|Year : 2016 | Volume
| Issue : 4 | Page : 226-230
What should dentists know and advise about electronic cigarettes to their patients
Shailee Fotedar1, Vikas Fotedar2, Vinay Bhardwaj1
1 Department of Public Health Dentistry, H.P. Government Dental College, Shimla, Himachal Pradesh, India
2 Department of Radiation Oncology, Regional Cancer Center, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
|Date of Web Publication||13-Dec-2016|
Department of Public Health Dentistry, H.P Govt Dental College, Shimla, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Electronic cigarettes (e-cigarettes) are battery-powered devices that convert nicotine into a vapor which can be inhaled. The vapors from e-cigarettes are complex mixtures of chemicals, not pure nicotine. It is unknown whether inhalation of the complex mixture of chemicals found in e-cigarette vapors is safe. Worldwide use of electronic cigarettes has increased significantly over recent years but varies markedly between countries. The legal status of e-cigarettes is pending in most of the countries which are the need of the hour. The efficacy and effectiveness of e-cigarettes in smoking cessation or reducing the tobacco use are not established. The following review discusses the current data regarding e-cigarette, prevalence of e-cigarette, legislation of e-cigarettes, issues concerned with the use of the e-cigarette, and finally, the dentists being the health caregivers should be prepared to answer the patients' questions about the advisability of using e-cigarettes as a smoking cessation device.
Keywords: Electronic cigarette, nicotine, vapor
|How to cite this article:|
Fotedar S, Fotedar V, Bhardwaj V. What should dentists know and advise about electronic cigarettes to their patients. SRM J Res Dent Sci 2016;7:226-30
|How to cite this URL:|
Fotedar S, Fotedar V, Bhardwaj V. What should dentists know and advise about electronic cigarettes to their patients. SRM J Res Dent Sci [serial online] 2016 [cited 2023 Feb 6];7:226-30. Available from: https://www.srmjrds.in/text.asp?2016/7/4/226/195632
| Introduction|| |
Electronic cigarettes (or e-cigarettes) are battery-powered devices that contain liquid which is vaporized with inhalation of the e-cigarette without any combustion or smoke and consist of a combination of propylene glycol, vege glycerin, various levels of nicotine, and flavor concentrates.  It was invented in their current form by Chinese Pharmacist Hon Lik in the early 2000s.  In addition to nicotine, the vapor also provides a flavor and physical sensation similar to that of inhaled tobacco smoke, whereas no tobacco, smoke, or combustion is actually involved. When a user inhales through the device, air flow is detected by a sensor, which activates a heating element ("atomizer") that vaporizes a nicotine solution contained in a cartridge in the mouthpiece. It is this vapor that is inhaled by the user. The device includes a rechargeable battery, a heating element, and mouthpiece. Mouthpieces ("cartridges") can be replaced, or users can refill them with a nicotine solution themselves. Nicotine-free cartridges are also available. ,
The cartridge contains a liquid known as e-liquid, e-juice, or smoke juice. The ingredients may be nicotine, flavoring's, water, citric acid as well as either propylene glycol and/or glycerol. The nicotine concentration depends on the brand and the product, ranging from 0 to 24 mg/ml and may be labeled as nicotine-free, or referred to as mild/low, regular/medium, or strong/high. In addition, e-liquids with 36-50 mg/ml of nicotine are available. A wide range of natural and/or artificial flavors may be incorporated into the nicotine or nicotine-free versions, for example, traditional tobacco flavors, fruit, chocolate, and various novelty flavors such as candy floss and margarita. The replaceable cartridges for e-cigarettes are preloaded with e-liquid, and bottles of 10, 30, or 50 ml of e-liquid are available for the liquid refillable e-cigarettes.
The number of puffs from an e-cigarette will depend on brand, product, and the way it is used and usually ranges from 150 to 300 puffs, where 300 puffs is equivalent to 40 cigarettes. With tobacco cigarette one can have 10-20 puffs. ,
| Prevalence of Electronic Cigarette Use|| |
Worldwide use of e-cigarettes has increased significantly over recent years but varies markedly between countries. In a recent study carried out in four countries, rates of using e-cigarettes even once in their life were 15% in the USA, 10% in the UK, 4% in Canada, and 2% in Australia, typically with higher rates among younger age groups.  There is evidence that in the USA, use of e-cigarettes has become more popular among young people and the use of e-cigarette even once in their life doubled between 2011 and 2012 from 3.3% to 6.8%, and current use increasing from 1.1% to 2.1%. , The increasing use of e-cigarettes in the USA is also demonstrated clearly in data on trends in sales of e-cigarettes which, in the USA, for example, demonstrated strong growth in volume and value of sales between 2012 and 2013. 
