Safety of Electronic Cigarettes for Smoking Cessation - Research Paper Example

Outline of the review: I. II. Introduction about the problem of tobacco smoking in general III. Methods used in the process of review IV. Review of the safety of ecigarettes A) General considerations about safety of using ecigarettes B) Toxicity of ecigarettes as presented by research studies C) Concerns regarding ecigarettes use D) Review of studies about acceptances and effectiveness of ecigarettes as antismoking aids 1. Consumer oriented studies that recruited ecigarette users a) Pychological effects of ecigarettes use as stated by the users. b) Effectiveness of ecigarettes as antismoking aids as stated by the users c) 3Physiology oriented studies conducted as an experimental method on users 2. Summary on user oriented studies, psychological and physiological impact of ecigarettes use. E) Monitoring ecigaretes as harm reduction tools, can they be accepted as harm reduction tool. F) Why ecigarete are effective harm reduction tool? V. Conclusion on the subject. Problem: Tobacco use, especially smoking, is a prevalent problem not only in the US, but entirely worldwide. The latest “solution” or stop smoking aid is the “electronic cigarette. How safe are these really? Most of these typical products still deliver nicotine to the user, but what else is being ingested? Cigarettes have many, many harmful chemicals released in the smoke, but what is being released by the “vapor” of theses electronic cigarettes that can be harmful? Thesis: The use of the “electronic” cigarette is a viable product in smoking cessation. Users should be aware of exactly what chemicals are being released in the “vapor” of these cigarettes. Safety of Electronic Cigarettes for Smoking Cessation Contents: 1.Abstract 1.1 Introduction 2. Methods 3. Review of the safety of ecigarettes 3.1General considerations about safety 3.2Toxicity of ecigarettes 3.3Concerns regarding ecigarettes 3.4Review of studies about acceptances and effectiveness of ecigarettes as antismoking aids 3.4.1 Consumer oriented studies 3.4.1.1 Pychological effects of ecigarettes 3.4.1.2Effectiveness of ecigarettes as antismoking aids 3.4.1.3Physiology oriented studyes 3.4.2 Summary on user oriented studies 3.5 Monitoring ecigaretes as harm reduction tools 3.6.Why ecigarete are effective harm reduction tool 4.Conclusion 1.Abstrct Tobacco use, especially smoking, is a prevalent problem not only in the US, but entirely worldwide. At the beginning of this century is was estimated that worldwide 1.22 billion people used tobacco, it is estimated that worldwide in year 2010 around 1.45 billion people used tobacco and this number is estimated to rise to 1.95 billion till the year 2025. The statistical data about adverse effect of smocking tobacco worldwide and in US are also alarming. These facts urge the need for finding effective methods for control of the worldwide epidemics of smoking. Ecigarettes are a new and emerging tool that is markets as smoking cessation tool and is widely accepted by the general population. Ecigarettes are the most often purchased on interned or in the local kiosks or shops. They are banned from use in many countries and in some counters as US ecigarettes are subjected to restrictions of import and distribution. Regardless of the wide availability of ecigarettes, their popularity and widespread use little is known about their safety. In this review we tried to present the facts regarding the safety of ecigarettes. We tried to make an educateded guess what are the pro and contra factors for ecigarettes use, should they be banned, how safe are they, are they safer than conventional cigarettes or are they safer than other nicotine replacement therapy. This is difficult question and conclusion about the safety of ecigarettes use was based on a review of studies and research conducted on this subject. On the end we concluded that regardless of the fact that ecigarettes are not safe and are not subjected to standardized production process, banning them will actually lead to increased mortality from tobacco use. 1.1 Introduction Tobacco use, especially smoking, is a prevalent problem not only in the US, but entirely worldwide. At the beginning of this century is was estimated that worldwide 1.22 billion people used tobacco, it is estimated that worldwide in year 2010 around 1.45 billion people used tobacco and this number is estimated to rise to 1.95 billion till the year 2025. The statistical data about adverse effect of smocking tobacco worldwide and in US are also alarming. It is estimated that in US tobacco consumption accounts for 443 000 deaths annually, or in other words one in five deaths in US are as a result of tobacco consumption. More people die in US from tobacco consumption compared to HIV, illegal drugs abuse, automotive accidents, murders and suicides combined (Guindon et al. 2003) (WHO 2008). Smocking is associated with a number of diseases that are predominantly caused by smocking where cessation of