E-Cigarettes

Overview

Electronic cigarettes are also called E-cigarettes, personal vaporizer (PV) or electronic nicotine delivery system (ENDS).

An atomizer (battery-powered heating element) heats a liquid (possibly containing nicotine) turning it into an aerosol that can be inhaled and creating a cloud that resembles cigarette smoke. The aerosol emitted is not simply water vapour but a high concentration of ultrafine particles.⁵⁶

Clinical considerations

For some patients, E-cigarettes may help with harm reduction (reducing the harmful consequences of cigarette smoking, without necessarily reducing or eliminating the use itself).^57,58 In Canada, E-cigarettes are not approved to contain nicotine. E-cigarettes with nicotine (in other markets) are thought to satisfy the chemical (by replacing nicotine) and behavioral aspects (by mimicking the hand-to-mouth ritual) of cigarette addiction.⁵⁹ In Canada, the NICORETTE^® Inhaler can serve a similar purpose and is authorized for sale by Health Canada.⁶⁰

However, there are also several safety concerns to consider with E-cigarettes:

• Dual use: using E-cigarettes while still smoking cigarettes may not produce health benefits⁶¹
• Side effects: cough, sore throat and increase in airway resistance and heart rate have been reported^62-64
• New England Journal of Medicine study: E-cigarettes powered at higher voltages actually produced up to 15 times more formaldehyde than a tobacco cigarette, resulting in a 5 times greater cancer risk versus traditional cigarette smoking⁶⁵
• Johns Hopkins School of Public Health laboratory study: mice exposed to E-cigarette vapour were significantly more likely to develop compromised immune responses to both the virus and the bacteria, which in some cases killed the mice⁶⁶
• E-cigarettes contain nitrosamines and other carcinogens, but at much lower levels than tobacco cigarettes⁶⁷

Moreover, the efficacy of E-cigarettes in smoking cessation has not been established in randomized, controlled trials.

Questions remaining to be answered:

• Do E-cigarettes undo some of the de-normalization of smoking?
• Are E-cigarettes a gateway to smoking, especially for youth?
• What are the second hand and long-term effects of E-vapour?
• Do E-cigarettes lead to quitting smoking (versus reduction)?
• Can we count on the chemical composition of E-liquid?^68,69
• What is the evidence for efficacy of E-cigarettes?^70,71

The Canadian perspective

Health Canada advises Canadians not to buy or use E-cigarettes because the safety of the products (both the nicotine-containing and non-nicotine-containing versions) has not been proven. The agency also reminded Canadians that no company has been granted market authorization under the Food and Drugs Act to manufacture and sell E-cigarettes that deliver nicotine.⁷²

When choosing a smoking cessation method, consider the clinical evidence of all treatments, as well as what may work for your patients’ needs.

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