CINCINNATI—Thinking of trying electronic cigarettes as a way to kick nicotine addiction? A University of Cincinnati (UC) addiction expert advises otherwise.
Shannon Miller, MD, a professor of clinical psychiatry at UC and program director for the addiction medicine research fellowship at the Cincinnati Department of Veterans Affairs (VA) Medical Center, expresses serious concerns about e-cigarettes and instead advises using evidence-based therapies to stop smoking, such as nicotine replacement therapies, proven anti-relapse medicines and addiction-specific psychotherapies.
"It’s an evolving product,” Miller says of e-cigarettes, whose commercial use dates back about 10 years. "Currently the Food and Drug Administration doesn’t recommend it as being safe or effective for reducing or stopping tobacco use, nor does the World Health Organization or the VA.”
E-cigarettes are tubes made of plastic or metal that use a battery to heat a liquid solution containing nicotine (known to be addictive). The resulting vapor is inhaled, delivering nicotine to the bloodstream.
Miller says his concerns about the e-cigarette and the claims that it helps people reduce or stop smoking tobacco are primarily twofold: safety and effectiveness.
"The ads that claim that e-cigarettes release only harmless water vapor are simply false. There have been studies that show that e-cigarettes deliver a variety of things that are potentially unsafe, including very small particles or pieces of metal, toxic chemicals, and carcinogens—depending on the product,” he says. "So while the exposure to harmful substances that you get with a tobacco cigarette might be lower with an e-cigarette, the e-cigarette may also deliver other items that may also have risk.”
Even without those particles and chemicals, Miller points out, the fact remains that e-cigarettes are delivering nicotine, and nicotine is known to be very addicting (depending on its form) and to potentially have cancer-promoting properties of its own. Additionally, studies have shown that nicotine has negative effects on the developing brain by "hijacking” receptors that can then be abnormally accessed by nicotine.
"This is a real problem because many of the users of e-cigarettes are adolescents—their brains are still developing,” Miller says. "You’re exposing them to a product that’s increasingly designed to deliver nicotine rapidly and significantly to the human brain at a developmental age when the human brain is perhaps more at risk for being abnormally altered, which may portend higher risk for nicotine addiction, more severe addiction, and possibly other psychiatric disorders later in life.”
There are also concerns that up to one-third of youth who try e-cigarettes have never previously smoked a traditional cigarette (indicating that e-cigarettes may be bringing youth into nicotine use who would otherwise not have used nicotine, an addictive drug). Marketing is often geared toward youth, Miller says, including the use of special flavorings. Further, e-cigarettes have been adapted as drug paraphernalia to administer other addictive drugs, including marijuana. And, he adds, second-hand exposure of non-users of nicotine/tobacco to e-cigarette aerosol results in measurable levels of nicotine metabolites in their blood.
As for effectiveness, Miller says early studies suggest that the e-cigarette is at best no better than FDA-approved nicotine replacement therapies (proven to be both safe and effective) and in some studies may only reduce the number of traditional cigarettes smoked daily by two.
"Health claims and claims about e-cigarettes being effective for reducing or stopping smoking are not currently supported by the scientific literature,” he says. "The big picture is that most tobacco smokers who try the e-cigarette find that they continue to smoke tobacco anyway. And because the ill effects of tobacco cigarettes on cardiovascular systems occur at very low levels of smoking, and cancer risk relates in part to duration of smoking, dual use may not afford any significant long-term health benefit.”
At the same time, Miller says, e-cigarettes may introduce new problems, as outlined previously.
Miller’s advice to smokers wishing to quit is to use evidence-based therapies—those that have been proven effective in clinical studies, and to seek out trained addiction professionals to help, as nicotine addiction is among the most difficult addictions to treat.
In addition to nicotine replacement therapies, there are FDA-approved and also off-label prescription medicines such as varenicline, bupropion and topiramate that work to rebalance the specific brain circuitry that has been abnormally affected through the use of nicotine.
Last month, the FDA—which regulates tobacco products—proposed regulating e-cigarettes for the first time. Proposed restrictions would include a ban on the sale of e-cigarettes to minors, a prohibition on distributing free samples and a requirement that e-cigarettes carry warnings that they contain nicotine. However, there would still be allowances given that are no longer available to tobacco products (television advertising would be allowed, for instance).
"The big picture is that we need more data and more studies,” says Miller.