Most of this increase has occurred as a result of use by people who already use some form of tobacco product. , Hence, they use it as a smoke cessation tool to help reduce and quit tobacco; as a harm reduction tool to help reduce the quantity of tobacco being smoked; to reduce effects of passive smoking.
Data from young people in 2011 to 2012 in the USA have shown that use of e-cigarette has almost replaced other forms of smoking in youngsters. ,
E-cigarettes are claimed to be cheaper than tobacco cigarettes. A price comparison by one company estimated the cost of using e-cigarettes to be 80% cheaper than smoking tobacco cigarettes.  The estimated cost for an e-cigarette, equivalent to 20 tobacco cigarettes, is <£2  compared to the average cost of about £7 for 20 tobacco cigarettes; the 20%. Tax on e-cigarettes is lower than the 80% tax on tobacco cigarettes. 
Current legislation of electronic cigarettes
The legal status of e-cigarettes is currently pending in many countries because of the relative novelty of the technology, the possible relationship to tobacco laws and medical drug policies, and public health concerns related to the use of e-cigarettes.  As of 2015, around two-thirds of major nations have regulated e-cigarettes in some way.  Current regulations vary widely, from regions with no regulations to others banning the devices entirely. 
Some countries such as Brazil, Singapore, the Seychelles, and Uruguay have banned e-cigarettes. In the United Kingdom, the use and sale of e-cigarettes are legal.  As of July 2014, with an absence of federal regulations in the USA, 44 states have adopted their own e-cigarette regulations.  E-cigarettes have been listed as drug delivery devices in several countries because they contain nicotine, and their advertising has been monetarily restricted until safety and efficacy of clinical trials are conclusive.  The emerging phenomenon of e-cigarettes has raised concerns in the health community, governments, and the general public. 
India does not have laws that deal directly with the sale of e-cigarettes, as they fall outside the purview of the Cigarettes and Other Tobacco Products Act, 2003, which regulates the sale, advertise, and use of tobacco products. India is yet to formulate a policy to curb the sale and use of e-cigarettes. Punjab was the first state to ban them last year followed by Maharashtra. 
An expert panel on e-cigarettes constituted by the health ministry has recommended a blanket ban on the product, saying its safety has not been established. "But the discussion is in too preliminary a stage to indicate a definite course of action."
Issues related to the use of electronic cigarettes
Issues related to e-cigarettes can be articulated in three groups:
- Efficacy in helping smokers to quit smoking and ultimately nicotine dependence
- Health risks to users and nonusers
- Interference with existing tobacco-control efforts and implementation of the WHO FCTC.
The efficacy of electronic cigarettes in smoking cessation and ultimately nicotine dependence
As per the WHO  although anecdotal reports indicate that an undetermined proportion of e-cigarettes users have quit smoking using these products, their efficacy has not been systematically evaluated yet. Only a few studies have examined whether the use of e-cigarettes is an effective method for quitting tobacco smoking.
The evidence for the effectiveness of e-cigarettes as a method for quitting tobacco smoking is limited and does not allow conclusions to be reached. However, the results of the only randomized control trial that compared the use of e-cigarettes, with or without nicotine, to use of nicotine patches without medical assistance in the general population, showed similar, although low, efficacy for quitting smoking.  A recent study also shows some, although limited, effectiveness in real-world conditions.  At this level of efficacy, the use of e-cigarettes is likely to help some smokers to switch completely from cigarettes to e-cigarettes. However, for a sizeable number of smokers, e-cigarettes use will result in the reduction of cigarette use rather than in quitting. This will lead to the dual use of e-cigarettes and cigarettes. Given the likely greater importance of duration of smoking (number of years smoking) over intensity (number of cigarettes smoked per day) in generating negative health consequences, dual use will have much smaller beneficial effects on overall survival compared with quitting smoking completely.  No e-cigarette product has yet been evaluated and approved for smoking cessation by a governmental agency. In considering e-cigarette as a potential cessation aid, smokers should first be encouraged to quit smoking and nicotine addiction using a combination of already approved treatments. However, at the individual level, experts suggest that in some smokers, who have failed treatment, have been intolerant to it or who refuse to use conventional smoking cessation medication, the use of appropriately regulated electronic nicotine delivery systems may have a role to play in supporting attempts to quit. ,
Health risks to users and nonusers
Mostly e-cigarettes have not been tested by independent scientists, but the limited testing has revealed wide variations in the nature of the toxicity of contents and emissions. The capacity of e-cigarettes to deliver nicotine to the user varies widely, ranging from very low to levels similar to that of cigarettes, depending on product characteristics, user puffing behavior, and nicotine solution concentration. The main health risk from nicotine exposure other than through inhalation is nicotine overdose by ingestion or through dermal contact. Since most countries do not monitor these incidents, the information is very scarce. Reports from the USA and the United Kingdom, nonetheless indicate that the number of reported incidents involving nicotine poisoning has risen substantially as the use of e-cigarettes has increased.
