Electronic cigarettes – The alternative we’ve been looking for?

This article was exclusively written for The European Sting by Mr. David Andre de Carvalho Fernandes Gil, a 2^nd year student of medicine (Nova Medical School) in Lisbon, Portugal. He is affiliated to the International Federation of Medical Students Associations (IFMSA), cordial partner of The Sting. The opinions expressed in this piece belong to the writer and do not necessarily reflect IFMSA’s view on the topic, nor The European Sting’s one.

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According to the World Health Organization, tobacco is responsible for the death of 7 million people each year ^[1]. Although the addictive substance of tobacco is nicotine, it plays a minor role in smoking-related diseases ^[2]. As such, electronic nicotine delivery systems (ENDS) have been developed, of which electronic cigarettes (e-cigarettes) are the most common ^[3]. These products, also known as “vapes”, were first invented in 2003, by the Chinese pharmacist Hon Lik, quickly becoming a worldwide phenomenon. E-cigarettes were first sold in 2004, and in 2007 were introduced to the European and American markets. The quick dissemination of these products was caused by the labelling of e-cigarettes as a healthier and cheaper alternative to smoking, also working as a cessation aid ^[4]. These products have three basic components: a battery which provides energy to the electrical heater, which in turn produces aerosolized vapours from a liquid (e-liquid), inhaled by the user. The main components of the e-liquid are nicotine, flavouring agents and propylene glycol ^[3]. This last substance is linked with the alteration of “clock genes” ^[5], leading to unknown long term consequences. Nicotine is highly addictive, due to the stimulation of pleasure and reward pathways in the brain ^[2]. Thus, it induces pleasure, controls mood, and reduces stress and anxiety ^[2]. Moreover, it has diverse effects on the cardiovascular system, culminating in the increase of blood pressure ^{6], formation of atherosclerotic plaques, and modifications of the architecture of the heart ^[6], all possible factors that conduct to heart failure. In clear contrast to the conventional cigarettes, ENDS release aerosols, when the user exhales, making the “second hand” effects of e-cigarettes a possibility ^[7]. Furthermore, the surfaces that were exposed to ENDS vapours retain some nicotine, becoming a “third hand” source ^[8]. Up until 2014, there was no regulation regarding e-cigarettes. On February 26, 2014, the European Commission Directive published a statement about the safety and use of e-cigarettes ^[9]. Regarding the statements that e-cigarettes could be used as a smoking cessation aid, the conclusions are twofold: On the one hand, survey studies observe an increase of smoking cessation with the increase of e-cigarette use ^[10]. On the other hand, recent meta-analysis conclude that e-cigarette use is associated with reduced smoking cessation ^[11]. The scarier picture in this panorama is that ENDS might serve as an introduction to smoking to adolescents ^[12]. Even though youth smoking is declining in the same time period as the expansion of e-cigarettes, as it has been for the past decades, the correlation cannot be made with certainty. Furthermore, there was no clear sign of accelerated decrease of youth smoking since the introduction of the e-cigarette. In conclusion, e-cigarettes present themselves as a less harmful method of nicotine delivery than regular smoking. Although the consequences of long term use are unknown, e-cigarette use reduces the exposure to tobacco carcinogens and tar, which is beneficial. The most worrying topic about e-cigarettes might be their role as an introduction to smoking, considering adolescent use. References

1. The WHO tobacco free initiative, Geneva, Switzerland. Cited April 25, 2019. https://www.who.int/en/news-room/fact-sheets/detail/tobacco
2. Benowitz, N.L. 2010. Nicotine addiction. N. Engl. J. Med. 362: 2295–2303.
3. The WHO tobacco free initiative, Geneva, Switzerland. Cited April 25, 2019. https://www.who.int/tobacco/communications/statements/eletronic-cigarettes-january-2017/en/
4. Zhu, S.H. et al. 2014. Four hundred and sixty brands of e-cigarettes and counting: implications for product regulation. Tob. Control 23: 3–9.
5. Lechasseur A, Jubinville É, Routhier J, et al. Exposure to electronic cigarette vapors affects pulmonary and systemic expression of circadian molecular clock genes. Physiol Rep. 2017;5(19):e13440. doi:10.14814/phy2.13440
6. Benowitz NL, Burbank AD. Cardiovascular toxicity of nicotine: Implications for electronic cigarette use. Trends Cardiovasc Med. 2016;26(6):515–523. doi:10.1016/j.tcm.2016.03.001
7. Czogala J, Goniewicz ML, Fidelus B, Zielinska-Danch W, Travers MJ, Sobczak A. Second hand Exposure to Vapours from Electronic Cigarettes. Nicotine & Tobacco Research. Jun 2014;16(6):655-662.
8. Goniewicz ML, Lee L. Electronic Cigarettes Are a Source of Thirdhand Exposure to Nicotine. Nicotine Tob Res. Aug 30 2014.
9. European Parliment. Manufacture, presentation and sale of tobacco and related products. [2014 Feb 26; accessed 2019 April 26]. Available from: http://www.europarl.europa.eu/sides/getDoc.do?pubRef=-//EP//TEXT1TA1P7-TA-2014-0160101DOC1XML1V0//EN
10. Zhu SH, Zhuang YL, Wong S, Cummins SE, Tedeschi GJ. E-cigarette use and associated changes in population smoking cessation: evidence from US current population surveys. BMJ. 2017;358:j3262. Published 2017 Jul 26. doi:10.1136/bmj.j3262
11. Kalkhoran S, Glantz SA. E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis. Lancet Respir Med. 2016;4(2):116–128. doi:10.1016/S2213-2600(15)00521-4
12. Soneji S, Barrington-Trimis JL, Wills TA, et al. Association Between Initial Use of e-Cigarettes and Subsequent Cigarette Smoking Among Adolescents and Young Adults: A Systematic Review and Meta-analysis. JAMA Pediatr. 2017;171(8):788–797. doi:10.1001/jamapediatrics.2017.1488

About the author David Andre de Carvalho Fernandes Gil is a 2^nd year student of medicine (Nova Medical School) in Lisbon, Portugal. He is 20 years old, and is working on their college’s journal FRONTAL, as event manager. Besides college, he has been a scout since he was 8 years old, mostly doing camping and hiking activities, but working besides at their local voluntary groups as well. He also plays the guitar, due to his love for music. Furthermore, he enjoys reading and writing, with some poems published in his high school’s journal, and in the middle of writing his first novel.