HR/June 19/10: Safer nicotine products - Types of e-cigarettes

Dr KK Aggarwal

Over the last decade, there are other options for ingesting nicotine which are not only less reinforcing than nicotine delivered in a combustible cigarette, but do not involve the high-level release of toxic chemicals.

These have been called safer nicotine products (SNP) in the report No Fire, No Smoke Global State of Tobacco Harm Reduction, 2018 and they break down into three main types: e-cigarettes, heat-not-burn (HNB) devices and an option that is very far from new but enjoying a renaissance: smokeless tobacco, in the form of snus from Sweden.

Types of e-cigarettes

There are now many types of e-cigarette. They range from entry level disposable types, which cannot be customised and are known as ‘closed systems’, through to mechanical modified types, or ‘mods’, which the vaper is able to fully customise and are at the top end of what are known as ‘open systems’. The higher up the device scale you go, the more control the vaper has over the whole vaping experience.

All e-cigarettes have three basic elements; a battery, which heats up a coil or atomiser, turning the flavoured e-liquid or juice into a vapour, which is then inhaled.

E-liquid comprises four ingredients: vegetable glycerine, propylene glycol, nicotine, and flavouring.

Some liquids can contain no nicotine.

Vegetable glycerine (VG) is a thick, naturally sweet liquid that provides the vapour from the liquid.

Propylene glycol (PG) is a thin liquid, which acts as the flavour carrier. Some people are allergic to PG and e-liquid without that ingredient is available.

The VG/PG ratio is the ratio of VG and PG in a liquid.

The higher the VG percentage, the more cloud and the smoother the vape, but there is less flavour.

Higher PG gives less cloud, more ‘throat hit’ and possibly more flavour. Throat hit refers to the feeling a smoker gets when inhaling nicotine. The problem that most smokers switching to vaping report is the fact that they do not feel the same kind of throat hit that they would with a regular cigarette.

The flavourings are the same as used in food and confectionery production and the range of flavours available for vaping runs into the thousands.

(Source: No Fire, No Smoke Global State of Tobacco Harm Reduction, 2018 (2018). London: Knowledge-Action-Change)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Do not equate big risks, small risks and hypothetical risks under one umbrella as unsafe

Dr KK Aggarwal

When the government warns us about the risks of fats, salt, sugar, alcohol or electronic cigarettes, they equate big risks, small risks and hypothetical risks under one umbrella as “unsafe.” No one talks about potential risks against potential benefits.

Cigarettes contain nicotine, tar and carbon monoxide. Of these tar and carbon monoxide are known carcinogens.

Electronic cigarette devices create a vapor (aerosol) people inhale, providing nicotine without the carcinogenic tar.   

They are very unlikely to be anywhere near as harmful as cigarettes. People who switch from smoking to “vaping” may be prolonging their lives and the lives of people around them.

While some studies have shown that electronic cigarettes contain carcinogenic compounds, and that the nicotine itself, while not a cause of lung disease, might be harmful, these are minor risks compared with smoking.

Vaping should be considered dangerous if it functions as a gateway drug, leading more people to smoke. Likewise, it should be considered beneficial if it acts as a substitute for smoking, giving people a safer alternative.

The public health approach known as harm reduction is associated with safe injection site programs. Sure, it would be better if nobody injected drugs, but in our imperfect world, clean needles save lives.

The public health community in the United Kingdom has embraced them, based on the estimate that they are 95% less harmful than smoking.

Teens would be much better off not using any nicotine products, as they run a high risk of addiction, but we need to be concerned only if vaping is leading to increase in cigarettes consumption in them. If smoking rate is reducing, at the cost of vaping, this is harm reduction.

Interpreters tend to err on the side of exaggeration over exoneration, but that is not always in the best public interest.

Exaggerating the risks of vaping might seem harmless, but it’s harmful if it gives people the impression that it’s so dangerous they might as well smoke.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Using nicotine to help smokers quit

Guest Editorial

Peter Hajek

Professor of Clinical Psychology and Director of the Health and Lifestyle Research Unit at the Wolfson Institute of Preventive Medicine

In my presentation on “Using nicotine to help smokers quit” at the 6th Global Forum on Nicotine in Warsaw, Poland, I was comparing the reactions to the launch of nicotine replacement treatments (NRT) in 1980s with the reactions that have been meeting the recent advance of alternative nicotine products.

