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Editor's Note
May 2014

If Only Electronic Cigarettes Were Effective Smoking Cessation Devices

JAMA Intern Med. 2014;174(5):813-814. doi:10.1001/jamainternmed.2014.167

Harm reduction is one of the pillars of modern public health. For example, when people criticized methadone treatment as only substituting one drug for another (heroin), public health advocates pointed to research showing that methadone use led to users decreasing or ceasing their heroin use and living more functional lives. Thus, as a harm reduction proponent, I would be willing to put aside the fact that any product with the name “cigarette” (e- or otherwise) causes me reflex tachycardia and support electronic cigarettes (e-cigarettes or electronic nicotine delivery systems) if there were good data indicating that they helped smokers to stop.

Unfortunately, the evidence on whether e-cigarettes help smokers to quit is contradictory and inconclusive. Grana and colleagues increase the weight of evidence indicating that e-cigarettes are not associated with higher rates of smoking cessation. Using longitudinal data from a web-enabled panel, they found that among smokers use of e-cigarettes was not associated with quitting 1 year later or smoking fewer cigarettes.

Although there are no data showing that e-cigarette use helps with cessation, there is potential harm. In particular, e-cigarettes are currently unregulated. Therefore, the tough restrictions on the sale of tobacco to minors do not exist for e-cigarettes. Also, the limitations on where people can smoke do not currently apply to e-cigarettes, with the result that the progress on changing social norms through smoking bans may be threatened. Finally, we simply do not know what potential harm e-cigarettes may cause to their users.

E-cigarettes should be regulated by the US Food and Drug Administration as a drug-delivery device. I agree with Grana and colleagues that sellers of e-cigarettes should not be able to advertise them as smoking cessation devices without sufficient evidence that they are effective for this indication.

3 Comments for this article
Question about methadone maintenance analogy
D L Keller | none
You stated "methadone use led to users decreasing or ceasing their heroin use and living more functional lives". As a libertarian, I am curious to know to what extent those same benefits could have been achieved by legalizing heroin, at least for established heroin addicts. Much of the harm done to heroin addicts is caused by the fact that heroin is illegal, which makes it expensive (causing the need for addicts to steal), of uncertain potency (leading to overdose deaths) and impure (causing infections). Many heroin addicts continued to shoot up while on methadone maintenance, which negated its value for them. Haven't other countries had greater success in reducing the burden of overdose deaths, infections (including HIV) and crime rates by legalizing heroin, morphine and other injected opioids for registered addicts?
Let the bad be the enemy of the truly horrendous
David L. Keller, MD | none
Much of the harm of smoking is known to be due to inhalation of hot smoke, carbon monoxide, and other products of tobacco combustion. E-cigarettes deliver nicotine to the lungs as a cooler vapor, absent combustion products. While nicotine is an addictive drug known to increase the risk of heart attacks, the argument for making e-cigarettes available to smokers is that e-cigarettes are predicted to cause far fewer lung cancers, due to the absence of carcinogenic "tar" particles or hot irritating gases in their vapor. In addition, e-cigarette users are not inhaling the carbon monoxide found in cigarette smoke, which contributes to coronary ischemia among other ill effects. Even if the use of e-cigarettes does not cut down the number of cigarettes smoked, at least we know that when a chain-smoker is inhaling from an e-cigarette at a given moment, he is not also smoking a regular cigarette at that same time. Smoking causes lung cancer and heart attacks, while e-cigarettes cause "only" the latter. Using e-cigarettes is a bad choice, but this is a case of letting the bad be the enemy of the truly horrendous. I advise my patients neither to smoke nor to e-smoke, but if I had to choose one vice, it would be the latter.
Your wish for evidence may have come true!
David L. Keller, MD | Independent
Your wish may have come true!The latest study concludes \"Among smokers who have attempted to stop without professional support, those who use e-cigarettes are more likely to report continued abstinence than those who used a licensed NRT product bought over-the-counter or no aid to cessation. This difference persists after adjusting for a range of smoker characteristics such as nicotine dependence.\"(1)Would you please write an editorial entitled \"If only there were a cure for Parkinson's disease\"? I would personally appreciate that, and although it seems unscientific, your editorials seem to get results in a remarkably quick fashion ;-)Reference1: Brown J, et al. Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study. Addiction. Pre-publication online at: http://onlinelibrary.wiley.com/doi/10.1111/add.12623/abstract