"Vaping:" Emergence of a New Paraphernalia.

As research, has progressed through ages, we have been able to uncover the true nature of nicotine addiction. Humankind is now aware of the various ailments that it brings with it. As the slogan for a smokeless world for a better world has been raised, a new practice called "vaping" has come to the forefront. The use of electronic cigarettes (EC) has been on the rise recently. Claims have been made over its role for nicotine deaddiction as well as reducing harmful use for chronic nicotine abusers. In the current review, we searched the PubMed database for available literatures on this practice. We conclude that though EC has the potential to work wonders in smoking cessation, the unforeseen adverse effects needs to be evaluated first before its large-scale introduction in market through solid evidence-based research.

“Giving up smoking is the easiest thing in the world. I know because I've done it thousands of times.”

INTRODUCTION

Smoking as we know it dates back in human civilization to almost 5000 B.C. When it was a part of shamanistic rituals of ancient America. With the advent of tobacco in Europe in the 16th century, it rapidly gained popularity among the general population. With the addiction, came various methods of enjoying it, and nicotine paraphernalia is evolving throughout the ages. “Paraphernalia most commonly refers to a group of apparatus, equipment, or furnishing used for a particular activity.”[1] The most well-known tool for tobacco users is definitely cigarettes, and it was Washington Duke from North Carolina, United States, who produced the first commercial cigarettes in 1865. More than a millennium has passed by since its advent. The world has changed dramatically with the advent of electronic revolution. To keep in pace, man's paraphernalia have evolved. In 2003, Hon Lik a Chinese pharmacist developed the earliest model of e-cigarettes (EC).[2] The very next year (2004), Ruyan Group (Holdings) Ltd., from China patented the very first EC or “e-cigarettes” or “electronic nicotine delivery device” (ENDD).[3] The device vaporizes a liquid which is inhaled by the user, from which the term “vaping” has emerged.

While the world is now more aware on the implications and consequences of long-term smoking, the marketing strategy for the “tobacco hungry” population has changed. Now, focus is more on “safe smoking” or “tobacco cessation tool.” Because of the realistic look, taste, and sensory satisfaction with an added promise of smoking cessation, EC has been accepted by the population in many parts of the globe. However, the real question still stands! Is it really effective or is it just a marketing gimmick?

THE ELECTRONIC NICOTINE DELIVERY DEVICE

EC is a battery powered device that emerged as an alternative to other traditional nicotine delivery systems such as cigars, pipes, or cigarettes. The idea is nicotine delivery without combustion in vapor form that provides a physical sensation and flavor similar to that of inhaled tobacco smoke. It is usually a tube of stainless steel inside which there are multiple micro-electric components with an outward appearance of a cigarette. One end contains a light connected with a battery while the other end contains an inhaler cartridge connected to container containing a liquid preparation. Other micro-components such as control circuit, pneumatic airflow sensor switch, and vaporizer, are present in the tube. Battery connects the light on one end and on the other it is connected with a vaporizer which has a heating device connected with a pneumatic switch and smoking liquid container.[4]

Electronic-cigarette cartridge

An EC cartridge is usually a refillable or replaceable cylinder which contains numerous chemicals that produces the aerosol. Chemicals that are usually found in the cartridges are nicotine, menthol, safrole, propylene glycol, 1,3-butanediol, 1,3-propanediol, ethylene glycol, glycerol, ethyl vanillin, camphor, α-thujone, coumarin, and diethylene glycol.[5]

Mechanism of operation

When the battery is turned on the pneumatic switch gets activated by inhaler pressure which further activates the electronic circuit by magnetic induction. When the circuit gets activated two things occur simultaneously. The light of the EC turns red, and the vaporizer atomizes the liquid present in the container. When individual stops inhaling, the inhaler pressure falls turning off the pneumatic switch, thus, disabling the circuit. Most parts of the EC are replaceable and reusable. When the light at the front becomes dimmer, one needs to change the battery; the cartridge needs replacement when the smoke quantity decreases.[4]

Method of literature search

A search of PubMed database was made with keyword “EC*” and search filters were set to “Title” only and “Clinical Trials.” The search conducted on September 20, 2016, resulted in 13 articles. Full-text articles were obtained by the authors and reviewed separately. Finally, all the 13 studies were included in the study.[6789101112131415161718]

RESULTS

The 13 studies included in this review are summarized in Table 1. Seven among the 13 included studies commented on the desire to smoke of study individuals and possibility of its role in smoking cessation.[6111314161718] Three studies commented on the acceptability and tolerability of EC.[61618] Only one study[11] commented on the overall awareness of EC in their study participants. Four articles studied on the risk factors of getting addicted to EC,[9111214] two articles on user satisfaction and acceptance[151618] commented on the safety of the device, whereas two other studies studied on the possible adverse effects of EC.[810]

Table 1

Details of included studies in the review

DISCUSSION

According to the studies included in the review, the lifetime prevalence of EC use is 4.7%.[12] The various aspects of EC use as evaluated by various included studies are presented as follows.

