by Ruth Beran
Researcher and public health doctor Associate Professor Chris Bullen from the University of Auckland, is supportive of electronic cigarettes (e-cigarettes). “If people are going to continue to use them for the nicotine and to prevent them relapsing back to smoking tobacco…that’s got to be a good thing,” he says.
The term e-cigarette is used to describe one of a vast range of devices that vaporise a solution of propylene glycol, vegetable oil and sometimes nicotine. “The official term that’s used increasingly [is] electronic nicotine delivery systems or ENDS,” says Bullen. With the spread of new products coming on the market people that do not necessarily use batteries or an integrated circuit, the terms being used is ANDS or alternative nicotine delivery systems. “Essentially what they are is something that looks vaguely like a cigarette that most of the time delivers nicotine in a vapour or aerosol form to people to inhale,” says Bullen.
E-cigarettes do not combust tobacco or produce smoke. “It only produces vapour when the user sucks on it and the vapour comes out of their mouth and then it vanishes almost instantaneously,” says Bullen. In this way, e-cigarettes provide a form of behavioural replacement, as they look like cigarettes.
“It really does remarkably replicate much of the behavioural characteristics of smoking a cigarette but without all the harms of combusted tobacco leaf and the 3 -4,000 other chemicals in that toxic cocktail which we know is one of the most dangerous products on the planet,” says Bullen.
E-cigarettes do not have 20-30 years of follow up studies for lung cancer or heart disease like tobacco cigarettes. However, Bullen believes that there is “almost certainly no doubt that these things are safer to individuals who use them than using a cigarette”.
Most people using these products are doing so to try and quit smoking or to cut down the number of cigarettes they smoke. “The evidence suggests about 6 or 7 out of 10 people who use them use them to cut down the number of cigarettes for their health or saving money because they usually work out to be cheaper than buying tobacco,” says Bullen. “About 3 or 4 out of 10 will use them to try and actually quit. Whether they succeed or not is another story.”
For example, a cigarette smoker who has tried e-cigarettes says: “Of all the options that I’ve tried (and I’ve tried patches, I’ve tried the nicotine inhalers) it’s easily …the most effective in terms of curbing your cravings and all of that sort of stuff.”
There are some considerations about the use of e-cigarettes though that also need to be looked at. For example, young people may take up smoking if exposed to e-cigarettes. “I think young people like to experiment with risky things,” says Bullen. “However the data that we’ve looked at from all around the world in a range of countries suggests that the numbers of children or adolescents who don’t smoke, who experiment with e-cigarettes and then go onto use them, is actually very, very small. It’s less than 1%.”
Bullen and his team conducted a randomised controlled trial called the ASCEND study looking at the effectiveness of e-cigarettes as a tool to quit smoking. The study was completed in mid 2013 and took 3 years to get underway and recruit about 660 participants from Auckland. The participants were all people who wanted to quit smoking who were heavy dependent smokers, each smoking on average about 20 cigarettes a day. People were randomised into three groups, one group received an e-cigarette with nicotine, another group received an identical e-cigarette that didn’t deliver nicotine, ie it was a placebo, and the third group received nicotine patches, the gold standard for people who want to quit smoking.
The study replicated the real world of obtaining these products. “So the people who were randomised to the patches received a QUIT voucher which they had to take to a community pharmacy to get their patch,” says Bullen. Both e-cigarettes groups "had the products couriered to them with some instructions, just as if they were ordering them over the internet.” In New Zealand, buying e-cigarettes with nicotine can only be done on the internet. “Both groups were able to contact QUIT line for some behavioural support counselling if they wanted to do it. And about 40% of those in each arm did,” says Bullen.
The groups were followed up for six months, after receiving the product for three months. After six months people who said they’d quit smoking came in to have a carbon monoxide breath test. Carbon monoxide is present when smoking tobacco cigarettes but not present when using e-cigarettes. Bullen and his team found that “the proportions of people who had actually quit verified by carbon monoxide testing in all three arms was practically the same.” So the results were modest, showing about 5 to 10% of people successfully quitting smoking after six months which is a similar figure to someone using patches from the supermarket, and receiving no counselling.
According to Bullen, the immediate success rate from the study was quite dramatic for e-cigarettes, but then it tailed off and eventually all three arms of the study were similar. The success rate for the placebo e-cigarette was about 5% compared with about 8% with the nicotine e-cigarette group, but this figure was not statistically significant.
There was no difference in adverse health events between the two groups after six months.
“There was no evidence of any, at least medium term, adverse events,” says Bullen. “So I’m pretty confident they are certainly a safer product than smoking tobacco.”
A one-day symposium entitled “E-cigarettes: Opportunity or threat?” will be hosted by the University of Auckland’s Centre of Addiction Research and held at the University’s Business School at the City Campus on 12 March 2015. It is expected to be the first New Zealand gathering for stakeholders interested in e-cigarettes.