Health risks due to chronic inhalation of e-cigarettes users are short-term effects such as eye and respiratory irritation caused by exposure to propylene glycol. Due to relatively recent entry of e-cigarettes into the market and the lengthy lag time for onset of many diseases  such as cancer, conclusive evidence about the association of e-cigarette use with such diseases will not be available for years or even decades. However, evidence based on the assessment of the chemical compounds in the liquids used in and aerosol produced by e-cigarettes indicate: (i) Potential cytotoxicity of some solutions that have raised concerns.  (ii) The aerosol usually contains some carcinogenic compounds and other toxicants found in tobacco smoke. For some brands, the level of some of these cancer causing agents such as formaldehyde and other toxicants such as acrolein have been found to be as high as in the smoke produced by some cigarettes. 
Bystanders are exposed to the aerosol exhaled by e-cigarette users, which increases the background level of some toxicants, nicotine ,, as well as fine and ultrafine particles in the air. Nevertheless, the level of toxicants, nicotine, and particles emitted from some e-cigarettes is lower than that of conventional cigarette emissions.  It is not clear if these lower levels in exhaled aerosol translate into lower exposure, as demonstrated in the case of nicotine. Despite having lower levels of nicotine than in second-hand smoke, the exhaled e-cigarette aerosol results in similar uptake as shown by similar serum cotinine levels.  It is unknown if the increased exposure to toxicants and particles in exhaled aerosol will lead to an increased risk of disease and death among bystanders as does the exposure to tobacco smoke. However, epidemiological evidence from environmental studies shows adverse effects of particulate matter from any source following both short-term and long-term exposures. The low end of the range of concentrations at which adverse health effects has been demonstrated is not greatly above the background concentration, which for particles smaller than 2.5 μm has been estimated to be 3-5 μg/m 3 and increases with dose, which means that there is no maximum concentration for harm and that public health measures should aim at achieving the lowest concentrations possible. 
Interference with existing tobacco-control efforts and implementation of the WHO FCTC
Here, the areas of concern are gateway and renormalization concerns. (a) The gateway effect refers to two potential circumstances - (i) the possibility that children (and generally nonsmokers) will initiate nicotine use with e-cigarettes at a greater rate than otherwise;  and (ii) the possibility that once addicted to nicotine through e-cigarette, children will switch to cigarette smoking. (b) The renormalization effect refers to everything which makes e-cigarettes attractive to smokers which in turn may enhance the attractiveness of smoking itself and perpetuate the smoking epidemic. E-cigarettes mimic the personal experience and public performance of smoking. However, their market growth requires marketing which is challenging commercial communication barriers erected to prevent the promotion of tobacco products.
The likelihood and significance of these two effects occurring will be the result of a complex interplay of individual, market, and regulatory factors and are difficult to predict. They can only be assessed with empirical data, which at present are virtually nonexistent.
The existing evidence from a handful of countries has shown trial with e-cigarettes is increasing rapidly among adolescents and that in itself is of great concern even if most of the young e-cigarette users also smoke. In fact, except in one case, the surveys show that there are few exclusive e-cigarette users who have never smoked (mostly around 1% of the population). ,, E-cigarettes are sold in flavors such as chocolate and strawberry that are banned in conventional cigarettes because of their appeal to youth. This data does not allow the conclusions to be drawn as to whether this is a sign of adolescent smokers switching to e-cigarette, an established pattern of dual use, or a temporary experimentation fashion. Therefore, in the absence of longitudinal data, existing evidence does not allow an affirmation or rejection of the role of e-cigarette in increasing nicotine addiction among adolescents above existing uptake rates, much less as to whether e-cigarette leads to smoking in these countries.
Among adults, the pattern of dual use seems also the predominant one; as a result, there is some reduction in conventional smoking and some never smokers starting to use e-cigarettes (below 1% of the population). 