Electronic-cigarettes in smoking cessation and modifying desire to smoke

Most of the included studies in this review has given positive comments on the possible role of EC in smoking cessation and decreasing the desire to smoke. A 2010 study conducted in New Zealand using a 16 mg V8 ENDD commented that only overnight abstinence from smoking it reduced the desire to smoke significantly. Another clinical trial conducted in Italy in 2011 on adult-dependent smokers commented that a trial with EC showed 50% reduction in number of cigarettes/day in 32.5% of the test participants, sustained reduction of 80% was obtained in 12.5% of participants and 22.5% reported complete sustained abstinence after 24 weeks. Another Italian study conducted in 2014 by Gallus et al.[11] reported a 67.7% reduction in traditional cigarette consumption, and reported that 10.4% of their study participants quit smoking. Steinberg et al.[16] found that 76% of their study participants were willing to make a quit attempt using an EC in sharp contrast to 24% of participants who preferred an inhaler. Furthermore, abstinence rate was much higher after a 3-day trial with EC over inhalers. Wagener et al.[17] reported that there was a 44% reduction in regular cigarette smoking while using the EC, provided that the total tobacco use/day was same.

In contrast to these finding, King et al.[13] reported a statistically significant finding that passive exposure to EC cues increases the urge to smoke an EC unlike that of a regular cigarette. Probably, the “coolness” tag associated an EC along with the added technology flash guides a nonsmoker to try an EC. Similarly, Prochaska and Grana, 2014[14] reported no significant change in smoking status or reduction in cigarettes/day among smokers with the use of EC in their trial conducted over a period of 18 months.

Acceptance and tolerability

Steinberg et al.,[16] and Polosa et al., 2011[18] both commented on the higher acceptance and tolerability of EC. When compared with other ENDD, EC has higher acceptability than inhalers.

Risk factors

Prochaska and Grana[14] in their study with 956 participants found the use of EC increased rapidly over a period of 4 years (2009–2014) from 0% to 25%. Hence, the risk of getting addicted to this tool of deaddiction is strongly present. The use was significantly higher among the smokers in the preparation phase of quitting. Risk factors that are found to have a positive association with EC addiction are male gender (however, Gallus et al.[11] found no significant differences in sex), having family (especially siblings), or friends on traditional cigarettes and older age group.[12] Adolescents who are exposed to commercial advertisements of EC were at a higher risk of future EC use,[9] especially because of the “coolness” factor[16] associated with it. Protective factors were higher levels of literacy, physical exercise,[12] female gender, and nonsmokers.[11]

Safety and adverse effects

Schober et al.[15] performed a safety profile study on EC consumers and commented that, though not combustible, EC is not totally emission free. EC liquid produces supersaturated 1,2-propanediol vapor that causes increased production of nitric oxide (an inflammatory signaling molecule). The use of EC causes significant cough reflex suppression as shown by Dicpinigaitis et al.[8] An Italian study by Ferrari et al.[10] however, claims that though there are side effects, those are not immediate.

CONCLUSION

The popularity of EC has increased over past few years rapidly. Owing to its technological bling and marketing tag of being “a safe alternative to traditional cigarettes, modern man has accepted it readily.” However, as we can see, a search of quality research work on this new paraphernalia yielded only a handful of articles. In this review, we have tried to bring out the main headlines of current researches. Although marketed as a noncombustible nicotine delivery system with minimal side-effects, one study has shown that EC is not emission free and has certain adverse effects. Most of the other studies, however, has mentioned about its potential use in smoking cessation and nicotine deaddiction with good acceptability and satisfaction. However, most of them had one major limitation, i.e., they were conducted on a minimal sample. They all insisted on the requirement of further research to establish their findings. The FDA has reported the presence of harmful chemicals such as nitrosamines and diethylene glycol in the e-liquids and recommended that EC use should be controlled.[19] Literature search could not find any relevant Indian studies on this issue. However, like other nations, EC has made its way in Indian market too. Hence, though EC has the potential to work wonders in smoking cessation, the unforeseen adverse effects needs to be evaluated first before its large-scale introduction in market through solid evidence-based research. Researchers from developing countries should take up a firm initiative too, to look into the matter and provide opinions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.