcome them.”
Richard’s enthusiasm clashes dramatically with the views of most Australian health professionals and he recognises that. “One of the remarkable things I’ve found about e-cigarettes in Australia is that when I vape in public people actually come up to me and tell me that e-cigarettes are more harmful than normal cigarettes. You have to ask yourself, where on earth do they get that information from?”
Straight to the brain
Adjunct Associate Professor Renee Bittoun, President of the Australian Association of Smoking Cessation Professionals, and International Editor-in-chief of the Journal of Smoking Cessation, says e-cigarettes are the cigarettes of the 21st Century. But that doesn’t mean she likes them.
E-cigarettes are “a very divisive issue,” says Bittoun. She recently attended a conference in Spain. “Some countries are opposed to e-cigarettes and some are very in favour,” she says.
As an expert in nicotine addiction, she understands why e-cigarettes are welcomed by people like Richard. Like cigarettes, they are able to deliver nicotine vapour into the alveoli of the lungs.
“This makes for a very quick delivery into the arterial blood and then straight to the brain. Smokers love it because it goes to the brain instantaneously,” she says.
Nicotine inhalers tend to dump the nicotine in the upper airways. Other nicotine-containing products such as gum or patches deliver their cargo much more slowly. The nicotine patch is particularly slow, taking hours, she says. “There isn’t a nicotine patch addict on the planet,” she adds.
Nicotine highly addictive
Their success in delivering a nicotine ‘hit’ is one reason Bittoun is against e-cigarettes. “Nicotine is incredibly addictive,“ she says. Studies by Professor Joseph DiFranza of the University of Massachusetts and others have shown that adolescents can become addicted to nicotine after having only smoked a few cigarettes and that some are hooked by their first cigarette, she says. E-cigarettes are likely to be similarly addictive, she suspects, plus she fears they could be a conduit to smoking.
Bittoun points to a recent paper in the New England Journal of Medicine which finds biological evidence in mice that nicotine is a gateway drug for cocaine, a finding which fits with epidemiological evidence in humans. If e-cigarette use becomes widespread in young people, we could see a rise in addiction to cocaine and other drugs, she believes.
Bittoun thinks nicotine addiction is likely to be the main problem with e-cigarettes. She and the other experts interviewed by the limbic agreed that, although their long-term safety effects remain unknown, e-cigarettes are likely to be less harmful to the already-addicted individual than cigarettes.
They do not produce thrombogenic carbon monoxide, contain far fewer chemicals and carcinogens and lower levels of particulates. The main uncertainty is the effect of long term exposure to propylene glycol and glycerin, the solvents used in the ‘e-liquid’ containing the nicotine.
A 2014 review in Circulation found flavoured e-cigarettes to be potentially more harmful than non-flavoured ones, simply because they contain more chemicals. The review also concluded that, because e-cigarettes don’t burn, ‘passive vaping’ is unlikely to be nearly as harmful as passive smoking. Instead the exposure is limited to exhaled vapour of which the main potentially harmful constituent is nicotine.
Big Tobacco wading in
Bittoun’s other concern is that, over the past two years, Big Tobacco has been steadily buying up the e-cigarette companies. “This is the cleaner greener cigarette of the 21st Century,” she says.
“Consumers need to know that the new generation e-cigarettes that the tobacco industry is making are potentially dependence producing. That’s the market value Big Tobacco sees in this. It’s important that doctors explain this to their patients.”
She says Australia has done extremely well in reducing smoking prevalence. “It ranges hugely from 6% in North Sydney to over 50% in a few isolated townships.”
“My grandchildren live in North Sydney and they’ve never seen a smoker,” she remarks. “There’s nowhere to smoke in North Sydney – you can’t smoke on the footpaths – now that might sound draconian but it actually drives smoking rates down.”
“So I’m strongly in favour of our considerable and very successful smoking regulations in Australia and if we go down the road of allowing e-cigarettes we’ll get the normalisation of nicotine addiction again.”
Modestly effective
Professor Chris Bullen of the University of Auckland’s School of Population Health in New Zealand is more favourably disposed towards e-cigarettes. He led one of the two randomised controlled trials on their efficacy for smoking cessation which was the only trial to look at people who actually wanted to quit smoking.
