UNC experts advise against routine recommendation of e-cigarettes for smokers

The health benefits of quitting smoking are widely accepted, but researchers from the University of North Carolina at Chapel Hill have taken issue with the suggestion that doctors should routinely recommend e-cigarettes as an alternative to cigarettes for their patients who smoke.

The researchers point out in a commentary published in today's Annals of Family Medicine that existing treatments are more effective than e-cigarettes to help people quit smoking, there are professional ethics concerns about providers who recommend them, and there is no strong evidence that e-cigarettes are safe.

"Providers should not routinely recommend e-cigarettes to patients until we have far more data on their safety and effectiveness compared to established, FDA-approved medications," said Adam O. Goldstein, MD, MPH, a UNC Lineberger Comprehensive Cancer Center member and professor in the UNC School of Medicine. "There are very few therapeutic devices that we recommend that aren't regulated, that have potential and real side effects, and that are addictive. There are safer and more effective smoking cessation products for the same condition."

The researchers described notable safety and health concerns about e-cigarettes. Batteries inside e-cigarettes have caught fire or exploded, and particulate matter from e-cigarettes, which has been shown to be present in similar numbers to cigarettes, can increase the risk of cardiovascular and respiratory diseases.

The UNC researchers' commentary served as a counterpoint to a paper in the same journal issue by Ann McNeill, PhD, professor of tobacco addiction at King's College London, that suggests e-cigarettes are a less harmful way for smokers, including those trying to quit, to use nicotine.

"Though e-cigarettes are likely not as harmful as conventional cigarettes, a growing number of studies report that they are by no means harmless," said Clare Meernik, MPH, a research specialist in the UNC Department of Family Medicine. "Short-term effects include exposure to toxins, reduced respiratory and lung function and burn-related injuries from exploding devices."

The researchers also noted that e-cigarettes have been less effective than existing treatments to help people quit smoking.

"People are focused on should they use e-cigarettes or not. We can have a conversation about that, but part of the bigger picture is being lost," Goldstein said. "And that is that we need be using the tools that we currently have available, including seven FDA-approved medications in combination with behavioral treatment. We have quit lines that provide free counseling and physician counseling to help patients come up with concrete plans for quitting and developing the skills necessary to quit permanently and to increase social support - all of which significantly increase cessation."

This past May the U.S. Food and Drug Administration announced it was extending its authority over all tobacco products, including e-cigarettes. Greater regulatory oversight of e-cigarettes, the researchers said, will be a significant step forward toward ensuring higher safety standards.

"We need more data on effectiveness, we need more data on safety, we need technology that's safe so the products don't explode, we need to ensure they're childproof," Goldstein said. "Right now, we don't know the different amounts of ingredients in these products. We don't know about the nicotine levels that patients are getting."

In addition to examining existing research on e-cigarettes, Goldstein said their views came from clinical observations from helping tobacco users through the UNC School of Medicine Department of Family Medicine Nicotine Dependence Program. A branch of the program exists in the N.C. Cancer Hospital to help cancer patients and survivors safely quit tobacco products, he said

And while they advise against the routine recommendation of e-cigarettes, Meernik and Goldstein know firsthand that smoking cessation for individual patients is rarely black and white, and that providers must look at each patient's unique situation.

"The emergence of any intervention or product promoted as a smoking cessation aid excites many providers, but such tools need to be proven safe and effective before providers routinely utilize them," Meernik said. "Debates such as this can help clarify the evidence for providers and ensure that patients are receiving the highest quality treatment."