smoking is the single most important factor for the increased incidences of lung and throat cancer, chronic obstructive pulmonary disease, emphysema and chronic bronchitis. Cigarette consumption is associated with a number of other medical conditions like myocardial infarction and cardiovascular disease, hypertension, infertility impotention and a great number of other conditions (WHO 2008). This is why there are a many initiatives in order to reduce tobacco use worldwide. One of the latest initiatives to fight the world’s epidemic of smocking are the MPOWER measures introduced by the World health organization in 2009. It is a systematic approach, now accepted from many countries worldwide, to reduce the use of tobacco, implement tobacco free environment for the children, introduce treatments for smoking cessation and other measures that should be implemented in various steps and should be implemented as a public health policy in every country. Countries that accepted this initiative for example accepted that on the packaging of the cigarettes every company must print one of several images of severe medical conditions that are caused by tobacco consumption. There are many measures mentioned in this initiative and one of them is usage of nicotine replacement therapy (NRT) for individuals who can’t stop smocking but actively seek for solution to quit smoking (MPOWER 2011). MPOWER mentions a number of NRT that should be recommended to individuals as a help to quit smoking like nicotine patches, nicotine inhalers, chewing gums, lesions etc. However this global initiative doesn’t mention one aid for smoking cessation that is global phenomenon and is available all around us, however remains relatively undetected and uncommented not just by WHO but by governments, health or environmental organizations worldwide and in US also. This latest “solution” or “stop smoking aid” is the electronic cigarette. It is a product that is advertised as smoking cessation aid, nicotine replacement therapy or by number of other marketing approaches. Mainly ecigaretes are produced in China and there are several brands available on the market. All of them have similar construction, a cigarette like appearance, battery-powered devices that deliver nicotine without any combustion usually by vaporizing a solution of nicotine in propylene-glycol. Electronic cigarette (ecigarette) is widely available an used by the general population but very little is known about their safety, effectiveness as antismoking aid, presence of any adverse effects with prolonged usage, exact composition of the “mist” produced by this devices etc. Regardless of the fact that very little is mentioned about these ecigarettes by official health organizations, ecigaretes are broadly available and are consumed by the general population and their popularity increases with dramatic intensity. In this text we will try to answer how safe are ecigatettes? Most of these typical products deliver nicotine to the user, but what else is being ingested? Cigarettes have many harmful chemicals released in the smoke, but what is being released by the “vapor” of these electronic cigarettes that can be harmful? The use of the “electronic” cigarette is a viable product in smoking cessation. Users should be aware of exactly what chemicals are being released in the “vapor” of these cigarettes and how safe are they. 2. Methods In order to answer the above questions we will conduct systematic review of studies on the subject of ecigaretes. Ecigarettes are a relatively new product and there are not many studies that try to explore the qualities of this product. This is why we included a wider inclusion criteria and in this review we included range of studies that try to explore the production of these ecigarettes, process of advertising of these cigarettes and is this advirtisment in concordance with the results that are achieved with usage of this product. Also we wanted to explore the safety of these cigarettes and how can we compare ecigarettes with conventional tobacco cigarette. In order to find articles we used Google scholar search, JAMA database and NCBI database of articles. We identified a total of 15 articles that will be presented in this study. Google scholar search for “electronic cigarette” resulted in 58 700 articles, the same search on NCBI resulted in 1290 studies related to electronic cigarettes and the same search on JAMA resuted in 8862 articles of journal content. We additionally used keywords like “marketing”, “production”, “smoke”, “FDA” and resulted in 15 studies that will be mentioned in this text. Studies vary in their content and field of research ranging from the process of marketing and advertising of ecigarettes, process of production, distribution, public awareness about the ecigarettes, constitution of the substances and vapor released by these ecigarettes, safety of use and effectiveness as smoking cessation tool and other factors that may affect the safety of ecigarettes. All of the data will be presented as a continuous presentation of all of the findings presented in these studies. Very little is known about the origin and safety of ecigarettes and therefore we will try to present integrated and relatively complete picture about these questions. 3. Review of the safety of ecigarettes 3.1General considerations about safety Electronic cigarettes are new hand-held nicotine delivery systems that function as a battery powered devices that usually works by a process of vaporization by heating of nicotine solution in propylene glycol. The solution is contained in a disposable or reusable cartridge depending of the type or brand of ecigarette. This device is used very similar to usual tobacco cigarette where the process of smoking is called “vaping” which is designed to be very similar as normal cigarette use. However no combustion of tobacco occurs and the nicotine is dispersed in a fine mist that is inhaled and the excess smoke is exhaled similarly as a normal cigarette. Many studies point that the content of nicotine varies between different brands of ecigarette, and in the same time level of nicotine varies every subsequent inhalation of the vapor. Some studies measured the force or vacuum needed to inhale the vapor from electronic cigarettes (Anna et al. 2010). They used mechanical “puffer box” that was able to introduce the same level of vacuum for conventional or ecigarette. They also measured the density of the smoke using a spectrophotometer. They tested a number of branded conventional cigarettes and a number of ecigaretes that were supplied either on internet or from local dealers from mall kiosks or other local shops. In this study the authors found that ecigarettes produce relatively similar smoke density as conventional cigarettes, but only in the first 10 puffs of the usage. After this ecigarettes require stronger vacuum in order to produce the same amount of smoke and the density of the smoke is very variable regardless of the amount of vacuum used to produce the smoke. Authors note that density of the smoke in conventional cigarettes increases over the period of smoking, with usually highest smoke density at the end of the smoking process. Compared to this in ecigarettes the smoke density decreases significantly after 10 or more puffs. This can show us that compared to conventional cigarettes, ecigarettes are not consistent with the level of smoke they disperse with every inhalation, and in general require more vacuum force to inhale compared to conventional cigarettes and this force is stronger with prolonged use of the same cartridge. Authors suggest that this stronger vacuum needed to inhale ecigarettes could have adverse effects on human health because users must more vigorously inhale the mist produced by ecigaretes. 3.2Toxicity of ecigarettes This inconsistency of ecigarettes is reported by other sources. FDA also conducted research on the process of delivery and composition of the inhaled smoke from ecigarettes. They report that concentrations of nicotine vary significantly between brands and nicotine concentration with every inhalation varies even within the same brand (Bridget 2009). They also report that ecigarettes release some toxic and cancerogenic materials, material however that are also present in conventional cigarettes. FDA showed concerns about the consistency and safey of the process of refilling of the cartridges. For example in one of the solutions for refill of the cartridges they found concentration 1% ethylene glycol which is a toxic substance. However FDA report doesn’t provide details about the concentrations of these substances that are present in the mist of ecigarettes. Other authors report that concentrations of these adverse substances are very small and are within the limits that are present in other nicotine replacement therapies (NRT) like nicotine chewing gums, nicotine patches etc. Zachary and Siegelb 2010 mention that FDA failed to report the concentrations of these harmful materials in ecigarette vapor. They comment on a research that included 16 studies that were investigating the constituents found in the vapor or mist of ecigarettes. Authors report that primary the mist of ecigarettes is constituted of propylene glycol, glycerin and nicotine. Authors also comment on the two harmful materials commented by FDA - tobacco specific nitrozamines (TSNA) and diethylene glycol (DEG). In the studies they present only two studies mentioned detection of TSNA in ecigarette vapor at concentrations of 8.2 ng/g, which is very similar with nicotine patches which contain 8.0 ng/g. This concentration is much lower than the levels of TSNA in conventional cigarette. Authors also comment that none the studies reported any traces of DEG. The presence of DEG in cartridges analyzed by FDA authors attribute to usage of nonpharmacologycal purity of propylene glycol by the manufacturers. Zachary and Siegelb 2010 comment that other that TSNA and DEG vapor of ecigarettes does not contain any other substance that may cause any adverse effects. However this is only partially true because other authors report traces of acetaldehyde and mercury in the mist of ecigarettes that are not mentioned by above mentioned sources (Jean-François 2010). This only shows that substances released by ecigarettes may vary between different brands. Some studies showed that particle sizes of the mist produced by the ecigarettes are too small to be deposited into the lungs. This is important because particle size smaller than 5 microns tend to behave as a gas and do not deposit in the lungs but are exhaled with the rest of the air. This is positive characteristic of the ecigarettes compared to conventional cigarettes which is known to have particles that deposit in the lungs. Also some research show that nicotine released by ecigarettes results in more rapid increase of blood nicotine levels compared to nicotine inhalers but much slower compared to conventional cigarette, which means that conventional cigarette delivers higher concentrations of nicotine faster compared to ecigarettes (Laugesen 2009) (Jean-François 2010). On the other hand other studies failed to detect any increase of blood nicotine after inhalation of ecigarette mist (Andrea et al. 2010). 3.3Concerns regarding ecigarettes On the basis of the above mentioned we can conclude that traces of adverse substances have been found in the mist of ecigarettes, and the concentrations and types of substances vary between different brands, or even within the same brand of ecigarettes. This may be worrisome because some authors mention that nonpharmacological purity of materials is used. Also ecigaretes release different concentrations of smoke with every puff and on average users need to use larger forces to inhale the mist compared to conventional cigarettes. However as stated by Zachary and Siegelb 2010 smoke of conventional cigarettes contains between 40 000 and 100 000 different substances that vary of the type of tobacco used and the type of cigarette. Also only about 5000 of the substances are tested (less than 10% of the substances as stated by the authors) with more than 40 different carcinogenic materials that are regularly found in the cigarette smoke. So even though harmful materials have been found in ecigarettes those are found in very little concentrations, similar to the concentrations found in other NRT products (skin patches, chewing gums etc). Also important fact is that particle size of ecigarettes is much smaller and doesn’t deposit in the lungs compared to conventional cigarette that also has larger particles that deposit in the lungs. So is it possible to compare these two products? It is very concerning that there is no direct monitoring of the process of production, process of production of refill solutions or disposable cartridges and no one can safely conclude that maybe in the future some ecigarettes may contain higher toxic levels of harmful substances. However steps to improve the safety of ecigaretes and efforts to implement standardization of the process of production, refill, distribution and other aspects of this “new industry” are already on the way. This is surely stimulated by the reports of very high interests for this products and reported profits counting in millions of dollars. In USA there are several organizations that try to address this concern with safety of ecigarettes. Electronic Cigarette Association promotes implementation of standardization in the process of production, marketing and distribution of ecigarettes. Consumer Advocates for Smoke-Free Alternatives Association tries to promote ecigarettes as a harm reduction tool, something that we will comment later in the text. Another organization is Vapers International Inc. which is one research organization for ecigarette industry that, as stated by the organization, uses services from scientists and advocates for promotion of safe ecigarettes production and distribution. These are only first steps but show promise that this new ecigarettes industry will regulate the concerns about the safety of ecigarettes, especially considering the increasing interest from consumers for this product (Jonathan et al. 2010). We will research this claim further in the text. 3.4Review of studies about acceptances and effectiveness of ecigarettes as antismoking aids 3.4.1 Consumer oriented studies 3.4.1.1 Pychological effects of ecigarettes Regarding the comparisons of ecigarettes with conventional cigarettes and other NRT products we will further analyze studies that try to explore this subject. Research is showing that interest for this product is rapidly increasing and is widely used by the general population of smokers. In the same time companies that produce these ecigarettes report sales counting in millions of dollars worldwide (Jonathan et al. 2010). The awareness for this product is constantly rising over the last 2-3 years and American journal of preventive medicine reports that internet searches for ecigarettes in US exceeded the