Advertisement
Mayo Clinic Proceedings Home

E-Cigarettes: An Asset or Liability in Efforts to Lessen Tobacco Smoking and Its Consequences

  • Susan Galandiuk
    Correspondence
    Correspondence: Address to Susan Galandiuk, MD, Hiram C. Polk Jr, MD, Department of Surgery, University of Louisville, 550 S Jackson St, Louisville, KY 40202.
    Affiliations
    Hiram C. Polk Jr, MD, Department of Surgery, University of Louisville, Louisville, KY
    Search for articles by this author
      Every physician should agree that tobacco control and a reduction of smoking-related deaths is a desirable outcome. Holford et al
      • Holford T.R.
      • Meza R.
      • Warner K.E.
      • et al.
      Tobacco control and the reduction in smoking-related premature deaths in the United States, 1964-2012.
      have recently reported the dramatic reductions in premature deaths and the years of life already saved by successful tobacco control. However, much remains to be done. No single US Food and Drug Administration–approved cessation aid works for more than a small fraction of smokers. Despite the availability of varenicline, bupropion, and various nicotine replacement therapy products, getting current smokers to quit remains a challenge.
      In this month’s issue of Mayo Clinic Proceedings, 2 articles focus on yet another method of nicotine replacement therapy: electronic cigarettes, also known as e-cigarettes or electronic nicotine delivery systems (ENDS). In their Concise Review, Ebbert et al
      • Ebbert J.O.
      • Agunwamba N.A.
      • Rutten L.J.
      Counseling patients on the use of electronic cigarettes.
      present a somewhat negative view of ENDS, perhaps flavored by their exhaustive work in the field of smoking cessation and the immense challenges associated with getting patients to end tobacco and nicotine addiction. Kadimpati et al,
      • Kadimpati S.
      • Nolan M.
      • Warner D.O.
      Attitudes, beliefs, and practices regarding electronic nicotine delivery systems in patients scheduled for elective surgery.
      in a report on their pilot study, discuss attitudes of current smokers about to undergo elective surgery and report that those who have never tried ENDS have a higher interest in their perioperative use (as a method of diminishing dependence on smoking) than those who have previously tried ENDS.
      There are several issues at the core of these articles. For example, the study by Kadimpati et al
      • Kadimpati S.
      • Nolan M.
      • Warner D.O.
      Attitudes, beliefs, and practices regarding electronic nicotine delivery systems in patients scheduled for elective surgery.
      addresses the fact that a formal preoperative evaluation with surgical patients tends to cause those patients to focus on their health. Coaching patients about their health in this setting exploits “surgery as a teachable moment” in patient education. As Warner, a coauthor of the Kadimpati et al report, has previously proposed, when physicians take optimal advantage of this period, there is a potential for reducing the incidence of postoperative medical and surgical complications as a result of preoperative smoking cessation.
      • Warner D.O.
      Surgery as a teachable moment: lost opportunities to improve public health.
      Shi and Warner
      • Shi Y.
      • Warner D.O.
      Brief preoperative smoking abstinence: is there a dilemma?.
      have also clarified that the once-feared risks of increasing pulmonary symptomatology when smoking cessation is commenced immediately before surgery is a flawed concept based on a misinterpretation of the literature. As such, from the perspective of Kadimpati et al,
      • Kadimpati S.
      • Nolan M.
      • Warner D.O.
      Attitudes, beliefs, and practices regarding electronic nicotine delivery systems in patients scheduled for elective surgery.
      Warner,
      • Warner D.O.
      Surgery as a teachable moment: lost opportunities to improve public health.
      and Shi and Warner,
      • Shi Y.
      • Warner D.O.
      Brief preoperative smoking abstinence: is there a dilemma?.
      all efforts to have patients cease smoking, or transfer to a smokeless form of nicotine replacement, should be pursued before surgery, even immediately before surgery. This concept has been supported by others.
      • Myers K.
      • Hajek P.
      • Hinds C.
      • McRobbie H.
      Stopping smoking shortly before surgery and postoperative complications: a systematic review and meta-analysis.
      • Chow C.K.
      • Devereaux P.J.
      The optimal timing of smoking cessation before surgery: comment on “Smoking Cessation Shortly Before Surgery and Postoperative Complications.”.
      • Khullar D.
      • Schroeder S.A.
      • Maa J.
      Helping smokers quit around the time of surgery.
      With respect to using surgery as a “teachable moment,” the patients studied by Kadimpati et al
      • Kadimpati S.
      • Nolan M.
      • Warner D.O.
      Attitudes, beliefs, and practices regarding electronic nicotine delivery systems in patients scheduled for elective surgery.