Dentists advice to patients using electronic cigarette
What should dentists tell to their patients who smokes tobacco cigarettes, wants to quit, and is interested in e-cigarettes, or is already using e-cigarettes? What should clinicians tell the patient who may be using e-cigarettes in spaces where tobacco cigarettes are banned and who has no interest in quitting smoking?
Dentists play an important role in advising patients to cease tobacco consumption. Recently, it has been proposed that dentist must advise and aid in cessation of tobacco use.  At present, e-cigarette use as a smoking cessation tool is not supported. Based on the literature reviewed above, current advice about e-cigarettes for patients can be:
- E-cigarettes are likely to be less harmful than tobacco cigarettes ,
- The effectiveness of e-cigarettes as either a smoking cessation tool or a harm reduction tool is not yet established ,
- The long-term safety of e-cigarettes is not yet established ,,
- The vapors from e-cigarettes are complex mixtures of chemicals, not pure nicotine. Whether inhalation of the complex mixture of chemicals in e-cigarette vapors is safe is unknown
- There is increasing resistance to the use of e-cigarettes in public places and outright bans in a growing number of states. The promotion of e-cigarettes may communicate a message to children and adolescents that "vaping" is harmless, inadvertently increasing the risk of nicotine addiction and tobacco use in a vulnerable population
- At present, e-cigarettes are not licensed as a medicine, , and patients are recommended to use licensed nicotine replacement therapy (NRT) products to quit or reduce tobacco consumption ,
- Patients who are unable or unwilling to use licensed NRT products should be told that although the safety of e-cigarettes cannot be assured, they are likely to be a lower risk option than continuing to smoke. 
However, there is potential for change to this advice, as more findings from research on the safety and effectiveness of e-cigarettes are published and may vary from place to place as per the laws and regulations in that particular place.
| Conclusion|| |
Due to rapid increase of e-cigarette market, people are using e-cigarettes primarily as a stop smoking aid or as an alternative to conventional cigarettes. However, the safety, quality, and effectiveness of e-cigarette sand also on their efficacy as a smoking cessation, and harm reduction tool has not been established. Hence, further research in this direction is needed. Furthermore, there is a need for e-cigarettes to be regulated as medicines to ensure quality. Delays in regulation and legislation may potentially allow the markets to determine the course of their use. E-cigarettes may offer vast potential health benefits but maximizing those benefits, whereas minimizing harms and risks to society require appropriate regulation, careful monitoring, and risk management. However, the opportunity to harness this potential into public health policy, complementing existing comprehensive tobacco control policies, should not be missed. Meanwhile, as health professionals, we need to be able to answer the questions raised by patients about e-cigarettes and keep abreast of this rapidly developing market.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Etter JF, Bullen C, Flouris AD, Laugesen M, Eissenberg T. Electronic nicotine delivery systems: A research agenda. Tob Control 2011;20:243-8.
Grana R, Benowitz N, Glantz SA. Background paper on E-cigarettes (electronic nicotine delivery systems). In: WHO Collaborating Center on Tobacco Control. San Francisco; 2013. Available from: http://www.pvw.escholarship.org/uc/item/13p2b72n
. [Last cited on 2014 Mar 31].
Kuschner WG, Reddy S, Mehrotra N, Paintal HS. Electronic cigarettes and thirdhand tobacco smoke: Two emerging health care challenges for the primary care provider. Int J Gen Med 2011;4:115-20.
Adkison SE, O′Connor RJ, Bansal-Travers M, Hyland A, Borland R, Yong HH, et al.
Electronic nicotine delivery systems: International tobacco control four-country survey. Am J Prev Med 2013;44:207-15.
Centers for Disease Control and Prevention (CDC). Notes from the field: Electronic cigarette use among middle and high school students - United States, 2011-2012. MMWR Morb Mortal Wkly Rep 2013;62:729-30.
Choi K, Forster J. Characteristics associated with awareness, perceptions, and use of electronic nicotine delivery systems among young US Midwestern adults. Am J Public Health 2013;103:556-61.
Dutra LM, Glantz SA. Electronic cigarettes and conventional cigarette use among U.S. adolescents: A cross-sectional study. JAMA Pediatr 2014;168:610-7.
Kmietowicz Z. E-cigarettes are "gateway devices" for smoking among young people, say researchers. BMJ 2014;348:g2034.