When nicotine chewing gum first appeared, there were concerns about its safety, its potential to entice children to nicotine use, and doubts about giving smokers the drug they are trying to quit.

Evidence and common sense however prevailed fairly rapidly and NRT was accepted practically universally as a safe and effective treatment.

The same objections have been revived by opponents of e-cigarettes, with some new ones added, especially the claim based on animal studies that nicotine damages adolescent brains (support of the hypothesis by human data is lacking, e.g. dramatic reductions in adolescent smoking that took place in a number of countries were not accompanied by improvements in mental health).

There are also claims that smokers who switched to vaping did not really quit smoking (they did), that vaping prevents rather than facilitates quitting (it helps smokers quit), and that dual use, i.e. combining vaping and smoking, is more risky than smoking (it reduces toxin intake from smoking).

Evidence and common sense are facing a much harder battle the second time round.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Faster acting nicotine consumption is cardiac safe

The faster-acting nicotine replacement therapies (NRTs) include nicotine mouth spray, nicotine inhalers, nicotine nasal spray, nicotine nasal spray and nicotine sublingual tablet. Here is a brief overview of each.

Nicotine mouth spray: It delivers 1 mg nicotine per spray. Used as 1 to 2 sprays when craving occurs, up to 4 sprays per hour. Side effects occurring frequently with the oral spray include hiccups (occurring in more than 55% of those treated in one trial, throat irritation, and nausea (Eur Respir J. 2012;40:548).

Nicotine inhalers: They release nicotine vapor (not smoke). The ad lib use of the nicotine inhaler produces plasma nicotine levels that are roughly one-third of those that occur with cigarette smoking. Use 6 to 16 cartridges per day for the first 6 to 12 weeks and gradually reduce dose over the next 6 to 12 weeks. Commonly occurring side effects include localized irritation of the mouth or throat, particularly during the early stages of use. Because inhaled nicotine may cause bronchospasm, it may be less appropriate for smokers with a history of severe airway reactivity.

Nicotine nasal spray: It delivers an aqueous solution of nicotine to the nasal mucosa. The peak nicotine level occurs at 10 minutes. Dose is 1 or 2 sprays per hour for three months. The maximum dose is 10 sprays per hour, not to exceed 80 total sprays per day. Side effects include nasal and throat irritation, rhinitis, sneezing, and tearing. Nasal irritation is extremely common, occurring in 94% of patients during the first two days of use and continuing in 81% of patients after three weeks of therapy (Medical Economics, Montvale, NJ 1998).

Nicotine sublingual tablet: It is administered as 2 mg tablet sublingually (over 30 minutes) every one to two hours. Patients who are heavily nicotine-addicted can use 2 tablets sublingually (4 mg total) for each dose (Nicotine Tob Res. 2002;4:441). Side effects occurring commonly include sore mouth or throat and dryness or burning in the mouth.

Cardiac safety of NRTs

·         Nicotine replacement is delivered by nicotine polacrilex gum, nicotine lozenges, nicotine nasal spray or transdermal nicotine

·         The Lung Health Study cohort of 5887 middle-aged smokers with chronic obstructive pulmonary disease who were followed for five years compared smokers with those who quit with or without nicotine gum. There was no increase in hospital admission for cardiovascular events with nicotine gum treatment, regardless of the dose used. Participants who quit smoking successfully and used nicotine gum had a lower hospital admission rate for cardiovascular disease than subjects who did not quit smoking, regardless of whether or not they used the gum (fda.gov/Drugs/DrugSafety/ucm259161.htm).

·         The results of two other controlled trials of nicotine replacement and one population-based case-control study of patients with cardiovascular disease also provided no evidence for an increase in coronary events with replacement therapy (CMAJ. 2011;183:1359).

·         A randomized trial of 584 patients (almost all men) with at least one diagnosis of cardiovascular disease found no difference in the incidence of primary cardiovascular end points (death, myocardial infarction, cardiac arrest, and admission to the hospital for cardiovascular disease) at 14 weeks between the nicotine and placebo groups (5.4 vs 7.9 percent with placebo) (accessdata.fda.gov/drugsatfda_docs/label/2018/021928s045_046lbl.pdf). Overall, the evidence suggests that chemicals other than nicotine are responsible for the elevated risks of myocardial infarction and stroke in smokers. The risks of nicotine medication in patients with cardiovascular disease, if any, are much lower than those of smoking, and the benefits of nicotine medication far outweigh the risks of continued smoking in such patients.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA