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E-cigarettes: would you rather vape than smoke?

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Dr. Rüther, how dangerous or harmful is the e-cigarette?

It is by no means healthy, but - and this is clearly proven - it is much less harmful than the tobacco cigarette. This is what all national and international studies, all toxicological reports say. A smoker's switch from tobacco to e-cigarette is better for his health. Tobacco smoke contains around 4,000 different substances. We know of 70 that they are extremely harmful, around 20 are carcinogenic, but there are also arsenic, lead, nickel and many other combustion products. In e-cigarettes, so-called liquid is vaporized with the help of a filament. So there is no carbon monoxide and there are fewer substances in total. It would be even better, however, to quit smoking completely.

What substances does the liquid contain?

Of course it contains nicotine. From a toxicological point of view, however, nicotine is probably the most harmless of all the substances produced by smoking. In the dose ingested by the smoker, it is not toxic. In the liquid, it is evaporated together with the main carrier substance propylene glycol and some glycerine. The liquid also contains additives, mainly flavorings. What exactly may be included is not yet well regulated by the EU. The manufacturers emphasize that all flavoring substances used are permitted. However, most of them are only approved for consumption, not inhalation. We therefore say: The use of e-cigarettes is a large-scale human experiment. We just don't know what happens when propylene glycol is inhaled along with flavorings for many years. It is probably less harmful than inhaling tobacco smoke, but it is sure to be harmful too.

Is the e-cigarette a good way to quit smoking?

There are two Cochrane reviews on this, but only a few controlled studies. There are only three of the controlled studies of the highest quality, one of which was recently published in the Lancet. Accordingly, it currently looks as if you can use the e-cigarette to quit smoking. Studies on nicotine patches have shown that around 20 percent of study participants stop smoking just by putting the patch on. An English study now suggests: If you give one group of smokers an e-cigarette and give another nicotine patch, then those with the e-cigarette will stop smoking significantly more often after a year than the others: between nine and 18 Percent more. Of those who were smoke-free after a year, 39 percent were still vapers. So you just switched to the e-cigarette. The big addiction medical question that we are currently asking ourselves is: is that good or bad?

Shouldn't the goal be for people to overcome their addiction entirely?

Naturally. But don't forget that smoking is the number one preventable cause of death in the world. In Germany, 328 people die every day, i.e. a jumbo jet full of people. That corresponds to 120,000 people a year. We know that all tobacco cessation methods taken together, including our tobacco cessation courses, manage at most to get 50 percent of the participants to give up each year. General practitioners achieve values ​​of 20 to 30 percent - which is already very good. Smoking is a serious addictive disease that is fatal. The average smoker loses ten years, so we do anything we can to minimize these catastrophic health effects.

At the moment it looks like that many people who switch to an e-cigarette will also quit smoking for a longer period of time, because e-cigarettes are less addictive because the nicotine builds up more slowly than with normal smoking . A smoker feels a kick in the brain after just 20 seconds. This is much slower with e-cigarettes.

How is that with the nicotine patch?

Even with plasters, chewing gum, lozenges, mouth sprays, etc., the nicotine floods in more slowly. Therefore, they can be used well for smoking cessation. We believe that smoking cessation is still very important. Many say: Now with the e-cigarette you can finally wean. We say: yes, but only if you have tried the guideline-based smoking cessation beforehand. There has been an S3 guideline on this for a number of years, to which I also contributed. It contains very good evidence-based methods: a brief psychotherapy, counseling, nicotine supplements and two prescription drugs, bupropion and varenicline, which work very efficiently and can double the quitting rate. That is often forgotten.

The only question is: what happens to people who do not attend a smoking cessation course and cannot or do not want to take medication? For these people, the e-cigarette could be a boon - with the caveat that it is likely to be more harmful than nicotine supplements, which have been shown to have no side effects. The silver bullet is the course. There are certified courses that are also subsidized by health insurance companies.

