Evalulating the Latest Smoking Alternative: Electronic Cigarettes

If you have lung disease and you're a smoker, you undoubtedly know the importance of breaking the cigarette habit. You may even have tried to quit smoking before but to no avail. Could electronic cigarettes—also known as e-cigarettes—be the answer?

These battery-powered devices look like real cigarettes, have a light-emitting diode (LED) on the tip that lights up when you inhale, and even produce fake smoke in the form of water vapor. They also deliver nicotine via cartridges, but spare you the tar, carbon monoxide, formaldehyde and other toxins found in tobacco smoke.

If e-cigarettes sound too good to be true, that's because they probably are. With a dearth of rigorous studies on their safety and effectiveness, experts are increasingly concerned that e-cigarettes may do little to help you stop smoking—and may actually do more harm than good.

In April 2014, the U.S. Food and Drug Administration (FDA) issued a proposal to regulate e-cigarettes. This proposal will require manufacturers to register with FDA and disclose each product's ingredients, and prevent tobacco companies from making health claims about electronic tobacco products without FDA review. The regulation also establishes 18 as the minimum age for the legal purchase of these tobacco products in the United States.

Health Effects of Nicotine

When you smoke, the nicotine from your cigarette causes receptors in the brain to release dopamine and other chemicals that produce a pleasurable effect. But if you quit cold turkey, you'll likely experience nicotine withdrawal symptoms, for example, intense cigarette cravings, irritability and difficulty sleeping.

Nicotine replacement therapies (patches, gum, lozenges, spray, inhalers) work by gradually decreasing the amount of nicotine a smoker gets. This lessens the impact of nicotine withdrawal symptoms, which, in turn, increases the likelihood that you will be able to stop smoking.

E-cigarettes: Another Option?

Some manufacturers of e-cigarettes tout their products as an effective form of nicotine replacement therapy. And, in theory, they could work, since the principle is the same. The e-cigarette's cartridges are available in progressively lower concentrations of nicotine (they come in high, medium, low and no-nicotine varieties), so you can wean yourself off nicotine over time just like with traditional nicotine replacement products.

So what's the problem? For one thing, some e-cigarettes may not deliver enough nicotine to the bloodstream to effectively suppress cravings. In one study, published in 2010 in Tobacco Control, the investigator compared levels of nicotine in the blood of 16 smokers after they smoked two of their usual brand of cigarettes, puffed on two unlit cigarettes, or "smoked" two brands of e-cigarettes, each containing a 16-mg (high) cartridge of nicotine. (Each smoking session took place on separate days to be sure all of the nicotine from the previous session had cleared from the participants' bloodstream.)

After smoking the e-cigarettes, nicotine levels in the participants' blood was virtually the same as it was after puffing on an unlit cigarette and was significantly lower than the blood nicotine levels detected after smoking a conventional cigarette. In addition, the smokers' heart rate increased after smoking tobacco but not after using the e-cigarette or unlit cigarette, again suggesting a negligible delivery of nicotine to the bloodstream with the e-cigarette.

An unpublished update of these findings with twice as many participants was slightly more positive: The e-cigarettes did help reduce nicotine withdrawal symptoms, but not to the same degree as smoking a real cigarette.

Another problem: Some cartridges may contain more or less nicotine than noted on the label. In July 2009, the FDA released the results of a laboratory analysis of 19 cartridges from two leading brands of e-cigarettes. They found that one high-nicotine cartridge had twice as much nicotine as an FDA-approved nicotine inhaler.

The analysis also revealed that all but one of the cartridges labeled as nicotine free contained small amounts of nicotine, and three cartridges labeled with the same amount of nicotine actually had markedly different amounts.

A third problem: Cartridges can be refilled using drops of a solution sold in bottles containing more than 500 mg of nicotine—an amount that is nearly 10 times the lethal dose. In April 2014, a study conducted by the CDC showed a significant increase in emergency calls related to e-cigarettes to poison control centers. Poisoning related to e-cigarettes resulted in 215 calls to poison centers in February 2014. More than 51 percent of cases involved children under the age of 5 and about 42 percent involved people over the age of 20. Liquid containing nicotine that is used in e-cigarettes can cause poisoning through ingestion, inhalation, or absorption (eyes or skin). Exposure can cause nausea, vomiting, and eye irritation.

What Else Is Inside E-Cigarettes?

More evidence from the FDA indicates that some e-cigarettes contain dangerous chemicals. Their tests have revealed the presence of diethylene glycol, a chemical used in antifreeze that is toxic to humans; nitrosamines, which have been proven to cause cancer; and other impurities suspected of being harmful to humans.

Our Advice about E-Cigarettes

Some manufacturers and retailers of e-cigarettes claim these products are healthier than normal cigarettes and can help you quit smoking. But in the absence of scientific evidence to support those contentions, it's best to avoid e-cigarettes until more research has been done.

For now, if you're trying to quit smoking, stick with these proven, FDA-approved stop-smoking strategies:

  • Nicotine-replacement products. As mentioned previously, these medications work by using progressively lower doses to wean the smoker off nicotine. Some of the products—lozenges, gum, and patches—are available without a prescription. Nicotine inhalers and nasal spray require a prescription from your doctor.
  • Oral medications. Available by prescription, varenicline (Chantix) is an oral medication that blocks nicotine receptors in the brain, reducing the pleasurable effects derived from smoking. It also helps reduce nicotine cravings and control withdrawal symptoms. The prescription antidepressant bupropion also reduces the urge to smoke and is approved for use as a smoking cessation aid known as Zyban. It works by increasing the production of dopamine and other pleasure-stimulating chemicals in the brain.
  • Counseling and support. Several studies have shown that psychological support increases the chances that a person who is trying to stop smoking will succeed. Support from relatives and friends also can help, particularly if they quit smoking, too. A study published in 2008 in The New England Journal of Medicine found that smokers were 67 percent less likely to smoke if their spouses quit, 36 percent less likely if a friend quit, and 25 percent less likely if a sibling quit.
  • Keep trying. If you have tried smoking before, do not give up. Numerous studies show that it often takes four or more attempts before you are able to quit the habit for good.

Updated by Remedy Health Media

Publication Review By: Peter B. Terry, M.D., M.A.

Published: 08 Aug 2011

Last Modified: 24 Apr 2014