      are clearly not like my own. Specifically, my own patients are very anxious before surgery; so anxious, in fact, that they often forget almost everything I tell them, including many more imminently important matters than advice about smoking. This perception on my part is consistent with that reported in the indexed literature, in which patients more commonly than not forget physician instructions about medical conditions, medications, and the reasons for taking those medications.
      • Makaryus A.N.
      • Friedman E.A.
      Patients’ understanding of their treatment plans and diagnosis at discharge.
      Perhaps these differences in experience relate to the fact that Mayo Clinic, where Kadimpati et al practice, has a unique surgical practice, and I suspect that their patients are seen by anesthesiologists even closer to the time of surgery than my own patients are. In most US medical environments, the time from a perioperative visit with the anesthesiologist to the time of surgery is 2 weeks or less. I question whether this is sufficient lead time to substantially impact smoking-related complications, even if smokers “buy in” to the idea of using ENDS.
      As Kadimpati et al
      • Kadimpati S.
      • Nolan M.
      • Warner D.O.
      Attitudes, beliefs, and practices regarding electronic nicotine delivery systems in patients scheduled for elective surgery.
      eloquently elaborate, there are many deleterious effects of smoking before elective surgery, including cardiac, respiratory, and wound complications. A vaporized nicotine product could conceivably reduce some of these problems. Many plastic and reconstructive surgeons have long refused to perform cosmetic procedures or operations involving the use of tissue flaps in patients who are smokers because of the relative tissue hypoxia caused by both the vasoconstrictive effects of nicotine and cigarette smoke–associated carbon monoxide.
      • Jensen J.A.
      • Goodson W.H.
      • Hopf H.W.
      • Hunt T.K.
      Cigarette smoking decreases tissue oxygen.
      • Bartsch R.H.
      • Weiss G.
      • Kästenbauer T.
      • et al.
      Crucial aspects of smoking in wound healing after breast reduction surgery.
      My plastic surgery colleagues specifically instruct patients that they must be abstinent from all forms of nicotine (including ENDS) before surgery. With respect to wound complications, further research is needed to determine to what extent these complications are due to carbon monoxide and what portion is due to nicotine-associated vasoconstriction. Interestingly, these aforementioned surgeons do not have the same aggressive stance against caffeine, which will similarly cause vasoconstriction. The duration of the vasoconstriction with respect to the withdrawal time of the stimulus also needs further examination. Nicotine itself has been shown to have notable effects on skin in in vitro studies.
      • Misery L.
      Nicotine effects on skin: are they positive or negative?.
      The use of nicotine vapor might not be associated with a reduction in wound complications. Although such a product would not contain carbon monoxide and would therefore eliminate the effects of that substance on wound healing, clinically important nicotine-associated vasoconstriction might still be present. As Ebbert et al
      • Ebbert J.O.
      • Agunwamba N.A.
      • Rutten L.J.
      Counseling patients on the use of electronic cigarettes.
      note, the effect of ENDS on pulmonary function and their impact on respiratory complications is uncertain. One study, however, found improvement in peripheral vascular tone with nicotine replacement therapy in the form of nicotine gum and patches, as measured by an improvement in the augmentation index and stability of the pulse wave velocity.
      • Roux A.
      • Motreff P.
      • Perriot J.
      • et al.
      Early improvement in peripheral vascular tone following smoking cessation using nicotine replacement therapy: aortic wave reflection analysis.
      Several prospective, randomized trials have evaluated the positive effect of preoperative smoking cessation on reducing the incidence of postoperative complications overall and wound complications in particular.
      • Thomsen T.
      • Tønnesen H.
      • Møller A.M.
      Effect of preoperative smoking cessation interventions on postoperative complications and smoking cessation.
      • Møller A.M.
      • Villebro N.
      • Pedersen T.
      • Tønnesen H.
      Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial.
      In one study, however, a 2- to 3-week period of smoking cessation was inadequate for a substantial reduction in the frequency of postoperative complications such as wound complications, anastomotic leak, pneumonia, or need for ventilator support.
      • Sørensen L.T.
      • Jørgensen T.
      Short-term pre-operative smoking cessation intervention does not affect postoperative complications in colorectal surgery: a randomized clinical trial.
      This finding again highlights the concern that a preoperative visit with the anesthesiologist may be too late to produce any meaningful improvement in the smoker’s postoperative course.
      Ebbert et al
      • Ebbert J.O.
      • Agunwamba N.A.
      • Rutten L.J.
      Counseling patients on the use of electronic cigarettes.
      highlight different, yet important, issues regarding ENDS: regulatory and safety issues and the issue of the efficacy of nicotine replacement therapy as a method of smoking cessation. The recent statements by the World Health Organization

