E-Cigarettes: Are They Safe? Are They Effective?

Lisa Schulmeister, RN, MN, APRN-BC, OCN®, FAAN

Editor-in-Chief OncLive Nursing

Oncology Nursing Consultant, Adjunct Assistant Professor of Nursing Louisiana State Health Sciences Center in New Orleans, Louisiana

Electronic cigarettes, also known as e-cigarettes, are battery-operated products designed to contain cartridges that deliver aerosolized additives. Depending on the brand, e-cigarette cartridges typically contain nicotine, a component to produce the aerosol (propylene glycol, glycerol, or vegetable glycerin), and flavorings such as fruit, mint, or chocolate.

A starter kit that contains the device, wall, and USB chargers, and a starter pack of e-cigarette cartridges retails for around $100. A single cartridge, available with or without nicotine, contains about 250 “puffs” and retails for $10 to $20 depending on its contents. The nicotine-containing cartridges typically have various strengths, such as high strength that delivers 13 to 16 mg of nicotine, medium that delivers 8 to 12 mg of nicotine, and low that delivers 6 to 8 mg. By comparison, a tobacco cigarette contains 9 to 18 mg of nicotine.

E-cigarettes often look like long, thin cigarettes, but also may look like cigars and pipes. They all work in the same way: when the user inhales, the air flow triggers a sensor that starts a small heater, the heater vaporizes the liquid in the cartridge (and usually activates a light at the end so that the e-cigarette appears lit), and the user receives a puff of hot gas that resembles tobacco smoke. When the user exhales, a cloud of vapor is produced that looks like smoke.

Although the prevalence of e-cigarette use or “vaping” is unknown, data from the Centers for Disease and Control and Prevention suggest that since their introduction in the United States in 2006, 21% of adults who smoke traditional cigarettes have used e-cigarettes, and about 6% of US adults have tried them.

E-cigarettes which are not marketed for therapeutic purposes are currently unregulated by the FDA, and in many states there are no restrictions on the sale of ecigarettes to minors. The FDA is currently considering banning the sale of e-cigarettes because the products appear to require FDA approval for marketing, but have not been reviewed by the FDA. In December 2013, Canada’s health agency banned the importation or sale of e-cigarette products.

Various claims have been made by e-cigarette manufacturers. Some manufacturers suggest that ecigarettes may help smokers quit (the World Health Organization has asked marketers not to make this claim). For smokers who don’t plan to quit, manufacturers suggest that e-cigarettes may be a way to reduce nicotine intake. E-cigarette manufacturers point to the nicotine, chemicals, and 43 carcinogens in tobaccocontaining cigarettes and assert that people should have the right to choose what they smoke.

Manufacturers suggest that e-cigarettes are safer than tobacco-containing cigarettes. However, welldesigned safety studies have not been conducted.

Critics of e-cigarettes also point out that there is an FDA-approved nicotine inhaler already available in the United States. Pfizer’s Nicotrol® is a prescription-only nicotine inhalation system that is a smoking cessation aid that reduces nicotine withdrawal symptoms. It’s designed to be a component of a comprehensive behavioral smoking cessation program.

Current research shows there are detectable levels of nicotine in nonsmokers who have been in close proximity, for extending periods of time, to people using ecigarettes containing nicotine. In addition, preliminary research of some brands of e-cigarette vapor found trace metals, including tin and copper.

E-cigarettes have not been fully studied so their potential risks are not known, the amount of nicotine and/or potentially harmful chemicals being inhaled are not known, and it’s not known if the products carry any benefit. It’s possible that e-cigarettes may lead people, especially young people, to try harmful tobacco products. In addition, there is concern that young nonsmokers might be attracted to flavored e-cigarettes, such as those that are chocolate flavored.

Oncology clinicians need to be informed about ecigarettes and how they work because our patients are increasingly asking about them. However, patients also need to be informed that it is unknown if e-cigarettes are safe and effective, and it’s not known if they have a role in smoking cessation programs.