searches for all other aid or smoking cessation products combined (Ayers et al. 2011). There are studies that try to assess the usage and effectiveness of ecigarettes as smoking cessation tool. One of the main routes for consummation of ecigarettes is internet and therefore this is logical place for research regarding usage and effectiveness of ecigaretes. Jean-François 2010 conducted online survey on a smoking cessation website which included active and previously active smokers who are using or have been using ecigarettes. Survey was published on a public website and subjects had to present information’s about their history of smoking, how did they purchased the ecigarettes, how satisfied are with them, have they have any concerns regarding ecigarettes and other questions. In the result of this study it is significant that exceptionally large percentage of 81 eligible subjects, or79% reported that ecigarettes helped them to quit cigarettes “a lot”. On the questions what is the biggest benefit of ecigarettes subjects stated that it is “improved breathing and respiration”, “less breathlessness on exertion” or even “I quit smoking without problems”. About the negative aspects of ecigaretes, subjects reported poor quality of the device, impractical to use (the process of refill for example) etc. One very important question and concern that was stated by the participants was: are ecigarettes safe and toxic? Authors of this study found that subjects were in general satisfied with ecigarettes, regardless of the fact that they were concerned about the quality and safety of the ecigarettes. But regardless of their concern about the safety subjects on average consumed 175 puffs a day and only 8 participants stopped using them from various reasons (not just safety). Based on this study we can conclude that smokers like the concept of ecigarette and are willing to use them regardless of the fact that they have concerns about their safety. But they also want a better quality product and better information’s about their safety. This study only confirms that cigarette smokers like the concept ecigarettes and probably the trends of usage will continue to rise in the years that follow. This is concerning considering the fact that ecigarettes are used frequently and require many puffs (175 on average) and still are not under any control and are not subjected under the regulation for safety. Then why are they still using them? Obviously they consider that ecigarettes are still less harmful than conventional cigarettes. 3.4.1.2Effectiveness of ecigarettes as antismoking aids The effectiveness of ecigarettes as a smoking cessation tool reported by the subjects in the above mentiones study are similar to the results obtained by the study conducted by Michael et al. 2011. They similarly used online survey in order to investigate the habits of ecigarettes users and the effectiveness of ecigarettes as smoking cessation tool. For this purpose they used the email database from one of the leading ecigarette distributors to contact first time ecigarette users 6 months after the purchase of ecigarettes, and send them a survey of questions. From a total of 5000 email they managed to obtain 216 usable feedbacks. Results reported by the authors are very interesting. More than 2/3 of the subjects (or 66.8%) reported that they reduced the number of cigarettes a day and 49.3% reported reduced nicotine use, also 48.8% reported that they quitted smoking for a period of time after purchasing the ecigarettes. Authors also report that 31% of the subjects were non-smokers at 6 month after ecigarettes purchase. From those who quit smoking at 6 months 56.7% still used ecigarette, 9% used tobacco free nicotine products and 34.3% didn’t use nicotine at all. It is more interesting if we compare these number with the average effectiveness form other available NRT. For example Stead et al. 2008 reported that overall prevalence of smoking cessation after 6 mounts of usage of NRT tools is 17.8% and the prevalence’s of smoking abstinence periods in that same period was 11.9%. As we can see ecigarettes effectiveness in this study is more than double of that registered by other NRT tools. Authors of this study rightfully suggest that ecigarettes could be considered as effective tool for smoking cessation. 