A fresh look at tobacco harm reduction: the case for the electronic cigarette

Abstract

Smokers of any age can reap substantial health benefits by quitting. In fact, no other single public health effort is likely to achieve a benefit comparable to large-scale smoking cessation. Surveys document that most smokers would like to quit, and many have made repeated efforts to do so. However, conventional smoking cessation approaches require nicotine addicted smokers to abstain from tobacco and nicotine entirely. Many smokers are unable--or at least unwilling--to achieve this goal, and so they continue smoking in the face of impending adverse health consequences. In effect, the status quo in smoking cessation presents smokers with just two unpleasant alternatives: quit or suffer the harmful effects of continuing smoking. But, there is a third choice for smokers: tobacco harm reduction. It involves the use of alternative sources of nicotine, including modern smokeless tobacco products like snus and the electronic cigarette (E-cig), or even pharmaceutical nicotine products, as a replacement for smoking. E-cigs might be the most promising product for tobacco harm reduction to date, because, besides delivering nicotine vapour without the combustion products that are responsible for nearly all of smoking's damaging effect, they also replace some of the rituals associated with smoking behaviour. Thus it is likely that smokers who switch to E-cigs will achieve large health gains. The focus of this article is on the health effects of using an E-cig, with consideration given to the acceptability, safety and effectiveness of this product as a long-term substitute for smoking.

Figures

Figure 1

Snus smoke-free tobacco. Snus is an oral tobacco product that comes in a pouch of some sort, designed to be placed between the gums and upper lip. Snus is not chewed and requires no spitting. The standard pouch holds 1 gram of finely ground tobacco. Snus is regulated as a food in Sweden, and thus held to strict quality standards. Swedish snus was developed to greatly reduce TSNA content, and research shows that snus does not increase the risks of cancer of any type.

Figure 2

Structure of a standard entry model electronic-cigarette (e-Cigarette). The e-Cigarette is a battery-powered electronic nicotine delivery device (ENDD) resembling a cigarette designed for the purpose of providing inhaled doses of nicotine by way of a vaporized solution. The product provides a flavor and physical sensation similar to that of inhaled tobacco smoke, while no smoke or combustion is actually involved in its operation. It is composed of the following key components: (1) the inhaler – also known as 'cartridge’ (a disposable plastic mouthpiece - resembling a tobacco cigarette’s filter containing an absorbent material saturated with a liquid solution of propylene glycol and vegetable glycerin in which it may be dissolved nicotine); (2) the atomizing device (the heating element that vaporizes the liquid in the mouthpiece and generates the mist with each puff); (3) the battery component (the body of the device - resembling a tobacco cigarette – which houses a lithium-ion re-chargeable battery to power the atomizer). The body of the device also houses an electronic airflow sensor to automatically activate the heating element upon inhalation and to light up a red LED indicator to signal activation of the device with each puff. The LED indicator also signals low battery charge.

Figure 3

Medical Infograph. This Infograph compares the potential health risks of cigarette smoke with the health risks of vapor. Since e-cigarette liquid contains only propylene glycol, vegetable glycerin, flavorings, and nicotine, the resulting vapor is unlikely to present any more disease risk than medicinal nicotine products -- the risk of nicotine addiction. The many more toxic and carcinogenic ingredients in tobacco smoke are linked to numerous health problems.