Monday, April 09, 2012

Commentary in Addiction Urges More Balanced Consideration of Electronic Cigarettes

A commentary published online ahead of print last Friday in the journal Addiction, co-authored by Dr. Ted Wagener of the University of Oklahoma, Dr. Belinda Borrelli of Brown University, and me, argues that a more balanced consideration of electronic cigarettes is needed, as the previous literature and scientific debate over these products has been dominated by negative perspectives that have not appropriately taken into consideration their potential and established benefits.

This commentary was written partially in response to Perspective article in the New England Journal of Medicine by Cobb & Abrams, who argued that electronic cigarettes are ineffective for smoking cessation because they do not deliver nicotine adequately for that purpose.

In the commentary, we write: "Cobb & Abrams argue that e-cigarettes are unlikely to be useful for smoking cessation because of ineffective nicotine delivery, as evidenced by low plasma levels of nicotine by the smokers who used them. However, the study [7] that they cite to support this argument actually showed that one e-cigarette brand was able to significantly reduce subjective craving for cigarettes despite low plasma levels of nicotine. Another study [8], not mentioned by Cobb & Abrams, found that e-cigarettes not only deliver nicotine effectively (more rapidly than a nicotine inhaler), but that they significantly reduce cigarette craving and number of cigarettes smoked at a level similar to that of nicotine replacement products. Furthermore, a recent clinical trial [9] published after the Cobb & Abrams article showed that e-cigarette use may motivate quitting. Among 40 smokers who were initially not interested in quitting but who were asked to use the e-cigarette ad libitum, 22.5% achieved sustained smoking abstinence (biochemically verified) at 6-month follow-up [9]. Furthermore, an additional 12.5% and 32.5% reduced their smoking by [at least] 80% and [at least] 50%, respectively [9]."

We note that: "Several survey studies support these findings. In a large international survey of current, former or never users of e-cigarettes, 72% of users reported that e-cigarettes helped them to deal with cravings and withdrawal symptoms, 92% reported reductions in their smoking when using e-cigarettes, and only 10% reported that they experienced the urge to smoke tobacco cigarettes when using the e-cigarette [10]. Moreover, of more than 2000 former smokers in this survey, 96% reported that the e-cigarette helped them to stop smoking, and 79% reported fearing that they would start smoking again if they stopped using it [10]."

Our most important conclusion is: "Consequently, removing e-cigarettes from the market or discouraging their use could harm public health by depriving smokers of a potentially important option for smoking cessation."

We also note that electronic cigarettes offer another benefit that has largely been overlooked: they could potentially reduce secondhand smoke exposure substantially for nonsmokers, especially for children who live in homes with smokers who may now experience high levels of exposure.

Finally, the commentary discusses how the FDA misled the public into believing that electronic cigarettes had been shown to pose a large cancer risk by distorting the findings of its laboratory study of these products:

"We also encourage e-cigarette investigators to draw conclusions within the appropriate context to prevent misleading conclusions. For example, the FDA held a press conference during which it warned consumers not to use e-cigarettes because of the presence of toxic chemicals, including diethylene glycol and carcinogens (tobacco-specific nitrosamines) [18]. What the FDA did not report was that it detected only trace levels of carcinogens (0.07–0.2% of the corresponding levels in cigarettes) [19,20] at levels similar to the nicotine patch and nicotine gum, and found diethylene glycol in only one of the 18 samples tested (a chemical that has not been found in any other brand since) [20]. Viewed in this context, instead of warning consumers not to use e-cigarettes we would argue that these data suggest that e-cigarettes may pose much lower carcinogenicity than regular cigarettes and are probably similar in carcinogenicity to FDA-approved nicotine replacement products."

The Rest of the Story

I believe that FDA regulation of electronic cigarettes is necessary in order to address basic quality control issues and to monitor product use to ensure that youth do not begin to experiment with these devices. However, rather than throw electronic cigarettes out with the anti-harm reduction mindset that has gripped much of the anti-smoking movement, I believe that federal policy should embrace these products as a potentially promising strategy that could save countless lives by helping smokers quit at rates not seen with the dismally effective current "FDA-approved" strategies.

No comments: