e-cigarettes

the whole issue of e-cigarettes is pretty confusing. several of my patients have been using them with pretty significant cigarette quit rates even after stopping the e-cigarette. one of my patients brought in one (a BLU, as i remember), asking me what it contained.  after thoroughly scouring the e-cigarette and packaging, i could find no indication of what was inside the cigarette. there were a couple of articles that helped clarify the situation.

1. recent randomized controlled trial in lancet from new zealand. 657 adult smokers averaging 18 cigarettes/d randomized to 16mg e-cigarettes, 21mg nicotine patch, or placebo e-cigarette (no nicotine), beginning one week before quit date. only low intensity support provided -- voluntary telephone counseling. (see smoking ecigarettes lancet 2013 in dropbox, or http://dx.doi.org/10.1016/S0140-6736(13)61842-5). verified abstinence after 6 months:

    --7.3% with nicotine e-cigarettes

    --5.8% with patches

    --4.1% with placebo e-cigarettes

    --median time to relapse was longer with nicotine e-cigs (35 days), vs 14 days with patches, 12 days with placebo e-cigs

    --mean cigarette consumption also 2 cigarettes lower with nicotine e-cigs

    --no diff in adverse events

achievement of abstinence was lower than anticipated for the power calculations, so unable to assess statistical superiority of nicotine e-cigs or patches to placebo e-cigs.

2. Time magazine article 9/30/13: Electronic cigarettes could save lives -- or hook a new generation on nicotine, by Eliza Gray.  main points:

    --20% of smokers have tried e-cigs

    --e-cigs use a tiny metal coil to vaporize nicotine liquid

    --appeal is that they do not have the >3000 additives of cigarettes, they do not smell like cigarettes to others, do not stain teeth, and are cheaper than cigarettes -- bottle of 16mg nicotine costs $8, $38 for refillable e-cigarette (includes atomizer, rechargeable battery, and charger). the $8 bottle lasts for one week in a 1 ppd smoker, cheaper than the $10/day for a pack of cigarettes. non-rechargeable BLU costs $10, has 400 puffs or approx 1 1/2 packs of cigarettes equivalent

    --rapidly growing market: $300M in retail sales last year, estimated to grow to $1.8B this year

    --advertised as sexy (ads by katherine heigl and leonardo dicaprio), and safer

    --at this point unregulated. no indication of ingredients. unregulated in terms of actual nicotine delivered. but as of October, FDA to regulate

    --big players coming into the market (lorillard, reynolds, altria, british american tobacco), likely to squeeze out the current smaller makers. (and undoubtedly increase advertizing -- FDA may come out with regulations on how and to whom the ads can be directed, whether legal to have internet sales, etc)

    --fear is that these new e-cigs may re-glamorize smoking, discourage smokers from quitting entirely, and entice new smokers

    --stores (called Vapers) popping up to sell these cigarettes. with different flavors (eg chocolate, tobacco, menthol), styles of e-cigs (cheaper ones which look more like cigarettes, rechargeable as above are much longer and look pretty different)

    --the additives mentioned in e-cigs include propylene glycol (i guess it lowers a person's freezing point), and still has aerated fine particles. unclear of the safety of the flavors or of other additives not mentioned

so, may be helpful for some current smokers to quit.  BUT, big concern about legitimizing/glamorizing cigarettes. increasing people who never smoked (and, we know that nicotine addiction is very powerful.  there are many patients who have told me and others that it is much easier to get off heroin or alcohol than cigarettes. some of the addiction is just the addiction to nicotine, some is the very positive effects of nicotine: wakes you up when you are sleepy; relaxes when you're anxious; satiates when you are hungry; and withdrawal symptoms are not pleasant but better than heroin or alcohol -- not that i am encouraging you to smoke....). and the e-cig companies are trying to make e-cigs feel like/taste like regular cigarettes. all in all, pretty scary.