Electronic Cigarette World. Electronic Cigarette World Buyer′s Guide. Pamphlet. Electronic Cigarette World; 2013.
Grana R, Benowitz N, Glantz SA. E-cigarettes: A scientific review. Circulation 2014;129:1972-86.
Tremblay MC, Pluye P, Gore G, Granikov V, Filion KB, Eisenberg MJ. Regulation profiles of e-cigarettes in the United States: A critical review with qualitative synthesis. BMC Med 2015;13:130.
Lippi G, Favaloro EJ, Meschi T, Mattiuzzi C, Borghi L, Cervellin G. E-cigarettes and cardiovascular risk: Beyond science and mysticism. Semin Thromb Hemost 2014;40:60-5.
Saitta D, Ferro GA, Polosa R. Achieving appropriate regulations for electronic cigarettes. Ther Adv Chronic Dis 2014;5:50-61.
Electronic Nicotine Delivery Systems. Report by WHO. WHO Framework Convention on Tobacco Control; 2014. p. 5.
Bullen C, Howe C, Laugesen M, McRobbie H, Parag V, Williman J, et al.
Electronic cigarettes for smoking cessation: A randomised controlled trial. Lancet 2013;382:1629-37.
Brown J, Beard E, Kotz D, Michie S, West R. Real-world effectiveness of e-cigarettes when used to aid smoking cessation: A cross-sectional population study. Addiction 2014;109:1531-40.
The Health Consequences of Smoking - 50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services; 2014.
Fiore MC, Schroeder SA, Baker TB. Smoke, the chief killer - Strategies for targeting combustible tobacco use. N Engl J Med 2014;370:297-9.
Grana R, Benowitz N, Glantz SA. E-cigarettes: A scientific review. Circulation 2014;129:490-2.
Bahl V, Lin S, Xu N, Davis B, Wang YH, Talbot P. Comparison of electronic cigarette refill fluid cytotoxicity using embryonic and adult models. Reprod Toxicol 2012;34:529-37.
Goniewicz ML, Knysak J, Gawron M, Kosmider L, Sobczak A, Kurek J, et al.
Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control 2014;23:133-9.
Schober W, Szendrei K, Matzen W, Osiander-Fuchs H, Heitmann D, Schettgen T, et al.
Use of electronic cigarettes (e-cigarettes) impairs indoor air quality and increases FeNO levels of e-cigarette consumers. Int J Hyg Environ Health 2014;217:628-37.
Czogala J, Goniewicz ML, Fidelus B, Zielinska-Danch W, Travers MJ, Sobczak A. Secondhand exposure to vapors from electronic cigarettes. Nicotine Tob Res 2014;16:655-62.
McAuley TR, Hopke PK, Zhao J, Babaian S. Comparison of the effects of e-cigarette vapor and cigarette smoke on indoor air quality. Inhal Toxicol 2012;24:850-7.
Flouris AD, Chorti MS, Poulianiti KP, Jamurtas AZ, Kostikas K, Tzatzarakis MN, et al.
Acute impact of active and passive electronic cigarette smoking on serum cotinine and lung function. Inhal Toxicol 2013;25:91-101.
World Health Organization. WHO air quality guidelines for particulate matter, ozone, nitrogen dioxide and sulfur dioxide: Summary of risk assessment. Geneva: World Health Organization; 2006.
Lee S, Grana RA, Glantz SA. Electronic cigarette use among Korean adolescents: A cross-sectional study of market penetration, dual use, and relationship to quit attempts and former smoking. J Adolesc Health 2014;54:684-90.
Goniewicz ML, Zielinska-Danch W. Electronic cigarette use among teenagers and young adults in Poland. Pediatrics 2012;130:e879-85.
Preventing Tobacco Use Among Youth and Young Adults. A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services; 2012.
Public Health England. Electronic cigarettes: PHE position & Q and A. London: PHE; 2013.
British Medical Association. BMA calls for stronger regulation of e-cigarettes. London: BMA; 2013. Available from: http://www.bma.org.ukmedia/Files/
. [Last accessed on 2015 Jun 30].
European Commission. Questions & answers: New rules for tobacco products. Brussels: European Commission; 2014. Available from: http://www.europa.eu/rapid/press-release
. [Last accessed on 2015 Jul 02].
Medicines and Healthcare Products Regulatory Authority, Working Group on Nicotine Containing Products. Quality, safety and efficacy of unlicensed NCPs. MHRA; 2013. Available from: http://www.mhra.gov.uk/home/pdf
. [Last accessed on 2015 Jul 08].