      Backgrounder on WHO report on regulation of e-cigarettes and similar products. World Health Organization website. http://www.who.int/nmh/events/2014/backgrounder-e-cigarettes/en/. Published August 26, 2014. Accessed November 9, 2014.

      and a recent article in The New York Times

      Richtel M. Dire warnings by big tobacco on e-smoking. New York Times website. http://www.nytimes.com/2014/09/29/business/dire-warnings-by-big-tobacco-on-e-smoking-.html. Published September 28, 2014. Accessed November 9, 2014.

      discuss the warnings that tobacco companies (whatever their real motive) have placed on these products in the absence of government mandates; these warnings may cause many physicians to not recommend such products for their patients as an aid for smoking cessation. It is, however, important to note that the World Health Organization’s opposition to ENDS has been criticized by a prestigious group of tobacco research and policy experts.

      World Health Organization needs to see e-cigarettes as part of the solution, not the problem, say leading specialists in nicotine science and public health. Nicotine Science and Policy website. http://nicotinepolicy.net/n-s-p/1753-who-needs-to-see-ecigs-as-part-of-a-solution. Accessed November 9, 2014.

      One must also realize that no therapy is entirely without risk, the US Food and Drug Administration’s black box warning on varenicline being a case in point.

      Brooks M. Keep Chantix black box warning, FDA panel says. Medscape website. www.medscape.com/viewarticle/833402. Published October 17, 2014. Accessed November 9, 2014.

      Another real concern is the marketing of ENDS and the vast array of liquid humectant flavors, which many rightly or wrongly feel specifically target the young and underage consumer.

      Barrington-Trimis JL, Samet JM, McConnell R. Flavorings in electronic cigarettes: an unrecognized respiratory health hazard [published online ahead of print November 10, 2014]? JAMA. http://dx.doi.org/10.1001/jama.2014.14830.

      This concern is expressed in an excerpt from a website that focuses on childhood smoking: “It’s not surprising that youth use of e-cigarettes has gone up at the same time that e-cigarettes are being promoted using many of the same tactics long used to market regular cigarettes to kids. These include celebrity endorsements, slick TV and magazine ads that portray e-cigarette use as glamorous and rugged, sponsorships of race cars and music festivals, and sweet flavors such as gummi bear and cotton candy.”

      Liss SM. New CDC study finds more non-smoking kids are using e-cigarettes, shows need for FDA to quickly finalize and strengthen regulations [press release]. Campaign for Tobacco-Free Kids website. http://www.tobaccofreekids.org/press_releases/post/2014_08_25_cdc. Published August 25, 2014. Accessed November 9, 2014.

      In addition, there have been increasing reports of accidental poisoning due to nicotine liquid used in ENDS.

      Poisoning cases related to e-cigarettes keep spiraling upward. Campaign for Tobacco-Free Kids website. http://www.tobaccofreekids.org/tobacco_unfiltered/post/2014_09_26_e-cig. Published September 26, 2014. Accessed November 9, 2014.

      Many have urged the introduction of child-resistant packaging for these products as well as many others.
      I treat a large cohort of patients with Crohn disease, and extensive research has revealed that cigarette smoking aggravates the severity of Crohn disease.
      • Mahid S.S.
      • Minor K.S.
      • Soto R.E.
      • Hornung C.A.
      • Galandiuk S.
      Smoking and inflammatory bowel disease: a meta-analysis.
      Despite this finding, in a prospective clinical trial, we were unsuccessful in getting patients to switch from smoking to a smokeless tobacco product. It is hard to overestimate the satisfaction patients derive from inhaling, puffing, and handling cigarettes. I was, however, very impressed recently when one of my patients with Crohn disease told me of her successful attempt to quit smoking using ENDS. She initially began using products with the highest nicotine liquid concentration and gradually weaned herself down until she was only using what was essentially propylene glycol. This is a real success story, and it is far from an isolated case.

