Monday, June 1, 2009

More on Electronic Cigarettes or E-cigs

I continue to receive multiple comments on my original post Electronic Cigarettes and appreciate them all. There is an avid group of e-cig users that does not appreciate my opinion on this topic. Rather than respond to several recent comments on the original post, I thought it would be more effective to just generate a brand new post. Here are my responses to some general concerns/criticisms.

If electronic cigarettes are a safer alternative to tobacco cigarettes, why do you oppose them?
I think most people, even tobacco cigarette smokers, will agree that tobacco cigarettes are harmful in many ways. E-cigarettes may be safer than tobacco cigarettes. However, I have no way of knowing this. There is simply no published studies in the medical literature (and the few in existence are from the manufacturers). Yes, e-cigs don't have the carcinogens that tobacco cigarettes contain, and it is most likely that they pose no more dangers than those we already know to be attributed to nicotine. However, without regulation and research, I can not recommend these to patients. My opposition is more with the regulators than the electronic cigarettes. First, e-cigs are drugs by definition. Therefore, the fall within the jurisdiction of the FDA, who has turned a deaf ear to this issue. Many users buy these products online from China, and there have been several recent health related risks with products from China. In addition, many of the e-cigs sold in the US are sold in retail shopping malls. Since the FDA has chosen to ignore e-cigarettes, there is nothing really stopping vendors from selling these to minors. I strongly believe that the FDA should regulate these products as the drugs they are, which would include ensuring that they are safe. If patients choose to use e-cigarettes as tobacco cigarette alternatives, I would rather them purchase this from behind the counter of a CVS then from a questionable online site selling non-US made products.


There are plenty of nicotine replacement products out there. These are safe, so why do you think electronic cigarettes post a threat?
First, all nicotine replacement products (patch, gum, etc.) are regulated by the FDA and have been proven to be safe. E-cigarettes have not been proven safe. Secondly, nicotine has risks associated with it. These risks are clearly labeled on all nicotine replacement products. Every medicine we dispense has risks and benefits. With nicotine replacement products, the risk of short term nicotine use is outweighed by the benefits of stopping (hopefully permanently) tobacco cigarette smoke. No nicotine replacement product is intended for long term use. Caffeine also has side effects. Though I think it is OK for patients (without certain health conditions) to drink a cup or two a day, I would not recommend six or seven cups of coffee a day because of adverse effects. Thus, even if e-cigarettes are proven as safe as nicotine replacement products, I still would not recommend their regular use (though if studies were done, I would agree that this would be preferred to tobacco smoke).

I have tried everything to stop smoking. Electronic cigarettes were the only thing that worked for me. Why do you oppose e-cigs when current methods don't work and some, especially Chantix, might even be dangerous.
Current methods do work and about double your chance of successfully quitting. E-cigarettes may be effective smoking cessation devices, but they have not yet proven to be effective. Also, there is a difference between quitting tobacco cigarettes and quitting nicotine products. Nicotine replacement products like the patch are not intended for permanent use. E-cigarettes were designed to be tobacco cigarette replacement products, not smoking cessation aides. It is also possible that smokers will use e-cigarettes in place of SOME of their tobacco cigarettes. Although this does decrease exposure to known dangerous products, e-cigarettes might therefore actually prolong tobacco cigarette smoking.
Lastly, Chantix has gotten a bad rap. have posted several times about Chantix here, here, here, and here and most recently in the post Prescription Drugs: Risk vs. Benefit vs Cost- The Chantix Example . Chantix is the most effective smoking cessation agent available. Though post-marketing safety data suggest that Chantix may be associated with depressed mood, agitation, and suicidal behaviour or ideation; these also occur with smoking cessation alone. Thus, it is unclear if some these reports are due to taking Chantix or stopping smoking. Since there was at least one report of these side effects with a patient who was taking Chantix, but still smoking, the FDA appropriately decided to add this to the warnings section on Chantix' label and is currently conducting an extensive safety review. Again, all medications have risks and benefits. Being the most effective agent, these potential and rare risks are likely worth the benefit. E-cigarettes have not been tested so the risk is not known, and it is unclear whether they are effective in smoking and nicotine cessation.

17 comments:

Anonymous said...

Dr. Mintz -

"There is simply no published studies in the medical literature (and the few in existence are from the manufacturers)."

Who provided the studies for the current FDA approved NRT's? Were they not provided by the manufacturers of the products?

Anonymous said...

Dr. Mintz,

I understand your concern about offering them to patients. You seem to be a physican that does not promote harm reduction, but abstinence.

You state, "First, e-cigs are drugs by definition. Therefore, the fall within the jurisdiction of the FDA, who has turned a deaf ear to this issue...I strongly believe that the FDA should regulate these products as the drugs they are, which would include ensuring that they are safe."

Can you see how horribly wrong this is when the exact same thing could be said in your comments above by dropping the "e" from in front of cigarettes?

Cigarettes are drug delivery devices are they not? Should the FDA ensure they are safe before putting them on the market? I think you know the answer to that when the largest tobacco industry (Altria) is a co-writer of the tobacco bill before the senate. Naturally this "drug delivery device" won't be banned.

How can you, in good conscience, mean what you said above when Americans are confronted with cigarettes almost everywhere they go and the only alternative to the ones that want to smoke is quit or die? Why can't there be a tobacco product that delivers this "legal" drug without the extreme dangers of cigarettes?

I know you want the optimal outcome, but in reality, cigarettes are legal drug delivery devices and as long as they are don't you think a reduced harm delivery device would be greatly benefical?

There have been tests to show they are much less harmful than cigarettes. Yes, this is funded by the manufacturer, but most funding for new drugs are done by the manufacturer. http://www.healthnz.co.nz/ecigarette.htm

Please look into the studies that have been done.

Thank you for your time.

Vocal EK said...

I'm curious as to how you would construct a study that would be approved by an IRB. I doubt that they would allow you to require half the people to continue smoking tobacco cigarettes as a condition of participation. Double-blind is not going to work because it is easy to tell a tobacco cigarette from an e-cigarette. How about a longitudinal population study?

Actually, there is something akin to a self-directed one going on right now. Read the comments of participants here: http://www.thepetitionsite.com/1/keep-life-saving-electronic-cigarettes-available

Let's compare known harm: According to our government, over 400,000 Americans died during the past year of smoking related illness. Compare that to the number of deaths from e-cigarettes, world-wide: Zero.

Smokers don't have time to wait for the stypes of studies that get published in the medical journals. Every cigarette they light up and inhale could be the one that triggers their COPD or cancer. If you were within reach of someone about to step in front of a speeding car, would you hesitate to grab them and pull them out of the way? After all, it's possible they might be bruised or scratched.

Monte_Alto said...

I just wanted to provide a couple of links for you since you seem to be unaware of the risks involved in using Chantix. You really should take a read through the information.

You are a doctor after all and as a result of your views on the product, you most likely support the use of this product and recommend it to your patients ...
http://www.ismp.org/docs/vareniclineStudy.asp

This one is a great link ... you can take a look at all the other references to the serious health concerns ... as voiced by the FDA
http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm106540.htm

Feel free to stop by my website if you like ... there's quite a bit more information to read through.

http://smoke-vs-vapor.webs.com/

Anonymous said...

If we will going to compare the e-cig to old nasty cig. Accdg to its source you will state that it is safer than the old one. humans are smart. No doubt about it.


electronic cigarette review

electroniccigarettes said...

Dr. Mintz,

Your post was well thought out and addressed several of my concerns about electronic cigarettes.

You're right there is no proof regarding the safety of E Cigs.

But there is no evidence that they are unsafe.

To take an alarmist position would be premature at this point.

However, I believe that your post isn't alarmist just very conservative.

I did poke a little fun at you on my electronic cigarettes blog. Hope you don't mind!

Cheers,

Steve McCleen

ragz said...

Here is a simple question: Would you rather a patient smoke or vape?
Remember e-cigarettes are marketed as a smoking alternative and limited to those of us who are over 18.
I smoked for 40 years and this is the first time I've been smoke free since a 3 month period in 1979.