3.4.1.3Physiology oriented studyes In the same context we can analyze the study conducted by Andrea et al. 2010. In contrast to the above mentioned studies Andrea et al. 2010 tested the psychological and physiological effects of ecigarettes compared to conventional cigarettes. They tested differences between smoking ecigarettes and conventional cigarettes particularly differences in the blood levels of nicotine, concentration of exhaled carbon monoxide after smoking and subjective effects of smoking on different aspects (craving for cigarette, anxiety, urge to smoke etc.) in a32 participants. They found that compared to cigarettes, ecigarettes did not increased blood nicotine levels, did not produce increase in exhaled carbon monoxide levels compared to conventional cigarettes. However participants stated that ecigarettes reduced their carving for a cigarettes and their urge to smoke. Andrea et al. 2010 comment that regardless of the fact that ecigarettes failed to raise the blood levels of nicotine still had the ability to reduce the feeling of carving for a cigarette in the participants, and interestingly authors suggest that ecigarette can be used as an alternative or competitive product for cigarettes. This is comparable to above mentioned studies that show that ecigarettes produces significant reduction of the carving and urgency for taking a cigarettes which was the reason for reduction of number of cigarettes. This study also shows that ecigarette affects not just physiological needs for nicotine but also addresses behavioral need for the “ritual” od smoking and reduces the need for smoking by mechanisms other than nicotine consummation. 3.4.2 Summary on user oriented studies We can see that above reviewed studies obtained similar results. In studies conducted by Jean-François 2010 and Michael et al. 2011 we found that ecigarettes resulted in significant reduced tobacco consumption and also in significant percentages subject reported complete abstinence from smoking with usage of ecigarette. One thing that is significant is that high percentages of participants that reported reduced cigarette smoking or quitted smoking in the same time reported high intensity of using ecigarettes. Based on this we can safely conclude that ecigarette acts as a direct competition to cigarette smoking and subjects that use ecigarette usually doesn’t stop the actual “process” of smoking and nicotine consumption. This idea for competition effect between ecigarettes and conventional cigarettes was observed by Andrea et al. 2010 also. So we can conclude that ecigarettes maybe should be viewed as a “new brand of cigarettes” where the negative effects of conventional cigarettes are replaced by the much smaller negative effects of the ecigarette. Because of their widely accepted usage and increasing number of users their usage and side effects must be monitored in the primary care health system in order to asses eventual negative effects of ecigarettes. This will surely minimize the eventual negative effects of ecigarette consumption (Ware et al. 2011) 3.5 Monitoring ecigaretes as harm reduction tools Based on the above we should ask the question: is this process of transmission from conventional cigarette to ecigarette safer, what are the risks if any and what are the possible negative or positive implications? Zachary and Siegelb 2010 suggest that in essence ecigarettes can be monitored as a harm reduction process, where smoking is substituted with less harmful “vaping” of ecigarettes but yet still harmful. Harm reduction is one of the policies of public health and its intention is to reduce the negative effects of usage of recreational drugs and other risk factors, nut by quitting the habit but merely reducing its negative effects. Principles of harm reduction so far seemed inapplicable for tobacco smoking because of several reasons, as mentioned by Zachary and Siegelb 2010. Here we will present the key concerns that were the reason for the belief for impracticality of harm reduction procedures in tobacco smoking epidemics and in the same time why ecigarettes overcome those concerns: - One of them is that presenting less harmful alternative may lead individuals who other ways would stop smoking completely, to start using other alternative that is less, but still harmful: authors conclude that ecigarettes are not tobacco alternative but new form of NRT that addresses both pharmacological and behavioral needs of the smokers and therefore they stimulate smokers who other ways wouldn’t to try to quit smoking, to try quit smoking. - Other argument was that tobacco consumption is dependent of tobacco combustion and no process can make this safer: ecigaretes doesn’t combust tobacco so therefore this concern doesn’t apply to ecigarettes - Alternatives, as the so called “Light” cigarettes for example, actually lead users to start compensating for the lower nicotine and consume even more “Light” cigarettes: authors conclude that available studies show that ecigarettes doesn’t contain any of the 10 000 chemicals present in conventional cigarettes, and even though harmful materials have been detected they are at very low doses. - Next reason is that NRT are ineffective, unappealing and the users don’t like them, therefore they actually help the tobacco industry with the fact that they are so ineffective: as we mentioned above users of ecigarettes actually liked ecigarettes and they helped them in large percentage to reduce or quit smoking, so they are not as ineffective as other NRT tools and can actually be viewed as competition to conventional cigarettes - And the final argument is that tobacco industry cannot be trusted, which authors comment, had been proven on a numerous occasions: this also doesn’t apply to ecigarettes because they are produced by other manufacturers and actually as Jonathan et al. 2010 stated, ecigarettes are part of a new industry and already steps have been made to make ecigarette production standardized in order to improve the quality and safety (Jonathan et al. 2010). 