Electronic Cigarettes: Common Questions and Answers

 

Electronic cigarettes (e-cigarettes) are popular devices designed to heat a liquid solution, often containing nicotine, that generates an inhaled aerosol, or vapor. e-Cigarettes have been marketed as healthier alternatives to traditional cigarettes. Thus, most adult users are current or former smokers who use e-cigarettes to reduce or quit cigarette smoking. Switching completely from cigarettes to e-cigarettes is associated with reduced toxicant exposure and reduced short-term respiratory symptoms; however, long-term health effects of e-cigarettes are unknown. Although a recent randomized trial suggests that e-cigarettes may promote smoking cessation, systematic reviews have had low certainty of evidence regarding cessation. e-Cigarettes pose several potential health risks, including exposure to heavy metals and toxicants, and nicotine poisoning. e-Cigarettes are also popular among youth, with rates of e-cigarette use surpassing those of cigarette use in this population. Youth e-cigarette use is associated with increased risk of subsequent cigarette and marijuana use. Screening for e-cigarette use in youth and adults, including pregnant women, in conjunction with screening for tobacco use, is advised. Education and interventions to prevent e-cigarette use should be provided to all youth. Youth should be counseled to stop using nicotine/tobacco products, including e-cigarettes. Although the impact of e-cigarette use in pregnancy is unknown, nicotine is a teratogen; thus, pregnant women should be counseled to abstain from using all nicotine/tobacco products.

What Is an e-Cigarette?

Electronic cigarettes (e-cigarettes) are battery-operated devices that heat a liquid solution to generate an aerosol that users inhale. The liquid solution in most e-cigarettes contains nicotine, the primary addictive agent in traditional cigarettes, and is available in a variety of flavors. Because e-cigarette aerosol is commonly called vapor, patients may refer to e-cigarette use as vaping. Currently, the most popular e-cigarette brand is Juul, which uses small, rectangular flavored cartridges that resemble a thumb drive. Most adults report using e-cigarettes to reduce or stop cigarette smoking.

WHAT IS NEW ON THIS TOPIC

Among U.S. youth, rates of e-cigarette use surpassed rates of traditional cigarette use in 2014. In 2017, one in five U.S. high school students reported using e-cigarettes in the previous year.

A recent meta-analysis indicated that among teens and young adults who have never smoked, the odds of smoking initiation are three to six times greater in those who have ever used e-cigarettes than in those who have never used e-cigarettes.

The U.S. Preventive Services Task Force concludes that the current evidence is insufficient to recommend e-cigarettes for tobacco cessation in adults, including pregnant women.


e-cigarette = electronic cigarette.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Ask about e-cigarettes when screening for tobacco use in youth and adults, including pregnant women. Multiple terms should be used, including slang terms and brand names (especially Juul), to help identify all e-cigarette users.8,40,41

C

Computerized school-based surveys conducted at two high schools (n = 1,960)

e-Cigarettes, e-cigarette liquids, and all products containing nicotine should be kept out of reach of children. Adults should be counseled on safe storage practices and symptoms of nicotine poisoning.24,25

C

Case-series studies (review of 8,269 exposures registered in the National Poison Data System between January 2012 and April 2017); review of 26 case reports

Women should be counseled and assisted with quitting all nicotine/tobacco products, including e-cigarettes, during pregnancy.29

C

Narrative review of 326 human and animal studies

e-Cigarettes are not recommended for youth. Youth should be counseled to stop all nicotine/tobacco products, including e-cigarettes.4,30

C

Consensus guidelines (surgeon general's report and policy statement of the American Academy of Pediatrics)

Smokers should be counseled to quit using evidence-based smoking cessation guidelines, including behavioral counseling and/or U.S. Food and Drug Administration–approved smoking cessation products.12,37,39,40

A

Two systematic reviews/meta-analyses with a small number of studies and low certainty of evidence; one recent positive randomized controlled trial

If evidence-based smoking cessation methods are ineffective or the patient does not comply with them, e-cigarettes may be discussed for smoking cessation

The Authors

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MICHAEL D. KLEIN, MD, FAAFP, is a clinical assistant professor in the Department of Family Medicine at the Warren Alpert Medical School of Brown University, Providence, R.I., and a physician shareholder at Compass Medical, Easton, Mass....

NATASHA A. SOKOL, ScD, is a postdoctoral fellow at the Center for Alcohol and Addiction Studies at the Brown University School of Public Health, Providence, R.I.

LAURA R. STROUD, PhD, is a professor in the Department of Psychiatry and Human Behavior at the Warren Alpert Medical School of Brown University and is a senior research scientist at the Centers for Behavioral and Preventive Medicine at The Miriam Hospital, Providence, R.I.

Address correspondence to Michael D. Klein, MD, FAAFP, Dept. of Family Medicine, 111 Brewster St., Pawtucket, RI 02860 (email: Michael_D_Klein@brown.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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