Is smoking defined as the inhalation of nicotine, the use of tobacco, the exhale of smoke-like vapor/smoke, the ritual and emotional attachment of things one does as a smoker, or a combination of all those things? Who decides, and once decided, what happens next?
Electronic Cigarettes: More Questions than Answers
The use of electronic cigarettes is an evolving situation, one in which treatment protocols will change as new information is revealed. Currently, research is limited. The effects of long term use have not been studied, product safety is unknown, and e-cigarettes lack quality control oversight. That means marketing claims about e-cigs may not be/are not correct.
Depending on how one defines smoking, using an E-cig may or may not be considered smoking. The act of vaping is behaviorally identical to smoking, minus the tobacco and the smoke. E-cig manufacturers have declared their use a safer form of smoking. Some employers, states, towns, and insurance companies consider vaping to be smoking, and people who use the E-cig will test positive for nicotine. On the other hand, those who quit smoking tobacco cigarettes and use the E-cig often consider themselves quit.
Some establishments allow E-cigs only in designated smoking areas. Others allow their use in areas where smoking traditional cigarettes is prohibited. An increasing number of states are passing E-cig use and age of purchase restrictions. E-cig marketing promotes 'restriction-free' smoking among many other claims that may not be true. Nicotine free E-cigs may not really be nicotine free, but if they are that adds further question to what is or is not considered smoking.
From a tobacco treatment standpoint, the main components of a successful quit involve breaking the behaviors, habits, and emotional attachments surrounding the act of smoking. Letting go of nicotine is part of the quit process. Many E-cigs contain nicotine. All the FDA approved quit support options are designed to help a person quit smoking while breaking their lifelong behaviors associated with smoking. Lifestyle change is a necessary part of remaining a nonsmoker. By comparison, E-cigs are for the most part 'smoking to quit smoking'. Use of them does not offer room for new habits, new behaviors or new emotional coping tools. Depending on the E-cig chosen, it may not even remove inhaled nicotine from the equation.
Some people might quit smoking tobacco by using E-cigs. While vaping is currently believed to be safer than smoking a traditional cigarette, that is not the same as saying vaping is safe or healthy. E-cigs may or may not have a place in smoking cessation. There are no statistics available that measure actual quit success rates, relapse rates, or the number of would be quitters that now use E-cigs in addition to regular tobacco products. E-cig users may have a higher potential for relapse, given the perpetuation of smoking attachments and behaviors.
If you are contemplating using an E-cig to quit smoking, established research demonstrates your chance for success increases by choosing NRT, Zyban or Chantix instead. If you are already using an E-cig, it is wise to work towards becoming completely nicotine and cigarette free. Quitting smoking is the best thing you can do for your health. There is no safe way to smoke. The smartest choice is to stop inhaling from any type of cigarette.
Vikki Q CTTS-M
Master Certified Tobacco Treatment Specialist
"The reality is that if e-cigarettes really are effective quitting tools, the research is going to prove it, and we're going to promote them. No conspiracy here."
Electronic cigarettes have been heavily marketed the past 8 years, first as a miracle quitting aid and now as a substitute for conventional smoking. Maybe you yourself have used them to quit or moderate your tobacco use. As tobacco treatment specialists, we're in favor of anything that diminishes a smoker's odds of suffering tobacco-related illness or death. Should e-cigarettes be considered legitimate quit-tools?
Being a science-and-evidence-based quit-smoking program, QuitNet can officially recommend only treatments that are FDA approved, clinically researched, and proven effective over placebo. That doesn't mean that other methods don't work for smokers, or that we insist that they not use them -- only that we have a high standard of clinical proof we're required to honor. Although we review our position every six months (based on ongoing and increasing research), QuitNet doesn't currently include the use of e-cigarettes in its roster of suggested tobacco treatments, for the following reasons:
• E-cigarettes are not proven quit-tools.
Because e-cigarettes are still so new on the mass markets, there is little controlled, long-term research on their role in helping smokers become tobacco-free. A handful of limited (relying on self-supporting) and/or manufacturer-funded studies indicate a potential harm reduction benefit to users, and anecdotal evidence points to a possible quit-benefit, but none have yet demonstrated a causal relationship between use and subsequent long-term tobacco/nicotine abstinence.
• E-cigarettes are officially designated as tobacco products.
Recommending e-cigs would put us in the position of hawking tobacco products to smokers. U.S. federal courts ruled that electronic cigarettes cannot be considered quit-smoking aids by the FDA, but must be regulated as tobacco products. After this ruling, the largest distributors of e-cigarettes admitted their products were intended all along as smoking substitutes, not quit-aids (two of many examples):
“Understand that this is a cigarette. We are acting as a cigarette company. We have all the applicable warnings on all our packaging that actually backs that up...We do not represent the product as healthy or safe.” Ray Story, VP of Smoking Everywhere
“We can now market our product the way we always should have been able to... This is plain and simple [sic] an alternative to smoking for committed, longtime smokers." Matt Salmon, CEO of Sottera Inc
• E-cigarettes reinforce most aspects of conventional smoking.
Unlike existing quit-smoking aids (including nicotine inhalers), e-cigarettes deliver nicotine directly to the lungs -- making users potentially as dose-responsive to them as they are to conventional cigarettes. Also unlike NRT, e-cigarettes allow users to continue engaging in most of the potentially harmful mental and behavioral patterns associated with smoking. Unlike NRT, e-cigarettes present multiple physical, visual and behavioral relapse triggers at every use.
• E-cigarettes are not the same as Nicotine Replacement Therapy (NRT), and NRT itself is not a 'cure'.
NRT significantly raises the odds of ex-smokers remaining smoke-free while they are using it. (NRT is a short-term quit aid, designed to give ex-smokers time to develop new habits and other long-term support; like e-cigarettes, it can't help prevent relapse once one stops using it). The primary action of e-cigarettes -- inhaling nicotine directly into the lungs, getting nicotine to the brain in seconds -- runs counter to the action of NRT. The slow uptake of small, measured levels of nicotine is how NRT breaks down established smoking behaviors and routines (like getting the fix, preparing the fix, lighting the fix, hand-to-mouth with the fix, etc).
Numerous inspections of e-cigarette products also demonstrate wide variations between claimed and actual nicotine doses (even from 'puff-to-puff'), making self-monitoring and/or stepping down/weaning off unreliable and less effective.
• E-cigarettes, while undoubtedly less harmful than tobacco cigarettes, are not proven safe.
One thing we know about NRT is that it's about as safe as any quit medication we can recommend. We don't know that for sure about e-cigs. They haven't been on the market long enough to study the short or long-term consequences of regular use, nor is the effect known of glycolized e-cigarette steam on smokers' lungs. Manufacturing standards have not been set, nor is any oversight entity charged with creating or enforcing them. Dosages vary widely, and some cartridges have been found to contain enough nicotine to kill an adult human if ingested all at once.
There's a lot of conspiracy talk in e-cigarette forums, etc (including in the comments below), with the general thread being that tobacco treatment specialists like ourselves would rather have smokers die than approve e-cigarettes for use. That's pretty silly. Most of us do what we do because we've lost loved ones to tobacco and are dedicated to wiping out tobacco illness. The reality is that if e-cigarettes really are effective quitting tools, the research is going to prove it, and we're going to promote them! No conspiracy here.
The fact remains that we can't, under our own standards, give e-cigs the thumbs-up until the research says we can. That takes time and study, and we'll continue to monitor the research and re-evaluate as we go along. We don't urge smokers who use e-cigs to stop doing so (and some of us have worked with smokers who have used them to quit real tobacco), and we hope that they help you quit nicotine for good. In the meantime, please share with us your stories of e-cigarette use, and don't quit quitting till you quit.
Alan S. Peters, CTTS-M