There is more to smoking than nicotine addiction. There is the throat hit part that I didn't realize was so important until I started vaping, in fact it is almost as important than as the nicotine. Then there is the smoke or vapor part that is also important. The feeling of vapor being exhaled and actually it is visually stimulating as well. This might explain why the way over priced patches and gum are so ineffective.

And then there is Chantix. If you are willing to write a prescription for that then e-cigarettes shouldn't be a problem. That crap should be illegal.

What I don't think you understand is that if enough of you guys in the medical community keep raising the alarm that you think this might be dangerous (but really don't know except for the nicotine part) and a ban is imposed or it is priced out of reach for those of us that are uninsurable then I and many others like me will be back on cigarettes because we are simply incurable or don't really want to be cured.

BTW, my constant hacking cough of thirty years is gone.

Greensmoke Electric Cigarettes said...

Good article. The e-cigarette is a great alternative because it allows smokers to have the “experience” of smoking a cigarette, but with less nicotine, no tar, and none of the smell and icky butts left over. Some people are using them to quit smoking but even if someone has no intention on quitting, it's a much better alternative.

Joye eGo said...

Americans are confronted with cigarettes almost everywhere they go and the only alternative to the ones that want to smoke is quit or die? Why can't there be a tobacco product that delivers this "legal" drug without the extreme dangers of cigarettes?

Dr. Matthew Mintz said...

I am in favor of this product being legal, I just want it regulated. Most e-cigarettes are made overseas and their safety is questionable. Also, I don't want these products sold in shopping malls where kids can get them. Fine to sell them in CVS, just like other nicotine products. Finally, I don't want them promoted as smoking cessation aids, unless they are proven to get patients off all nicotine products. "Safer alternative" to tobacco cigarette smoke seems reasonable, but since they are unregulated, they are promoted in all sorts of ways.

Vocal EK said...

A year ago, Judge Richard J. Leon of the U.S. District Court for the District of Columbia granted an injunction against FDA. His opinion stated that as long as a vendor makes no health claims, FDA would need to regulate the products under the Family Smoking Prevention and Tobacco Control Act. FDA refused to do so and appealed the injunction. In December, the Appeals Court reinstated the injunction and advised FDA to regulate the products under the Tobacco Act. FDA has refused again and asked for a rehearing. So much for protection of public health on the part of the FDA, and so much for avoiding waste of taxpayer dollars.

ragz said...

It's not the e-cig that you have a problem with it's the 'juice'. An e-cig is nothing more than an atomizer and a battery.

As far the 'juice' goes, it's a nicotine solution plus PG and/or VG plus food flavorings and I haven't heard of anybody dying from the stuff. Can you say the same about Chantix? How many suicides? How many murders? To me the FDA is controlled by big money and has lost all credibility.

sxajhy said...

Electronic cigarettes can't help you quit smoking, they are safer and a lot cheaper. Plus they don't smell bad, they don't stain the teeth and are generally healthier than tobacco cigarettes.

Joye 510 said...

E-cigarettes may be effective smoking cessation devices, but they have not yet proven to be effective. Also, there is a difference between quitting tobacco cigarettes and quitting nicotine products.

Medical coding said...

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Dr. Matt said...

It's far more irresponsible for a health care professional to publicly argue against people using e-cigarettes than it is to encourage them to do so (or at least look the other way, not harm them by posting blogs that scare them).

There is simply NO WAY that e-cigarettes are more dangerous than smoking. Preliminary data says they work, and they're safe. That's enough to give people the go-ahead.

Proof is Michael Siegel's analysis from Boston University, and more here: http://wp.me/p1ZTqG-Mb

Anonymous said...

My mother has smoked for almost 40 years. She has COPD among other things. I spoke with a friend who's mother turned to e cigs about six months ago and hasn't had to use an inhaler or her other meds in almost a month. My mother got a x-ray of her lungs done a week ago and the only thing they saw was her metal clasps from her bra. I know she wants to quit, she's told me, and has tried many times. I got her an e cig and even got me one too. There are different strengths of the 'juice' and it falls on the person to be responsible enough to use it properly. I hope to quit as I have a lower dose when I vap and my mother also hopes to lower her dose. We both are aware of the risks between smoking and vaping. I don't want to see my mother slowly suffocate as she has been for years!