      E-cigarette User Testimonials. Consumer Advocates for Smoke-free Alternatives Association website. http://casaa.org/E-cig_User_Testimonials.html. Accessed November 9, 2014.

      The comparative efficacy of other types of nicotine replacement therapy and varenicline in smoking cessation has already been discussed in this journal.
      • Brose L.S.
      • West R.
      • Stapleton J.A.
      Comparison of the effectiveness of varenicline and combination nicotine replacement therapy for smoking cessation in clinical practice.
      In that UK study, the agents were nearly equally effective, and overall, approximately 40% of patients were carbon monoxide–validated abstinent from smoking at 4 weeks. If ENDS or other recreational nicotine products can add to those numbers, their use may be justified. However, we must ensure that they are appropriately regulated as tobacco products and are not marketed to children.

      Acknowledgment

      I would like to acknowledge the helpful advice and suggestions of Brad K. Rodu, DDS, Professor in Medicine, Endowed Chair, Tobacco Harm Reduction Research, James Graham Brown Cancer Center, University of Louisville, Louisville, KY.

      Supplemental Online Material

      References

        • Holford T.R.
        • Meza R.
        • Warner K.E.
        • et al.
        Tobacco control and the reduction in smoking-related premature deaths in the United States, 1964-2012.
        JAMA. 2014; 311: 164-171
        • Ebbert J.O.
        • Agunwamba N.A.
        • Rutten L.J.
        Counseling patients on the use of electronic cigarettes.
        Mayo Clin Proc. 2015; 90: 128-134
        • Kadimpati S.
        • Nolan M.
        • Warner D.O.
        Attitudes, beliefs, and practices regarding electronic nicotine delivery systems in patients scheduled for elective surgery.
        Mayo Clin Proc. 2015; 90: 71-76
        • Warner D.O.
        Surgery as a teachable moment: lost opportunities to improve public health.
        Arch Surg. 2009; 144: 1106-1107
        • Shi Y.
        • Warner D.O.
        Brief preoperative smoking abstinence: is there a dilemma?.
        Anesth Analg. 2011; 113: 1348-1351
        • Myers K.
        • Hajek P.
        • Hinds C.
        • McRobbie H.
        Stopping smoking shortly before surgery and postoperative complications: a systematic review and meta-analysis.
        Arch Intern Med. 2011; 171: 983-989
        • Chow C.K.
        • Devereaux P.J.
        The optimal timing of smoking cessation before surgery: comment on “Smoking Cessation Shortly Before Surgery and Postoperative Complications.”.
        Arch Intern Med. 2011; 171: 989-990
        • Khullar D.
        • Schroeder S.A.
        • Maa J.
        Helping smokers quit around the time of surgery.
        JAMA. 2013; 309: 993-994
        • Makaryus A.N.
        • Friedman E.A.
        Patients’ understanding of their treatment plans and diagnosis at discharge.
        Mayo Clin Proc. 2005; 80: 991-994
        • Jensen J.A.
        • Goodson W.H.
        • Hopf H.W.
        • Hunt T.K.
        Cigarette smoking decreases tissue oxygen.
        Arch Surg. 1991; 126: 1131-1134
        • Bartsch R.H.
        • Weiss G.
        • Kästenbauer T.
        • et al.
        Crucial aspects of smoking in wound healing after breast reduction surgery.
        J Plast Reconstr Aesthet Surg. 2007; 60: 1045-1049
        • Misery L.
        Nicotine effects on skin: are they positive or negative?.
        Exp Dermatol. 2004; 13: 665-670
        • Roux A.
        • Motreff P.
        • Perriot J.
        • et al.
        Early improvement in peripheral vascular tone following smoking cessation using nicotine replacement therapy: aortic wave reflection analysis.
        Cardiology. 2010; 117: 37-43
        • Thomsen T.
        • Tønnesen H.
        • Møller A.M.
        Effect of preoperative smoking cessation interventions on postoperative complications and smoking cessation.
        Br J Surg. 2009; 96: 451-461
        • Møller A.M.
        • Villebro N.
        • Pedersen T.
        • Tønnesen H.
        Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial.
        Lancet. 2002; 359: 114-117
        • Sørensen L.T.
        • Jørgensen T.
        Short-term pre-operative smoking cessation intervention does not affect postoperative complications in colorectal surgery: a randomized clinical trial.
        Colorectal Dis. 2003; 5: 347-352
      1. Backgrounder on WHO report on regulation of e-cigarettes and similar products. World Health Organization website. http://www.who.int/nmh/events/2014/backgrounder-e-cigarettes/en/. Published August 26, 2014. Accessed November 9, 2014.

