02/15/2011 08:47 am ET | Updated Nov 08, 2011

Are E-Cigs Safe? The Debate Continues

There is a long history of the cigarette industry selling health. Early advertisements showed physicians, dentists, nurses, scientists and researchers all explaining how it was safer to smoke some new kind of cigarette (see my website for a history of cigarette ads). Early cigarettes were promoted to cure colds and asthma. Filtered cigarettes were supposed to be safer. Unfortunately, Kent produced the micronite filter, which was later found to contain asbestos as one of its ingredients (1). Low tar "light" cigarettes have now been linked to rapid increases among smokers in cases of adenocarcinoma, once a rare form of lung cancer in the periphery of the lung, because people puffed on them harder (2). Buyer beware!

Having said this, perhaps electronic cigarettes really are different. Why? In theory, having a cigarette-like experience with pure nicotine sounds promising. It sounds like a more consumer-friendly version of something we already have: Nicotine Replacement Therapy (NRT). But why not test it out first as a way to quit as well as for its safety? Why not regulate it and make sure it isn't a new way to entice children into smoking? After all why is it that e-cigs come in different flavors such as chocolate, strawberry and mint? Or perhaps e-cigs are a new way to create life-long customers for a new cigarette brand? Will most people come off of them as they come off NRT without much problem within a few months? Or will e-cigs become another financial burden to them, like their cable bill, but without the programming? What are the risks of inhaling nicotine directly into the lungs, which is a different delivery system than employed by NRT? History shows that without properly regulating and testing new cigarettes, you run the risk that you find out problems later.

For example, clinically, many people I have seen use the e-cigarette and then switch back and forth with their regular brands. They are using e-cigs to control, not quit, smoking. There are reports (3) that the amount of nicotine varies quite a bit in e-cigs from how it is labeled. The FDA found chemicals in some e-cigs which are also used in anti-freeze, as well as carcinogens in a sample it tested. The FDA also reported such unpleasant symptoms as "racing pulse, dizziness, slurred speech, mouth ulcers, heartburn, coughing, diarrhea and sore throat" (see the link at the end of this blog for more information from the FDA).

In contrast to this new, unregulated product, which is now a big and growing business on the Internet, we know that nicotine replacement therapy is a quality-controlled medication to quit smoking. You know what you are getting, that it doesn't harm your lungs or cause cancer and has minor effects on cardiovascular health. It is so safe that using NRT for two weeks before stopping smoking has recently been shown to double the chances of success at quitting with NRT, with no additional safety issues (4). This treatment has now been named Pre-Quit Treatment with Nicotine Patch (PQNP), and has already been approved in Australia and the U.K.

Researchers from the Boston University School of Public Health (5) recently came out with a new study on electronic cigarettes, which has been widely cited in the media. Based on less than one in every 20 people responding to a survey they sent out, the study's authors made some very speculative statements about the promise of e-cigs. In all usual smoking cessation studies, it is assumed that all smokers who don't respond to research follow-up are still smoking. This is a conservative, but logical assumption. In any case, if you want to compare this study of e-cigs to the research on NRT, you would have to make that assumption. The authors reported that out of the 216 e-cig users who responded, approximately 67 people said they quit, out of an original sample of 4,884. By normal methods, this equals about 1.4 percent of users, which is far less than the naturally occurring quit rate!

It is also very possible that those who responded are those who had a more positive experience with the product. We just don't know. In any case, it's not enough of a sample to know whether that smaller group is truly representative of the whole group.

Another problem with this Boston University study is we don't know yet how e-cigs compare to NRT, or to taking nothing at all, which is how most people successfully quit, because those comparisons just weren't done. So being scrupulously fair, let's say we don't know enough for the public to make informed decisions about whether e-cigs help to quit smoking, and how safe they are.

Another problem with the mad rush to promote e-cigs as "harm reduction" is the constant and, I believe, unfair bashing of NRT. People rarely are counseled on how to use NRT effectively. For example, combining the patch and the gum or the patch and the nicotine inhaler has been shown in the most recent U.S. government clinical practice guidelines (6) to be the most successful medication strategy for quitting! Yet how often is this recommendation given or taken?

Existing NRT products have been carefully tested and can be especially helpful when combined with a support program or cognitive-behavioral therapy (CBT) for smoking cessation. We already know how to help smokers quit, but the gold standard NRT plus cognitive-behavioral therapy is not offered by most health clinics, despite helping over half of all smokers quit in randomized controlled clinical trials.

Dr. Seidman is author of "Smoke-Free in 30 Days: The Pain-Free, Permanent Way to Quit" with a foreward by Dr. Mehmet Oz (Fireside Trade Paperback Original, January 2010). An audio book is available from Random House. Dr. Seidman first introduced his own program to stop smoking as a featured expert on "The Oprah Winfrey Show" with Dr. Oz early in 2008, after 20 years of helping smokers at Columbia University. For more details about the book go to

1. Crocidolite Asbestos Fibers in Smoke from Original Kent Cigarettes. William E. Longo, Mark W. Rigler, and John Slade. Cancer Res June 1, 1995.
2. Acheivements in Public Health, 1900-1999: Tobacco Use--United States, 1900-1999. CDC November 05, 1999/48 (43); 986-993.
3. Novel Nicotine Delivery Systems and public Health: The Rise of the "E-Cigarette". Nathan K. Cobb, Justin Byron, David Abrams, and Peter Shields. American journal of Public Health December 2010, Vol 100, no. 12.
4. Nicotine Patch Therapy Prior to quitting Smoking: A Meta-Analysis," Addiction, 103, 4 March 13, 2008: 557-563. published online.
5. Electronic Cigarettes As a Smoking Cessation Tool: results from an Online survey. Michael B. Siegel, Kerry L. Tanwar, Kathleen S. Wood. American Journal of preventive Medicine 2011. Published online.
6. Treating Tobacco Use and Dependence 2008 Update. Michael Fiore et al. Rockville MD: US Dept of Health and human Services, Public Health service, 2008.