The introduction of electronic cigarettes has forced us to examine how to incorporate this invention in our society responsibly.  Currently, there are claims that e-cigarettes play a role in smoking cessation as they offer a safer alternative to traditional smoking. On the other hand, they may be viewed as a gateway to cigarette smoking for the youth and adolescents.

What is an e-cigarette?

It is an electronic device operated by battery to heat a liquid such as glycerin or polyethylene glycol into an aerosol for inhalation, or vaping. The liquid may contain nicotine or flavourful additives. And similar to a traditional cigarette, it contains contaminants such as volatile organic compounds, carbonyls, aldehydes, tobacco-specific nitrosame (TSNAs) and metal particles but in much less quantity. In Canada, e-cigarette is legal but unregulated. They also do not contain nicotine.

What are the claimed benefits?

It is well known that smoking is linked to many health concerns such as lung cancer, chronic obstructive pulmonary disease (COPD) and cardiovascular diseases which can be a serious public health concern as well as financial burden for the health care system. So any attempt for smoking cessation if deemed successful will not only save the health care system money but seen as a major benefit in disease prevention.

Recently, one study looked at the safety and efficacy of e-cigarettes in a 12-month cohort study.  Preliminary findings suggest that using e-cigarettes concurrently with traditional cigarette did not change smoking cessation rate; yet when e-cigarettes were used alone, the success rate appeared somewhat promising.  These results suggest if smokers are motivated to quit, e-cigarettes may work.

In 2014, a Cochrane review was conducted to determine the efficacy of e-cigarettes in smoking cessation. They concluded that two randomized controlled trials to-date have demonstrated efficacy benefits but given limited number of trails, low event rates and wide confidence interval around the results all suggest that we need more high quality evidence to confirm these findings.

Last month, the Royal Collage of Physicians in Britain has released a document entitled Nicotine without Tobacco.  It contains a comprehensive review of the tobacco industry in Britain, the current policies in tobacco harm reduction as well as available strategies and interventions.

The document also encourages the greater use and acceptance of e-cigarettes as a smoking cessation strategy as it has proven to be well accepted by smokers as compared to other nicotine replacement therapies.

What are the potential safety concerns?

Again e-cigarettes have only been around for a short time in an unregulated environment. Hence, there isn’t enough surveillance program in place to monitor their use and the potential risks to establish their safety profile.  Since they contain similar but smaller amount of constituents as traditional cigarettes, they are predicted to have similar but lower risks in developing lung cancer and / or COPD.  e-Cigarettes that contain nicotine can be unsafe if exposed to pregnant women and adolescents affecting the brain development of the fetus as well as the youth.  It is still unclear how the heated liquid containing glycerin or polyethylene glycol affect the lung on repeated exposure.  Because e-cigarettes are not regulated, they are not obliged to comply with any specific quality standards, making them potential hazards from poor quality assurance perspective.  There are also many concerns related to fire hazards. In one instance, the battery in the e-cigarette blew up in a person’s coat pocket resulting in second degree burn.

Where do we go from here?

The popularity of e-cigarettes has proven that they are well accepted by smokers looking for ways to minimize tobacco exposure or as aids for smoking cessation.  Although the ease of access may be seen as gateway to tobacco consumption for youth and non-smokers, these concerns are still unfounded and yet to be proven in clinical studies.

We can either wait to see how the e-cigarette industry is being swallowed by the tobacco industry and monopolized to their advantage, or look for partnership opportunities for smoking cessation.  We are still in the process of gathering all the data to confirm safety and efficacy. Yet if they are proven to be safe and effective, we should look at ways to actively incorporate their use for smoking cessation by dealing with some expected obstacles:

  • Fire hazards 

Currently, e-cigarettes are prohibited in hospitals because of fire hazards. Yet it is likely the most opportune time in hospital to introduce effective smoking cessation ideas, especially after a patient has recovered from pneumonia or another exacerbation of COPD. How is e-cigarette as a fire hazard different from an oxygen tank? If we have strategies to allow oxygen tanks to exist in hospital, then there must be a way to allow e-cigarettes to be used or introduced in hospitals.

  • Regulation of e-Cigarettes

Many of the safety concerns with e-cigarettes are related to the fact that they are unregulated, and thus there is no formalized method for quality assurance as well as safety surveillance.  Yet if they are regulated as a pharmaceutical,  we may lose the advantage of being easily accessible. Their cost may go up, making them not affordable for many individuals.  e-Cigarettes that do not contain nicotine may need more public education and awareness promoting the safe handling and use of these products. They may need more specifications on product labeling and precautions.

I wonder if pharmacy can compound nicotine containing liquid to be used in e-Cigarettes for individuals wanting to try nicotine-containing e-cigarettes for smoking cessation – all under prescription authorization from prescribers.  This concept will introduce some level of quality assurance in terms of the prescribed nicotine dose as well as a system to monitor use via prescription refills.

  • Continued Research

There is still a lot of unknown about the e-cigarettes but we have a “buy-in” and acceptance by the public as demonstrated by their popularity. If we proactively engage in research to understand their long term benefits and risks, we may be successful in combating the problem of smoking as a public health concern.

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