Modern alternatives to age old habits have gained utmost popularity in recent times because of increased knowledge on health and adverse effects of lifestyle changes that hinder efficient way of living. Smoking has become an integral part of lifestyle in many nations that the aftermath is horrendous which led to the skyrocketing of lung cancer cases. Due to increased awareness of adverse effects smoking cigarettes, companies started marketing alternatives which they "claimed" as much safer. This led to the birth of the “vaping or e-cigarette” culture. Is it as safe as they claim it to be? Let’s dig deeper.
E-Cigarettes were first patented on August 27, 1965 by Herbert A. Gilbert
E-cigarettes are reported to have been developed in 2003, by a 52 year old pharmacist, Hon Lik; of Beijing, China.
Hon Lik, known as the "Father of the electronic cigarette" a smoker and inventor, is said to have invented the electronic cigarette after losing his father, also a heavy smoker to lung cancer.
Electronic cigarettes (cigarettes) were developed in 2003 and introduced into the US market in 2007.
They have quickly grown in popularity as a nicotine source for many patients.
WHAT IS AN E-CIGARETTE?
E-cigarettes are designed to simulate smoking by heating a nicotine containing solution that includes flavorings, and a delivery system such as propylene glycol glycerin, producing an aerosol, and then inhaled by the user.
How do E-cigarettes work?
A typical e-cigarette consists of a battery, a heating element and a cartridge containing nicotine, propylene glycol and water
The levels of nicotine in the cartridges can vary drastically and many also contain candy-like flavorings,
They operate by electronically vaporizing the nicotine solution, creating a mist that is inhaled into the lungs.
After the user inhales, the residual aerosol, or vapor, is exhaled into the surrounding air.
Many e-cigarette models include a voltage potentiometer that allows the user to select the amount of aerosol produced, thereby selecting the amount of nicotine to be inhaled.
Other operational details depend on the e-cigarettes intended use. There are disposable models intended for one-time use. Others are intended for multiple uses and must be refilled either manually or with pre-filled cartridges, and regular cleaning is necessary.
Solution Cartridge (E-liquid)
• The solution cartridge contains the flavored nicotine solution for aerosolisation.
• This liquid includes a vehicle solution (propylene glycol, low molecular propylene glycol, or vegetable glycerin), artificial flavorings, and variable concentrations of nicotine.
• This may be refillable by the user or exchanged for pre-filled cartridges
• The number of choices in the composition of e-cigarette solutions is increasing, and there is significant variability between the labeled content and the actual content and concentrations.
The Current Scenario
The short and long-term effects of e-cigarette use remain unclear, but their use is increasing.
Some acute effects of e-cigarettes on heart rate, blood pressure, and airway resistance have been reported.
Although there are some reports of improved cessation in a subset of users, there are also studies reporting decreased cessation in dual users of regular and e-cigarettes.
E-cigarettes are a disruptive technology. Will they end traditional smoking?
Public health experts are concerned that e-cigarette use could renormalize smoking, delay or prevent cessation attempts, promote youth use, and draw former smokers back into nicotine addiction
Additionally, this booming industry is increasingly run by tobacco companies - the same companies that have long promoted dangerous products over consumer health.
On the other hand, many believe that e-cigarettes represent the best hope for a disruptive technology that can begin the end of traditional smoking, saving millions of lives.
ENDS: Electronic Nicotine Delivery Systems
Types of ENDS include:
No current regulation of these devices, and this allows virtually anyone with a form of online payment to obtain them.
WHO & E-CIGARETTES
September 2008, the World Health Organization (WHO) proclaims that it does not consider the electronic cigarette to be a legitimate smoking cessation aid and demands marketers immediately remove from their materials any suggestions that the WHO considers e- cigarettes safe and effective.
THE RUYAN STUDY
October 2008, The e-cigarette developer, Ruyan, funds a study through Health New Zealand, and concludes that "carcinogens and toxicants are present only below harmful levels. This study determined the nicotine dose to be comparable to that of a nicotine inhaler, and deemed a "safe alternative to smoking."
American Lung Association. Smoking Facts.
Early studies show that e-cigarettes contain nicotine and also may have other harmful chemicals, including carcinogens.
However, in initial lab tests conducted in 2009, the FDA found detectable levels of toxic cancer-causing chemicals—including an ingredient used in antifreeze—in two leading brands of e- cigarettes and 18 various cartridges.
A review of studies found that levels of toxins in e-cigarette aerosol varied considerably within and between brands.
A 2014 study found that aerosol from e-cigarettes with a higher voltage level contains more formaldehyde, another carcinogen with the potential to cause cancer.
The findings are alarming, and the American Lung Association urgently calls for FDA oversight of these.
FDA in March 2009 Directs US. Customs to reject entry of e-cigs into US ("Import Alert 66-41")
March 2009, Canada bans the sale, advertising, and importation of e-cigarettes. Health Canada advises citizens not to purchase or use them, claiming they contain a "known irritant" (propylene glycol)
October 2009, Amazon.com prohibits sale of electronic tobacco products on its website.
October 2009, PayPal freezes accounts of electronic cigarette vendors in the U.S. and prohibits them from using the service; however, vendors outside of the U.S. are allowed to continue using PayPal for electronic cigarette sales.
Unlike tobacco products, e-cigarettes are not age-restricted.
A recent study from the University of North Carolina found that even in small doses, inhaling the two primary ingredients found in e-cigarettes—propylene glycol and vegetable glycerin—is likely to expose users to a high level of toxins and that the more ingredients a user is inhaling, the greater the toxicity.
Researchers from CDC, FDA, and Georgia State University found that during 2011-2013 the number of youth who had never smoked a cigarette but had used e-cigarettes at least once increased three-fold.
ADVERSE EFFECTS OF E-CIGARETTES:
E-liquid→ Propylene glycol → heated in presence of oxygen→ formaldehyde→ cause cancer
Nicotine is a psychoactive drug which is 10X more addictive than cocaine and it causes the following adverse effects:
Increased blood pressure and cholesterol
Increased risk for heart attack and stroke
Exposure to high doses in adults can be fatal.
Promotes insulin resistance (pre-diabetes), also increases risk for cardiovascular disease.
TOBACCO cigarette smoking is a known risk for cancers, including oral cancer. Patients and clinicians (physicians, dentist and nurses) need to be aware that the use of electronic-cigarettes (E-cigarettes) or other electronic nicotine delivery systems (ENDS) may also be associated with an increased risk of oral cancer
SECOND HAND SMOKING:
In 2016, the Surgeon General concluded that secondhand emissions contain,
"nicotine; ultrafine particles; flavorings such as diacetyl, a chemical linked to serious lung disease; volatile organic compounds such as benzene, which is found in car exhaust; and heavy metals, such as nickel, tin, and lead."
ROLE OF DENTISTS
Dentists have an important role in helping people quit tobacco and promote tobacco prevention and control strategies.
Guide to counselling for Tobacco cessation (5 A’s):
ASK- About their tobacco use and check for oral signs
ADVISE- non users to never use tobacco
ASSESS- the patient’s readiness to quit and level of dependence - high/moderate/low
ASSIST- with quitting by suggesting alternatives like chewing saunf(aniseed), ajwain, eating nuts, drinking water, talking walks, exercising are helpful during periods of craving
ARRANGE- for follow ups, congratulate them on even small successes , empathise with difficulties
Nicotine replacement therapies (NRT)- INDIA:
NRTs available are :
Nicotine gum (available in India in 4mg nicotine pieces: gutka or mint flavour)
Nicotine nasal spray
All of them have controlled doses of nicotine and must be used under medical supervision. Controlled monitoring is necessary and must not be used for periods longer than 6 weeks.
2mg- those who smoke less than 25 cigarettes per day
4mg- those who smoke 25 or more cigarettes per day
Anti craving medication- for the people who suffer from chronic depression due to failed attempts at quitting several times.
1ST LINE DRUGS:
2ND LINE DRUGS:
COUNSELLING THOSE UNWILLING TO QUIT:
The 5R method:
Relevance of quitting
Risks of continuing tobacco use
Rewarding for quitting
Roadblocks to quitting
Repeat these at each visit
Helping patients by providing them with all the required information to help quit smoking and encourage them to lead a healthy lifestyle is the duty of every dentist.
“The greatest medicine of all is teaching people how not to need it ”