E-cigarettes: harm reducing?
Combustible cigarettes kill two-thirds of long-term smokers.10 E-cigarettes do not involve combustion; therefore, if a smoker switches to e-cigarettes, carbon monoxide exposure and health harms will be reduced. Yet, the evidence regarding e-cigarettes as a cessation aid is limited; dual use with combustible cigarettes is common; and the safety of e-cigarettes has not been established.
Half of current smokers report regular use of e-cigarettes.11 Any use of cigarettes is harmful, and the concern is that individuals who use e-cigarettes will continue to smoke conventional cigarettes rather than quit. The strongest evidence in support of e-cigarettes for quitting smoking has come from observational studies in the UK. One study, a time-trend analysis, concluded that for every 1% increase in e-cigarette use, the success rate of quit attempts increased by 0.098%.12 In contrast, a second study in the UK found that daily use of e-cigarettes was associated with increases in quit attempts and reductions in number of cigarettes smoked, but not with smoking cessation.13
Meta-analyses have been conducted to synthesize the findings in the literature. A systematic review of 20 controlled studies concluded that the odds of quitting cigarettes was 28% lower in those who used e-cigarettes than in those who did not use e-cigarettes.14 Observational designs are challenged by confounding variables related to who self-selects to use an e-cigarette. Only 2 randomized controlled trials have evaluated e-cigarettes as a method for quitting conventional cigarettes. The quality of evidence was judged to be low grade, and in both trials, e-cigarettes with nicotine were no different in efficacy for quitting smoking than placebo (nicotine-free) e-cigarettes.15 To date, research does not support the use of e-cigarettes for cessation.
The American Heart Association’s (AHA) policy statement on e-cigarettes does not recommend their use; however, if a patient has tried and failed evidence-based tobacco cessation methods or is unwilling to try them, the AHA recommends16:
• No dual use of traditional cigarettes with e-cigarettes
• That a quit date is also set for the e-cigarettes
Tobacco and mental illness
Smokers with mental illness consume nearly half the cigarettes sold in the US and die on average 25 years earlier than the general population, largely from chronic diseases, most tobacco-related. Tobacco use also creates a significant economic burden on patients, increases isolation, and affects the metabolism of a number of psychiatric medications.
Despite the obvious need to treat tobacco addiction, there has been a historic reluctance to do so out of concerns that mental health functioning may worsen with cessation. In a 2007 AAMC (Association of American Medical Colleges) Survey of more than 3000 physicians, psychiatrists were the least likely to address tobacco addiction—although findings indicate that psychiatric outcomes improve with tobacco cessation.17,18 The tobacco industry also plays a role by promoting the self-medication hypothesis (ie, that cigarettes reduce psychiatric symptoms). However, cigarettes reduce withdrawal symptoms of nicotine rather than psychiatric symptoms. Symptoms of nicotine withdrawal can mimic psychiatric symptoms (depression, insomnia, irritability, anxiety, restlessness).
In contrast to the unknowns regarding e-cigarettes, there are evidence-based and well-established cessation treatments that are underutilized.
Dr. Das is Clinical Assistant Professor, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine; Dr. Prochaska is Associate Professor of Medicine at the Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA.
Dr. Prochaska has been a consultant for Pfizer, which makes smoking cessation medications, and has been an expert witness for plaintiffs’ counsel in court cases against the tobacco companies.
1. Cummins SE, Zhu SH, Tedeschi GJ, et al. Use of e-cigarettes by individuals with mental health conditions. Tob Control. 2014;23(suppl 3):48-53.
2. Prochaska JJ, Grana RA. E-cigarette use among smokers with serious mental illness. PloS One. 2014;9:e113013.
3. King BA, Alam S, Promoff G, et al. Awareness and ever-use of electronic cigarettes among U.S. adults, 2010-2011. Nicot Tobac. 2013;15:1623-1627.
4. Goniewicz ML, Gupta R, Lee YH, et al. Nicotine levels in electronic cigarette refill solutions: a comparative analysis of products from the U.S., Korea, and Poland. Int J Drug Policy. 2015;26:583-588.
5. Leventhal AM, Strong DR, Kirkpatrick MG, et al. Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence. JAMA. 2015;314:700-707.
6. Miech R, Patrick ME, O’Malley PM, Johnston LD. E-cigarette use as a predictor of cigarette smoking: results from a 1-year follow-up of a national sample of 12th grade students. Tobac Control. January 2017; Epub ahead of print.
7. Morean ME, Kong G, Camenga DR, et al. High school students’ use of electronic cigarettes to vaporize cannabis. Pediatrics. 2015;136:611-616.
8. Rigotti NA. e-Cigarette use and subsequent tobacco use by adolescents: new evidence about a potential risk of e-cigarettes. JAMA. 2015;31:673-674.
9. Chatham-Stephens K, Law R, Taylor E, et al. Exposure calls to US poison centers involving electronic cigarettes and conventional cigarettes: September 2010 to December 2014. J Med Toxicol. 2016;12:350-357.
10. Pirie K, Peto R, Reeves GK, et al. The 21st century hazards of smoking and benefits of stopping: a prospective study of one million women in the UK. Lancet. 2013;381:133-141.
11. Population Assessment of Tobacco and Health (PATH) Study Public-Use Files. Inter-University Consortium for Political and Social Research (ICPSR). 2017. http://doi.org/10.3886/ICPSR36498.v3. Accessed April 28, 2017.
12. Beard E, West R, Michie S, Brown J. Association between electronic cigarette use and changes in quit attempts, success of quit attempts, use of smoking cessation pharmacotherapy, and use of stop smoking services in England: time series analysis of population trends. BMJ. 2016;354: i4645.
13. Brose LS, Hitchman SC, Brown J, et al. Is the use of electronic cigarettes while smoking associated with smoking cessation attempts, cessation and reduced cigarette consumption? A survey with a 1-year follow-up. Addiction. 2015;110:1160-1168.
14. Kalkhoran S, Glantz SA. E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis. Lancet Respir Med. 2016;4:116-128.
15. Hartmann-Boyce J, McRobbie H, Bullen C, et al. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev. 2016;9:CD010216.
16. Bhatnagar A, Whitsel LP, Ribisl KM, et al. Electronic cigarettes: a policy statement from the American Heart Association. Circulation. 2014;130: 1418-1436.
17. American Association of Medical Colleges. Physician behavior and practice patterns related to smoking cessation, summary report. Washington, DC: Association of American Medical Colleges; 2007.
18. Hall SM, Prochaska JJ. Treatment of smokers with co-occurring disorders: emphasis on integration in mental health and addiction treatment settings. Ann Rev Clin Psychol. 2009;5:409-431.