Cardiology Patient Page

Electronic Cigarettes Rachel A. Grana, PhD, MPH; Pamela M. Ling, MD, MPH; Neal Benowitz, MD; Stanton Glantz, PhD

lectronic cigarettes (E-cigarettes) to deliver nicotine, the addictive drug significance, does not support the claim Eare devices that deliver nicotine in cigarettes, without the toxic chemi- the product is harmless.2 to a user by heating and converting to cals produced by burning tobacco There is poor correlation between an aerosol a liquid mixture typically cigarettes and without exposing oth- labeled and actual nicotine content, as composed of propylene glycol, vegeta- ers to secondhand smoke. Marketing well as varying levels of other chemi- ble glycerin, flavoring chemicals, and for e-cigarettes often describes them cals and toxicants in the e-liquid and nicotine1 (Figure). E-cigarette use dou- as emitting only “harmless water aerosol.1 Nonsmokers (persons who bled in just 1 year among both adults vapor.”1 This message is often coupled do not use tobacco cigarettes or e-ciga- and children, from 3.4% to 6.2% in with claims that one can “smoke” any- rettes) who are exposed to the exhaled, adults (2010–2011) and 3.3% to 6.8% time and anywhere, often with a list or secondhand, e-cigarette aerosol in youth (2011–2012), with high levels of places where tobacco smoking is have measurable levels of the nicotine of dual use with tobacco cigarettes.1 restricted, including restaurants, bars, metabolite cotinine in their blood.1 Although most youth using e-cigarettes offices, and airplanes. If someone switched completely are dual users, up to one third of ado- from tobacco cigarettes to only using lescents who tried an e-cigarette have What Is Known About e-cigarettes, he or she would inhale never smoked a conventional cigarette, E-Cigarettes? fewer toxic chemicals to get the same indicating that some youth are initiat- The claim that e-cigarettes emit only dose of nicotine. However, most e-cig- ing use of the addictive drug nicotine harmless water vapor is not true.1 arette users continue to smoke tobacco with e-cigarettes.1 Although e-cigarette aerosol delivers cigarettes (dual use). Because the E-cigarettes are aggressively adver- lower levels of many toxins than ciga- effects of smoking on the heart, blood, tised on television, on the radio, on the rette smoke, the aerosol still contains and blood vessels occur at very low lev- Internet, and in magazines, and e-cig- nicotine, ultrafine particles, other toxic els of smoking (and even secondhand arettes companies sponsor sporting chemicals, and carcinogens. Users smoke),3 e-cigarette users are unlikely events and music festivals.1 E-cigarette inhale a heated propylene glycol or to experience any benefit in terms of advertising is very similar to cigarette glycerin-based solution for which there reduced rates of cardiovascular dis- advertising from the 1950s and 1960s, are no long-term studies. A short-term ease. Even cancer risk, which depends and e-cigarette products come in kid- exposure study showed that 5 minutes to some extent on smoking intensity friendly flavors (including grape, of e-cigarette use resulted in a signifi- (cigarettes per day), depends in large chocolate, bubble gum, and gummy cant increase in airway flow resistance, part on duration (years of smoking).4,5 bear). E-cigarette advertising promises which, although of unknown clinical Thus, use of electronic cigarettes to cut

The information contained in this Circulation Cardiology Patient Page is not a substitute for medical advice, and the American Heart Association recommends consultation with your doctor or healthcare professional. From the Center for Tobacco Control Research and Education, Department of Medicine, Helen Diller Family Comprehensive Cancer Center Tobacco Control Program, University of California, San Francisco, San Francisco. Correspondence to Stanton Glantz, PhD, Professor of Medicine, Director, Center for Tobacco Control Research and Education, Co-Director, Helen Diller Family Comprehensive Cancer Center Tobacco Control Program, University of California San Francisco, 530 Parnassus, Ste 366, San Francisco, CA 94143-1390. E-mail [email protected] (Circulation. 2014;129:e490-e492.) © 2014 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.114.008545 e490 Grana et al E-Cigarettes e491