“Most people who smoke these days would like to stop. And people are interested in something that’s novel because by the time they’ve got to their 40s they’re usually aware of the health effects. They are desperate to quit or cut down smoking tobacco and have tried all the standard approaches but have failed.”
“My view is that I think these products are modestly effective at helping people quit smoking. There is sufficient evidence from our study, and the recent Cochrane Review, that there is something going on. It looks like they are at least as good as nicotine patches.”
“The hand-to-mouth smoking ritual is likely to be a key part of the efficacy of these products. That’s the brilliance of this product,” he says.
He accepts that many people using e-cigarettes become dual users, like Richard, and still smoke some tobacco cigarettes.
“Surely it’s better if somebody smokes 10 cigarettes a day rather than 60, even if they haven’t quit completely. We have to start thinking more in terms of harm reduction – not just ‘quit or die’ – and try and support people to complete the journey of cutting out cigarettes altogether.”
“We need to be a little more relaxed about people taking two or three years over quitting, rather than doing it within the next few weeks, when it’s been a life-long addiction. People have a love-affair with cigarettes and the behaviour that goes with it. They are highly addicted. Their brain has been rewired and it’s very hard. These products I think offer the best substitute that we’ve had since cigarettes were invented.”
A tricky balance
He recognises the risk of nicotine addiction in young people with e-cigarettes. “There’s a personal health argument and there’s a public health argument,” he says. The personal health argument is that a smoker is likely to be healthier if s/he switches to e-cigarettes. The public health argument is about the risk of normalising nicotine addiction in society again.
“I’m sympathetic towards people who would like to quit smoking and have struggled to succeed with everything else and have found these products to be helpful. If e-cigarettes were banned those people would be likely to go back to smoking tobacco, which would be bad for their health.”
“How we balance that sort of sympathy and availability of safer alternative products versus the risk of hooking young people onto a product which could potentially lead them to smoking tobacco or lifelong addiction to nicotine is the tricky bit. That’s what governments are grappling with. I don’t have any easy answers!”
A backwards step
Bullen says Australia is noted for its anti e-cigarette approach. And he can understand why. “People who I respect immensely have fought Big Tobacco for 20 years in Australia and they are slowly winning the case – with fantastic initiatives like plain packaging. So one might well ask, why have this product with its associations with Big Tobacco?”
It’s not surprising, then, that Professor Matthew Peters, speaking for the Thoracic Society of Australia and New Zealand, is strongly against e-cigarettes.
“Our concern is that we’ve done really well in reducing overall smoking and nicotine use. The widely permitted use of e-cigarettes would be the first step we’ve had since the peak of the epidemic where nicotine use has actually increased,” says Peters.
“E-cigarettes may not cause the harms that combustible tobacco causes, but you can’t say with any certainty that there are no harms. So they might be safer than long-term cigarette smoking but what if they carried similar cancer risks to asbestos exposure or solariums?”
“If the argument is that these things should be legalised, liberalised and encouraged then you need a bit more evidence. It could be argued that anyone who wants to market an e-cigarette should go through exactly the same steps as the nicotine patch has gone through.”
“Above all – and I think this is a really important TSANZ position – the whole debate about e-cigarettes is distracting us from the really important things – like following on from plain packaging and doing the other things that will compel tobacco manufacturers to make cigarettes less addictive and attractive. It’s a very convenient sideshow.”
Deciding in a vacuum
Everyone agrees more work needs to be done to assess the safety and efficacy of e-cigarettes in quitting or reducing the number of conventional cigarettes smoked.
Although the Cochrane Review concluded e-cigarettes could help people quit smoking long term, compared with placebo, the quality of the evidence was low, largely because so few studies have been done.
More research needs to be done on the harms of nicotine addiction per se and whether use of e-cigarettes in young people is indeed a conduit to smoking, and, if so, how this might be affected by the relative pricing of conventional and e-cigarettes.
Meanwhile Richard has recently heard that ‘any cigarette is a bad cigarette which could cause a heart attack’. He is planning to switch over to e-cigarettes entirely. Some nicotine addicts like him are taking action which may prove to be in the interests of their better health. Bullen thinks it is similar to putting a heroin addict on methadone. As Bullen says, there’s a personal health argument and a public health argument….
The debate continues.
Don’t forget to follow us on twitter @the_limbic