Safety and Efficacy of Alternative Tobacco Products in Smoking Cessation: A Scientific Review on E-cigarettes

Nowadays, dependency on the internet and search engines has become a common practice before visiting a physician for medical advice. It’s more common among younger generations to research before making any decision regarding education, life, food/ restaurants, smoking, alcohol consumption, sex, etc., They rely on the reports that appear handy according to their expectations. The internet search related to e-cigarettes & smoking cessation will give a laundry list of results especially portraying one randomized clinical trial that was conducted on 886 subjects (23).

To a common man, it is very difficult to interpret these study results and to understand the outcome. In the e-cigarette group, of 69 participants who stopped smoking for 1 year, 80% were still using e-cigarettes and in the NRT group, only 9% were still using one of the products (46). This is a clear indication that though e-cigarettes helped in smoking cessation but caused switching to a new smoking habit. There was no significant safety information from the randomized clinical trial to conclude its safety. However, EVALI cases changed the perspective on e-cigarettes. It was believed that vitamin E in the e-cigarette causes EVALI and other products in the e-cigarettes were under investigation. So, CDC recommends all e-cigarette users refrain from using e-cigarettes and other vaping products (47).  Till January 07, 2020, a total of 2602 EVALI cases were reported to the CDC within the US including 57 fatalities (48).

Nicotinate e-cigarettes pump nicotine into the bloodstream via the lungs and stimulate epinephrine production which in turn stimulates the nervous system leading to an increase in blood pressure & heart rate. According to the research, e-cigarettes may be less harmful compared to cigarette smoking however, there is no difference in getting addicted to nicotine (49). Vaping process produces some potentially toxic chemicals and carcinogens which will be pumped directly into the lungs. In certain e-cigarettes, heating coils are made up of high levels of nickel and chromium. Like cigarettes, a few e-cigarettes contain low levels of cadmium that can cause breathing problems (50, 51).

The NRT may be associated with withdrawal symptoms with the most common adverse events like headache, skin rash, throat pain mouth, etc., However, in a study conducted on smoking cessation, nicotine gum and transdermal nicotine showed relieving withdrawal symptoms and 2-fold success rates compared to placebo. over placebo in trials of smoking cessation (52). In intensive Care Unit (ICU) patients, the NRT did not affect mortality or Serious adverse events but exhibited long-time alive with no delirium, sedation, and coma compared to placebo (53, 54). But Also, NRT is recommended for preventing withdrawal symptoms or treating aggressive activity in ICU-admitted smoking patients, regardless of its potential side-effects and in the presence of incoherent safety and effectiveness evidence (52).

Nicotine activates the nervous system and activates the brain stimulating the production of dopamine which reinforces rewarding behaviors. The pleasure gained by nicotine’s interaction causes some people to be addicted to nicotine (56). The NRT has been approved therapy by the FDA for smoking cessation. Then why people who intend to quit smoking are switching to e-cigarettes rather than NRT?

A nicotine patch may keep a person away from nicotine from active smoking, but it does not make them fully satisfied as they are missing some activity of keeping something between the lips & puffing. This psychological feeling makes people switching to e-cigarettes as the vapors give the smoker the ‘experience’. NRT products may have side effects but one should not forget that safety & efficacy has been evaluated and approved by the FDA for smoking cessation.

The internet searches provide a laundry list of articles saying that e-cigarettes help in smoking cessation compared to NRT. There is no smoking cessation but switching to another addiction of e-smoking. There is no evidence that nicotine-free or tetrahydrocannabinol -free e-cigarettes are safe (57). What are the long-term effects of sucking a battery and inhaling vapors? Benefits should be overweighed. E-cigarettes emulate cigarettes by having a smoking experience. There is no doubt. This might also help smokers adapt to new cigarette behaviors, but not to discourage them directly. The NRT may not help in long-term smoking cessation as 93% of over-the-counter NRT users started smoking within 6 months. However, adding some other antidepressants with the NRT enhanced long-term success rates (58,59).

Mentally, placebo plays a powerful role. When a person wants to stop smoking and decides to put a patch on his neck or upper arm, the placebo effect may give a dissatisfactory feeling compared to the smoking e-cigarette.  The mind of a smoker is fulfilled when they do it, light it up, inhale it, take it deep, and release it. Which gives smokers a new way of satisfying themselves. Nevertheless, it should be remembered that increased use of non-smoking tobacco products leads to serious health problems such as cancer and heart diseases (60).

In adults, brain development during 13-19 years of age is critical. As nicotine affects the brain’s function it not only leads to nicotine addiction but also makes them switch to other drugs.  Nicotine may affect attention and focus further causing problems in impulse control (61). More research is required if vaping is as effective as FDA-approved smoking cessation aids. Also, the CDC is monitoring the safety of chemical compounds used in vaping nicotine and non-nicotine e-cigarettes (52). It is advised to wait until CDC & FDA confirm the safety of various vaping compounds used in e-cigarettes.