Electronic cigarettes: A useful tool to accompany tobacco withdrawal?

Electronic cigarettes (e-cigarettes) have been introduced for profit by the tobacco industry and are not a medical device. The use of e-cigarettes has gained significant popularity over the last 10-15 years and is marketed as a safe alternative to traditional tobacco smoking. In many countries, e-cigarettes do not undergo the same regulation and legislation as conventional use of tobacco, and promotion via internet and media is extensive. The prevalence of e-cigarette usage varies between countries, but an increasing number of children, adolescents and adults are using e-cigarettes.

In the current brief review from Italy by Zoccai and co-authors (1), the authors discuss the challenges chronic smokers with cardiovascular conditions face when it comes to smoking cessation. Personalised treatment of smoking patients including psychological and medical support with nicotine replacement therapy and varenicline is recommended. In addition, the authors suggest a pragmati-harm reduction strategy, meaning that the e-cigarette could become a useful tool to accompany the smoking patients on their tobacco withdrawal path. The authors underline that they in no way want to stimulate use of e-cigarettes among non-smokers. It is stated by the authors that it is difficult to establish the real health risks of e-cigarettes, especially on long term. The short-term harmful effects are seen in the central, peripheral, gastrointestinal, endocrine nervous system and e-cigarettes are also considered an indirect carcinogen. Negative vascular, oxidative and platelet effects are also found in users of e-cigarettes, although less pronounced than in traditional tobacco smokers. The reduced risk of e-cigarettes compared to tobacco is the rationale why the authors are hoping to see favorable results with the cautious use of e-cigarettes in the fight against cigarette smoking for chronic smokers followed up by clinicians.

Personal comment

A recent systematic review including 38 experimental studies, showed that most studies suggested potential for cardiovascular harm from e-cigarette use, through mechanisms that increase risk of thrombosis and atherosclerosis (2). Another important finding was that studies with conflict of interest among the authors were significantly less likely to show negative cardiovascular effects from use of e-cigarettes. World Health Organization (WHO) has recently stated that e-cigarettes are undoubtedly harmful to health (3), although the long-term effects are yet unknown. One reason is that e-cigarettes are often used along with other tobacco products, thus combining the negative health effects. Additionally, the evidence is clear about the toxic chemicals including nicotine and carcinogens, as well as the increasing risk of cardiovascular diseases and lung disorders and adverse effects on the development of the fetus during pregnancy. WHO concludes that e-cigarettes should be strictly regulated, kept away from children and the safest is not to consume it at all. Finally, WHO is concerned about the growing body of evidence that never-smoking young individuals who use e-cigarettes at least double their risk of starting to smoke traditional tobacco later.

The EAPC Population Science and Public Health Section has recently published a position paper on e-cigarettes and health with special focus on cardiovascular effects (4). Their main recommendation is that health professionals should be cautious in recommending use of e-cigarettes to their smoking patients and the general public because of the mounting evidence suggesting that e-cigarettes are harmful to health, including to the heart. Other reasons are that smokers might end up using e-cigarettes as a supplement to smoking without cutting back their tobacco consumption. There is lack of robust evidence that e-cigarettes are effective as smoking cessation tool and e-cigarettes seem to be used instead of evidence-based smoking cessation products and smoking cessation clinics. If recommended, e-cigarettes should only be considered to aid tobacco cessation alongside a formal tobacco cessation program and for a very limited time that includes close follow-up of the smoker.

Zoccai and co-authors are a bit pessimistic about the continuous smoking epidemic globally and suggest e-cigarettes as one of the solutions for our patients (1). Another and more evidence-based tool is the advice given in the WHO Framework Convention on Tobacco Control, which was developed in response to the globalisation of the tobacco epidemic (4). In many countries that have followed the advice, smoking has now reached an all-time low prevalence. There is reason to be optimistic.

Note: The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology