Commentary on Wagener et al. (2012): Electronic cigarettes – the Holy Grail of nicotine replacement?


Electronic cigarettes are an interesting innovation, a new way to administer vapourized substances to the bronchia, lung and bloodstream. This opens new perspectives for smoking cessation and other fields (e.g. pulmonary medicine). Electronic cigarettes are increasingly popular: Google searches for this term have increased by 5000% over the past 2 years [1], 18% of US smokers have ever used them and 6% have used them in the past 30 days [2]. E-cigarettes are probably more satisfactory than nicotine medications: they have tobacco flavours, visible inhaled and exhaled vapour, they resemble a cigarette and can deliver high amounts of nicotine [3,4]. Even e-cigarettes that do not contain nicotine decrease craving and tobacco withdrawal symptoms, and are perceived as helpful to quitting smoking [5]. Using e-cigarettes costs about 1$ a day, which is five to seven times cheaper than smoking a pack a day for the same number of puffs, or than using nicotine medications at the recommended dosage [5].

Older models were often of mediocre quality, but these products evolve rapidly and newer models are much more effective: compare the e-cigarette industry with the pharmaceutical industry, which has not marketed any new nicotine medication for a decade. The nicotine inhaler is the same today as it was 2 decades ago, when it was first launched; it is unattractive and requires a hard draw and many puffs to obtain nicotine [6]. In contrast, the e-cigarette industry is much more innovative and reactive, it regularly launches new products and is able to segment the market (e.g. brands for women). Additional technological innovations are needed, in particular to vapourize nicotine directly, without propylene glycol or glycerol. The e-cigarette industry would almost certainly be less innovative if it was regulated, but regulation is nevertheless needed to ensure that these products are safe and effective [7].

Even though e-cigarettes were invented almost a decade ago (in 1993), relatively few research reports have been published [7]. Researchers have lacked curiosity. Research is needed urgently in vitro, in animal models, in clinical and in public health settings to document the safety, toxicity, efficacy and public health impact of these products [7]. Randomized trials are under way and will soon show whether e-cigarettes help smokers to quit; but who will fund this research effort? E-cigarettes are manufactured and distributed by relatively small companies, not by Big Pharma or Big Tobacco. These companies have little interest in publishing research; they even probably fear that studies may document adverse effects. Thus, there is a need for independent research supported by governments or foundations. However, we cannot wait until the results are known, as this may take years. Thus, for some time it may not be possible to base regulations, clinical advice and recommendations on a sound body of science.

Regulation agencies should balance the positive and negative aspects of any regulation, and keep in mind that the priority is to help smokers to quit. Prohibition would be incompatible with legal quality control. These products are sold mainly over the internet, and it is almost impossible to stop internet sales: if a shipment were blocked the legal risk to users would be minimal, and the sales volume is too high for customs officials to check more than a fraction of shipments. Nevertheless, there is a need for reasonable regulation, starting with standards of good manufacturing practice.

Even if manufacturing standards were enforced, users would continue to modify the products (‘mods’), adding larger batteries to produce more vapour, or adding substances of their choice to refill liquids [8]. Users should be informed that these ‘mods’ may convey some risk. Smokers often ask clinicians and smoking cessation counsellors about information on e-cigarettes, and clinicians should be trained to answer these questions adequately. Clinicians should inform users about the scarcity of relevant data on safety and efficacy, but they should also tell users that the risks are lower than for smoking. If users say that e-cigarettes help them to quit smoking, counsellors should focus on smoking cessation rather than on e-cigarette cessation [9]. Advising smokers to stop using e-cigarettes might be deleterious in many situations, in particular in people who failed to quit with other treatments. Hopefully, the timely paper by Wagener et al. will stimulate research and debate [10].

Declarations of interest