Editors' ChoiceSMOKING

Vaping—Vaccine or Virus?

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Science Translational Medicine  04 Jun 2014:
Vol. 6, Issue 239, pp. 239ec97
DOI: 10.1126/scitranslmed.3009415

Smoking electronic (e-) cigarettes, or vaping, was originally marketed as a healthier substitute to smoking. With sales exceeding $2 billion in 2013 and touted as producing “harmless water-vapor,” e-cigarettes are used by as many as 50% of smokers trying to quit. The vapor actually consists of nicotine in a nanoparticulate carrier, aerosolized and released along with low levels of other nontobacco toxins. In theory, e-cigarettes may reduce conventional cigarette use and exposure to tobacco smoke, but in practice, they can perpetuate nicotine cravings in some smokers while fostering new addictions in others. Indeed, most users smoke both conventional and e-cigarettes. More concerning are the never-before-smoking youth entrained by marketing campaigns and ensnared by addiction, as well as passive bystanders now being exposed to aerosolized particulates of unknown consequence. Rather than help smoking cessation, e-cigarettes can sometimes undermine antismoking efforts—a fact revealed by two recent systematic reviews.

Of 169 studies of e-cigarettes, Franck et al. deemed only seven suitable for inclusion in their analysis of clinical trials. Of these, sample sizes and study durations fluctuated widely; only two were double-blind, randomized controlled trials. E-cigarette users did show modest reductions in cigarette use, but all trials were confounded by significant biases, conflicts, or lack of adequate controls. Although more general and providing stern policy recommendations, a study by Grana et al. similarly found that only a fraction of studies (9 of 152) provided valid original data on the effects of e-cigarettes on smoking cessation. In contrast to the findings of prospective but confounded trials, observational analyses universally demonstrated reduced chance of smoking cessation among e-cigarette users [pooled odds 0.61 (0.50 to 0.75)], emphasizing our basic lack of understanding of this technology and its potential for harm.

How have e-cigarettes flourished despite the many translational hoops facing medical technologies? The answer lies in the fact that they are nonmedical, tobacco-free nicotine-delivery devices. Because they contain no tobacco, e-cigarettes have circumvented many of the marketing and usage bans imposed on conventional cigarettes, permitting their rapid adoption. Yet, because the delivered nicotine is derived from tobacco and therapeutic claims are not openly advertised, they are regulated as tobacco products rather than medical devices and are therefore shielded from demanding scientific and regulatory standards. Without high-quality objective evidence, patients, providers, and policy-makers must struggle to understand the merits of this device that has slipped through these unforeseen loopholes. It is a shame that a technology with the potential to be a true vaccine for smoking has found a way to spread like a virus.

C. Franck et al., Electronic cigarettes in North America: History, use, and implications for smoking cessation. Circulation 129, 1945–1952 (2014). [Abstract]

R. Grana et al., E-cigarettes: A scientific review. Circulation 129, 1972–1986 (2014). [Full Text]

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