Exploring the pros and cons of e-cigarettes

Today, the Ontario legislature passed a bill that, among other things, bans the use of e-cigarettes in public spaces — essentially treating e-cigarettes like conventional cigarettes, under the Smoke-Free Ontario Act.

There has been a lot of debate and discussion about this topic, and for many people it’s a very personal and emotional topic.

Like all arguments, there are two sides to this. Let’s first talk about the con side. What are the concerns that we have about e-cigarettes?

Firstly, we have studies that raise concerns about what the vapour actually contains. Studies have found various carcinogens in the vapour of both nicotine and non-nicotine e-cigarettes, some of which are also found in conventional cigarettes, but others of which are unique to e-cigarettes. We also have studies that show short-term effects like inflammation and decreased lung function immediately after vaping. The question is, what might be the effect of inhaling these carcinogens for 20 years? And what about effects of second-hand vapour? We just don’t know.

We asked ourselves similar questions in the 1930s and 1940s about conventional cigarettes, and we are obviously weary of making assumptions about safety and repeating those mistakes. So there’s a potential long term health risk there.

Next is what we call the “gateway theory.” The idea here is that e-cigarettes are a seemingly innocuous product, and as such might act as a gateway for young people to start smoking. An Ontario report found that 15 per cent of kids between Grades 9 and 12 had tried e-cigarettes. As youths are drawn in with things like candy flavored e-cigarettes, they become addicted to the nicotine, and the concern is that they will eventually switch to conventional cigarettes.

The next concern is that wide use of e-cigarettes might undo the benefits of current bans on smoking in public places. By banning smoking in indoor settings, we have provided a new stimulus for people to try to quit, and by forcing people to go for long periods without nicotine, these laws have helped to wean people off cigarettes. Enabling anytime nicotine access through e-cigarettes might undo these benefits.

The last concern has to do with regulation. Currently, there is no regulation of how and where e-cigarettes are produced, and what quality-control is in place. Not only have we heard of e-cigarettes exploding and burning people, but previous work has suggested that a high proportion of e-cigarette products labeled as “nicotine-free” actually do contain nicotine.

What about the pro side? This is the side of the debate that we often call the “harm reduction” argument. The idea here is that we acknowledge that there might be some low-level carcinogens in the vapour, but e-cigarettes can’t possibly be as harmful as conventional cigarettes, so if they help someone to quit smoking, they must provide a net benefit.

As a health care provider struggling to help patients quit, this is a very attractive argument. But on the same token, if I am going to consider e-cigarettes as a smoking cessation aid, it is a nicotine delivery device, and like any other drug or drug delivery device, I would expect rigorous scientific evidence around both benefit and safety. And what do we know? Unfortunately, very little.

There was a poster by Toronto scientists presented at the American Thoracic Society Conference last week that reviewed the literature on e-cigarettes as a smoking cessation tool. They found four studies that looked at efficacy, of which only two were randomized-controlled trials, and 18 studies that looked at safety.

For efficacy, e-cigarettes were better than placebo for achieving quit at the one-month mark, but this benefit faded by the three and six month marks. By the six month mark, only seven per cent of the users had successfully quit smoking cigarettes, and this was similar to effects with placebo and with nicotine patches. On the other hand, safety studies indicated more serious side-effects with e-cigarettes than with nicotine patches.

So how do we reconcile public health concerns with the needs of our individual patients, especially as we wait for further evidence? Patients ask me about e-cigarettes almost every week in the clinic, and many of these are patients who have severe lung disease. The challenge is that when I’m in that office, my responsibility as a doctor, to do what’s best for my patient, comes before my responsibility as a public health advocate. My approach is to offer patients all the proven strategies that we have to help them quit, and if all of those fail and a patient really wants to try an e-cigarette, I go through this pros and cons discussion and let them make the decision for themselves.

Ultimately, what we need is scientific proof of safety and efficacy of e-cigarettes as a smoking cessation aid. Once we have this, they can be approved, regulated as a drug-delivery device, and clinicians can prescribe them to the patients who might benefit most.

If the evidence is strong enough, provincial ministries of health might even cover their costs, as they do with other smoking cessation aids. To my mind, none of this is incompatible with the spirit of today’s legislation.