line), approved nicotine replacement therapies (eg, patch, gum, or inhaler), and oral nonnicotine medications such as Chantix (varenicline) or Zyban (bupropion),6 particularly if evidence- based treatments have not been used correctly in the past. If someone is already using e-ciga- rettes to quit smoking, support the quit attempt, and encourage him or her to quit all tobacco cigarette use, emphasiz- ing the lack of reduction in health risks from dual use. Inform him or her that e-cigarettes are not approved by the US Food and Drug Administration for smoking cessation. The limited research published to date has not proven that electronic cigarettes are effective smok- ing cessation aids. Inform patients that Figure. Electronic cigarettes (e-cigarettes) come in many forms and are often not called e-cigarettes by users. Other names include e-hookah, shisha pens, and vape pens e-cigarettes are unregulated and that (reproduced from Grana et al).1 users cannot be sure what they are exposed to. Given the lack of knowl- down on number of cigarettes smoked the relationship between e-cigarette use edge about long-term risks and potential per day is likely to have much smaller and quitting smoking. Because these harms, patients should also be urged to beneficial effects on overall survival studies did not measure whether people set a quit date for their e-cigarette use. than quitting smoking completely. were using e-cigarettes as a smoking cessation aid or other reasons for use Policy Recommendations What Is Known About such as to circumvent smoke-free laws, Smoke-free policies are a critical inter- E-Cigarettes and they did not directly test the efficacy of vention both to protect nonsmokers and Smoking Cessation? e-cigarettes as smoking cessation aids. to support smoking cessation attempts. E-cigarettes have not been approved These 5 studies taken together, how- To avoid reversing the effectiveness in the United States as cessation aids, ever, showed that smokers who used of these policies, e-cigarettes should and as of March 2014, none of the e-cigarettes were less likely to quit not be used anyplace where smoking e-cigarette companies had submitted smoking than smokers who did not use cigarettes is not allowed (including in 1 applications to the US Food and Drug e-cigarettes. homes that are smoke-free). There is no Administration to approve them as ces- reason to reintroduce toxins into clean sation aids. indoor air environments. As of March Nevertheless, many companies What Can Clinicians 2014, more than 100 communities directly or indirectly market the prod- Do When Patients Want (including New York, Los Angeles, San ucts as helpful for smoking cessation. to Use E-Cigarettes Francisco, and Chicago) and 3 states Many news stories report testimonials to Quit Smoking? (New Jersey, North Dakota, and Utah) from people who say that e-cigarettes A patient who asks a clinician about included e-cigarettes in their clean helped them quit smoking. using the e-cigarette for quitting smok- indoor air laws.1 Studies with convenience samples ing may be signaling readiness to quit As of March 2014, e-cigarettes were of e-cigarette users show that people smoking. It is most important to sup- not regulated by the US Food and Drug use e-cigarettes to try to quit smoking port the patient’s quit attempt and to Administration. The product should be cigarettes.1 In a randomized trial com- try to ensure that any advice given does regulated by the US Food and Drug paring the effects of the use of nicotine not undermine the patient’s motivation Administration, and therapeutic claims e-cigarette, nonnicotine e-cigarette, to quit smoking. Use the opportunity (eg, that they are effective for smok- and a nicotine patch, neither nicotine- to learn about the patient’s motivation ing cessation) should be prohibited containing or nonnicotine e-cigarettes to quit, to discuss past experience with until such time that the e-cigarette outperformed the patch, although the cessation, and to encourage and facili- companies provide evidence that, as users reported liking e-cigarettes bet- tate evidence-based treatment such as actually used, e-cigarettes improve ces- ter than the patch. As of March 2014, 5 smoking cessation counseling (includ- sation success. To prevent youth initia- population-based studies had examined ing use of a tobacco telephone quit tion, e-cigarette advertising should be e492 Circulation May 13, 2014

subject to the same restrictions (includ- Disease Research Program, the National 2. Vardavas CI, Anagnostopoulos N, Kougias M, ing being prohibited on television and Institutes of Health, or the US Food and Drug Evangelopoulou V, Connolly GN, Behrakis PK. Short-term pulmonary effects of using radio) as cigarette advertising, and the Administration. Dr Glantz is an American Legacy Foundation Distinguished Professor an electronic cigarette: impact on respira- use of flavors should be prohibited. in Tobacco Control. tory flow resistance, impedance, and exhaled nitric oxide. Chest. 2012;141:1400–1406. 3. Barnoya J, Glantz SA. Cardiovascular effects Sources of Funding Disclosures of secondhand smoke: nearly as large as Dr Grana is supported in part by grant 21FT- Dr Benowitz is a consultant to several phar- smoking. Circulation. 2005;111:2684–2698. 0040 from the California Tobacco-Related maceutical companies that market smok- 4. Tverdal A, Bjartveit K. Health consequences of reduced daily cigarette consumption. Tob Disease Research Program. Dr Ling is sup- ing cessation medications and has been Control. 2006;15:472–480. ported in part by grant CA141661 from the a paid expert witness in litigation against National Cancer Institute. Drs Benowitz 5. Thun MJ, Carter BD, Feskanich D, the tobacco companies. The other authors Freedman ND, Prentice R, Lopez AD, Hartge and Glantz are supported in part by grant report no conflicts. P, Gapstur SM. 50-Year trends in smoking- 1P50CA180890 from the US National related mortality in the United States. N Engl Cancer Institute and Food and Drug J Med. 2013;368:351–364. Administration. The content of this work is References 6. Fiore M. Treating Tobacco Use and solely the responsibility of the authors and 1. Grana R, Benowitz N, Glantz SA. Dependence: 2008 Update: Clinical Practice does not necessarily represent the official E-cigarettes: a scientific review. Circulation. Guideline. Darby, PA: DIANE Publishing; views of the California Tobacco-Related 2014;129:1972–1986. 2008.