      2. Richtel M. Dire warnings by big tobacco on e-smoking. New York Times website. http://www.nytimes.com/2014/09/29/business/dire-warnings-by-big-tobacco-on-e-smoking-.html. Published September 28, 2014. Accessed November 9, 2014.

      3. World Health Organization needs to see e-cigarettes as part of the solution, not the problem, say leading specialists in nicotine science and public health. Nicotine Science and Policy website. http://nicotinepolicy.net/n-s-p/1753-who-needs-to-see-ecigs-as-part-of-a-solution. Accessed November 9, 2014.

      4. Brooks M. Keep Chantix black box warning, FDA panel says. Medscape website. www.medscape.com/viewarticle/833402. Published October 17, 2014. Accessed November 9, 2014.

      5. Barrington-Trimis JL, Samet JM, McConnell R. Flavorings in electronic cigarettes: an unrecognized respiratory health hazard [published online ahead of print November 10, 2014]? JAMA. http://dx.doi.org/10.1001/jama.2014.14830.

      6. Liss SM. New CDC study finds more non-smoking kids are using e-cigarettes, shows need for FDA to quickly finalize and strengthen regulations [press release]. Campaign for Tobacco-Free Kids website. http://www.tobaccofreekids.org/press_releases/post/2014_08_25_cdc. Published August 25, 2014. Accessed November 9, 2014.

      7. Poisoning cases related to e-cigarettes keep spiraling upward. Campaign for Tobacco-Free Kids website. http://www.tobaccofreekids.org/tobacco_unfiltered/post/2014_09_26_e-cig. Published September 26, 2014. Accessed November 9, 2014.

        • Mahid S.S.
        • Minor K.S.
        • Soto R.E.
        • Hornung C.A.
        • Galandiuk S.
        Smoking and inflammatory bowel disease: a meta-analysis.
        Mayo Clin Proc. 2006; 81 ([published correction appears in Mayo Clin Proc. 2007;82(7):890]): 1462-1471
      8. E-cigarette User Testimonials. Consumer Advocates for Smoke-free Alternatives Association website. http://casaa.org/E-cig_User_Testimonials.html. Accessed November 9, 2014.

        • Brose L.S.
        • West R.
        • Stapleton J.A.
        Comparison of the effectiveness of varenicline and combination nicotine replacement therapy for smoking cessation in clinical practice.
        Mayo Clin Proc. 2013; 88: 226-233

      Linked Article

      • Attitudes, Beliefs, and Practices Regarding Electronic Nicotine Delivery Systems in Patients Scheduled for Elective Surgery
        Mayo Clinic ProceedingsVol. 90Issue 1
        • Preview
          Smokers are at increased risk of postoperative complications. Electronic nicotine delivery systems (ENDS; or electronic cigarettes) could be a useful tool to reduce harm in the perioperative period. This pilot study examined the attitudes, beliefs, and practices of smokers scheduled for elective surgery regarding ENDS. This was a cross-sectional survey of current cigarette smokers who were evaluated in a preoperative clinic before elective surgery at Mayo Clinic. Measures included demographic characteristics, smoking history, 2 indices assessing the perception of how smoking affected health risks, ENDS use history, and 3 indices assessing interest in, perceived benefits of, and barriers to using ENDS in the perioperative period.
        • Full-Text
        • PDF
      • Counseling Patients on the Use of Electronic Cigarettes
        Mayo Clinic ProceedingsVol. 90Issue 1
        • Preview
          Electronic cigarettes (e-cigarettes) have substantially increased in popularity. Clear evidence about the safety of e-cigarettes is lacking, and laboratory experiments and case reports suggest these products may be associated with potential adverse health consequences. The effectiveness of e-cigarettes for smoking cessation is modest and appears to be comparable to the nicotine patch combined with minimal behavioral support. Although a role for e-cigarettes in the treatment of tobacco dependence may emerge in the future, the potential risk of e-cigarettes outweighs their known benefit as a recommended tobacco treatment strategy by clinicians.
        • Full-Text
        • PDF
        Open Access