3.6.Why ecigarete are effective harm reduction tool Zachary and Siegelb 2010 analyzed all of these claims in the perspective of ecigarettes and their conclusions are very interesting. The most important conclusion that we can make from their research is that ecigarettes are a direct competition to tobacco industry, something that no other product until now was able to achieve. In the same time their research shows that ecigarettes promise to be very effective tool for harm reduction, something that no other product was able to do until now. This concept of harm reduction is widely accepted principle in public health and used in many aspects of life. One very simple example of harm reduction is the usage of seatbelts and airbags in motor vehicles. Even though seatbelts doesn’t prevent automotive accidents, or even prevent injury they significantly reduce the risks from injury. Supporters of harm reduction principles in cigarettes epidemics are louder and louder in their pressure to accept these principles in fighting this epidemic. Carl 2009 comments that general population is unaware about the principle of harm reduction regardless of the fact that there are available NRT tools that can qualify for this process and ecigarettes are certainly one of those tools. Carl 2009 comments that there are many claims why harm reduction is not presented as alternative and none of them is scientifically acceptable. Comments that harm reduction strategies may lead non-smokers to try these new, les harmful alternatives of smoking simply cannot be balanced with significant reduction of health risks with usage of NRT devices. Other claims are that with these new NRT, like ecigarettes one harmful addiction is only replaced by another one, less harmful but still harmful. However he comments that every act that discourages a cigarette smoker, even those smokers who would completely quit smoking, to switch to some form of lower risk alternative (including ecigarettes) is more likely to kill him than switching to the new low-risk alternative. In the same manner waiting for an improved and safer NRT (ecigaretes included) or other safer aid for smoke cessation, rather than encouraging the smoker to accept the existing ones, actually will kill more smokers than it will ever save. Considering the fact that none of the above mentioned studies doesn’t report any negative adverse effects of ecigarette use (even though some studies interviewed long-term users of these devices) shows that ecigarette definitely qualifies as an alternative for smoking. So what can we say about the fact that officially FDA issued a number of warning letters to ecigarette distributers in 2010 commenting that distribution of ecigarettes is violation of the legislation of Federal food, drug and cosmetic act (FDCA) and they must contact FDA for further analysis of the safety of these products. Also on several occasions FDA refused import of these products for a number of distributors. Based on the comments of Carl 2009 these attempts of FDA to restrict the distribution of ecigarettes will actually kill even more smokers. Is it possible to draw a line and make a conclusion? Based on all of the above we can conclude that at the moment there is nothing more harmful than smoking conventional cigarettes and every attempt to ban ecigarettes or discourage smokers to use them will certainly kill more people. 4.Conclusion Based on all above we can conclude that ecigarettes are definitively not a standardized product and the process of production, marketing and distribution is not regulated or controlled by any official governmental or nongovernmental organization. However there are some organizations already formed that are trying to implement some form of standardization and monitoring of the quality of these products. But regardless of these facts none of the studies mentioned above, including research conducted by FDA, shows that toxic or cancerogenic levels substances are present in the ecigarettes. Actually the opposite is true where all of the studies reported none or much smaller concentrations of harmful substances when compared to conventional cigarettes. Definitively performances of ecigarettes are not standardized and show significant variations between brands and even between same brand of ecigarette, or even within the same cartridge of ecigarette where the concentrations of nicotine and smoke vary with every puff, we didn’t detect any negative effects of ecigarette consumption. On the contrary the opposite is true, where users of ecigarette repotted improved breathing, improved feeling of breathlessness after exertion and other improvements after replacing conventional