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.”