Electronic cigarettes (ECs) are battery-powered vaporizing devices that heat liquid containing nicotine and other ingredients into an aerosol for inhalation. Since the introduction of ECs in the mid-2000s, there has been a steady increase in their use among cigarette smokers intending to quit. However, there is ongoing debate concerning the use of ECs in smoking cessation. Until sufficient long-term evidence shows that ECs are a safe and effective smoking cessation aid, health care providers should not support their use.
Studies suggest that ECs are as effective as nicotine replacement therapies, specifically nicotine patches, but the evidence remains limited and weak. A 2014 Cochrane review by McRobbie and colleagues included only two randomized controlled trials (RCTs) and 11 cohort studies. Although the RCT by Bullen and colleagues (2013) found that smokers using ECs had similar rates of smoking abstinence at six months as those using nicotine patches, these rates were not significantly better than those in the control group, who used ECs without nicotine; and the rates of smoking cessation were generally low in all groups, ranging from 4% to 7%. The second RCT, by Caponnetto and colleagues (2013), found that smokers not intending to quit who used ECs with or without nicotine decreased their cigarette consumption by statistically significant margins at 12 and 52 weeks. This suggests that the sensory and behavioral aspects of using a device similar to a traditional cigarette may be effective in smoking cessation, with or without nicotine replacement.
To date, the Food and Drug Administration (FDA) has not approved the use of ECs as a smoking cessation aid because of the lack of evidence.
The long-term health effects of ECs also remain unknown. ECs have only been on the market for about a decade, hence there is no long-term research available on adverse events and risks associated with their use. There is also conflicting evidence on ECs' immediate health effects. One study showed bronchial inflammation and increases in lung flow resistance after five minutes of EC use. But other studies have found little to no evidence of severe adverse events. To complicate matters, studies do not use the same types of ECs, which may reduce the generalizability of the literature. There are an abundance of ECs on the market that differ by nicotine concentrations, flavors, additives, battery wattages, and design.
Proponents of ECs argue that they are a less harmful alternative to conventional cigarettes. This position is grounded in the concept of harm reduction; EC users avoid several known deleterious health effects associated with tobacco cigarettes. Studies have found a substantial decrease in the most frequently reported adverse events-cough, dry mouth, shortness of breath, throat irritation, and headache-when users switch from cigarettes to ECs.
Supporters of ECs have also argued that they are a more effective smoking cessation tool than other options because they simulate the act of smoking. Much of this research comes from qualitative studies based on surveys and individual experiences. More robust research on the sensory and behavioral aspects of the EC experience compared with currently available smoking cessation aids is needed.
Until long-term studies are conducted, health care providers can suggest the use of several FDA-approved smoking cessation aids. A review of the literature by Patnode and colleagues (2015) found that combined behavioral (provider advice, counseling) and pharmacotherapy interventions increased smoking cessation by 82% compared with minimal interventions. Behavioral and pharmacologic interventions alone were also found to be effective.
The role of health care providers is to provide evidence-based information to patients to help them make informed decisions about their health practices. Currently, there is not enough robust research to support recommending the use of ECs.