Could you theoretically wean all smokers in Munich with your courses?

We could, but not that many come. Smokers are often ambivalent. Most want to quit but fail to take a course. Tobacco addiction is one of the strongest addictions of all - with the highest relapse rates. Their own resolution to quit - we call this the New Year's Eve method - only leads to five percent of them being smoke-free after one year. The short medical advice to quit smoking, on the other hand, already reaches ten percent. So if all general practitioners advised every smoker to quit, we would have thousands fewer smokers and thus far less suffering and death. Most doctors, however, fear that their patients will then become aggressive. But that's not true: most of them want to quit anyway and even wait for their doctor to advise them to do so.

Is the e-cigarette suitable for reducing the amount of smoke so that smokers use less “normal” cigarettes?

There are also Cochrane reviews on this, which say that lung function improves with the dual use of e-cigarettes and cigarettes. The only problem is that the quit rates are worse. If you switch to the e-cigarette, you should therefore switch completely. Then you have the chance to become abstinent.

How at risk are children and adolescents from e-cigarettes? Is the e-cigarette a kind of gateway drug?

Until recently I said: definitely no! According to German, British and American data, only 0.2 to 2 percent of all e-cigarette users were “never smokers”, so almost all users were ex-smokers. Until recently, because a new product has now come onto the market: Juul. The e-cigarette has a pod, a kind of USB stick, into which a capsule with a vaporizer and the liquid is inserted at the front. The manufacturer has managed to grow from a garage factory to a billion-dollar company within four years. Every second e-cigarette worldwide is now a Juul. The company did something very clever: they are using a new formulation of nicotine, a nicotine salt or benzoate. In combination with higher concentrations, it floods very quickly. The Juul behaves like a cigarette in relation to the nicotine delivery, so it probably has a comparable addictive potential. In the USA it is a big issue in the school playgrounds even among non-smokers, so I had to revise my opinion: Juul is an entry-level product, at least in the concentration as it is sold in the USA. There the pod contains 50 mg of nicotine per ml, in Europe this is reduced to 20, because fortunately we have a European law on this. As a result, the local juuls probably do not achieve such strong nicotine concentrations in the blood or plasma and thus do not dock so quickly on the receptors in the brain. But we don't know for sure yet, but are researching it first.

Are there any other differences between e-cigarettes?

There are four generations: The so-called cigalikes, which you can buy in the supermarket complete with battery, liquid and microprocessor, were the first. When they are empty they are thrown away. They just have poor nicotine delivery, however. Then there are e-cigarettes, in which you change the cartridges, and the classic tank models from the e-cigarette shops, in which you fill in the liquid yourself. And there is the latest generation, the so-called low-ohm or sub-ohm devices. These devices generate particularly strong steam. You can recognize them by the fact that people are literally enveloped in a cloud of steam with them. In addition, in addition to Juul, there has recently been IQOS ("I quit ordinary smoking") from Philip Morris.

What is so special about it?

IQOS is a tobacco heater that you can buy from good-looking people in special, very chic shops. Philip Morris has brought a new product onto the market, which, however, looks like a wolf in sheep's clothing: By not burning the tobacco, but only heating it, fewer pollutants are produced. However, with the same rapid exposure to nicotine. This means that the product is probably less harmful, but just as addictive. The problem is: So far, there are only research results on IQOS by Philip Morris himself - so no independent research.

Which e-cigarette would you recommend to colleagues for patients who cannot be won over to any other way of smoking cessation?

I would recommend a completely normal tank model to these patients and advise them to switch completely to the e-cigarette. You can get advice about the brand. However, doctors should always try other means first: The problem with nicotine preparations is that they are often used incorrectly: Nicotine should be given in high doses and for three months. It is the same with the drugs bupropion or varenecline. Applied correctly and with good advice, you can achieve an abstinence rate of 30, 40 or even 50 percent after a year.