cigarettes with ecigarettes. And this last term – “replacing conventional cigarettes with ecigarettes” is the key point in understanding the benefits of ecigarettes. Users definitely like ecigarettes more than other NRT tools, and they consistently report that ecigrette is effective in reducing their carving for cigarette and their urge to smoke a cigarette therefore users report that ecigarette effectively succeed to replace the conventional cigarette. This is very important fact because it shows the great potential of the ecigarette concept for future design of new and more effective NRT tools. However as Carl 2009 states simply waiting that newer and safer ecigarette, that is standardized, safer and maybe more expensive, will actually kill significantly more people than switching to ecigarette immediately. Therefore we can conclude that conventional cigarettes are exceptionally dangerous and make significant contribution to the morbidity and mortality in the whole world and ecigarettes at the moment seems to be one of the best smoking cessation tools regardless of the fact that there are reasons for concern regarding the usage of this device. 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Am J Prev Med 2011;xx(x)xxx, doi: 10.1016/j.amepre.2010.12.006 Stead L, Perera R, Bullen C, Mant D, Lancaster T (2008), Nicotine replacement therapy for smoking cessation (review). The Cochrane Collaboration 2008;3:1–160. Jonathan K Noel, Vaughan W Rees, Gregory N Connolly (2010), Electronic cigarettes: a new ‘tobacco’ industry?, Tobacco Control, Tobacco Controltobaccocontrol.bmj.com, Tob Control doi:10.1136/tc.2010.038562 Andrea R. Vansickel, Caroline O. Cobb, Michael F. Weaver, and Thomas E. Eissenberg (2010), A Clinical Laboratory Model for Evaluating the Acute Effects of Electronic “Cigarettes”: Nicotine Delivery Profile and Cardiovascular and Subjective Effects, American Association for Cancer Research, Cancer Epidemiology, Biomarkers & Prevention, Published OnlineFirst on July 20, 2010 as 10.1158/1055-9965.EPI-10-0288 Carl V Phillips (2009), Debunking the claim that abstinence is usually healthier for smokers than switching to a low-risk alternative, and other observations about anti-tobacco-harm-reduction arguments, Harm Reduction Journal 2009, 6:29 doi:10.1186/1477-7517-6-29 Ware G Kuschner, Sunayana Reddy, Nidhi Mehrotra, and Harman S Paintal (2011), Electronic cigarettes and thirdhand tobacco smoke: two emerging health care challenges for the primary care provider, Int J Gen Med. 2011; 4: 115–120. Published online 2011 February 1. doi: 10.2147/IJGM.S16908, PMCID: PMC3068875 Annoted bibliography: WHO Report on the Global Tobacco Epidemic, (WHO) 2008: the MPOWER package. Geneva: World Health Organization. 2008. ISBN 978-92-4-159628-2. WHO initiative for fighting world’s tobacco epidemics. It is a set of procedures and recommendations that should be accepted by the public health departments of the countries that will accept the MPOWER initiative. At the time of the publication 23 countries accepted these recommendations, mostly western countries. MPOWER is a systematic review of all accepted measures that can be used as a tool for reducing the incidence and prevalence of tobacco consumption, but in the same time reduce the risks of tobacco consumption to non smokers and children. Guindon, G. Emmanuel; Boisclair, David (2003) (PDF). Past, current and future trends in tobacco use. Washington DC: The International Bank for Reconstruction and Development / The World Bank. pp. 13–16. Retrieved 2009-03-22. This paper first estimates the number of tobacco users in 2000 and cigarette consumption from 1970 to 2000 by regions and levels of development and briefly discusses the advantages and disadvantages of estimating tobacco use on the basis of prevalence surveys or aggregate data. Secondly, prevalence (and its associated number of smokers) and cigarette consumption (total and per capita) are projected in the future using several scenarios of changes in tobacco use (prevalence and cigarette consumption), as well as different assumptions about population and income growth. The results show that even if all countries immediately implement a comprehensive set of tobacco control policies, the reduction in the number of tobacco users and the total consumption of cigarettes will be gradual.  Jonathan K Noel, Vaughan W Rees, Gregory N Connolly (2010), Electronic cigarettes: a new ‘tobacco’ industry?, Tob Control doi:10.1136/tc.2010.038562 It is a correspondence of the authors that are involved in the regulation and the problems with the safety of ecigarettes (Harvard School of Public Health, Global Center for Tobacco Control). Authors cite several organizations that are involved in the process of regulation for ecigarettes production, marketing and distribution. Authors conclude that this are only first steps but very important because ecigarettes can be monitored as a new industry with registered significant interest and profit. Ayers JW, Ribisl KM, Brownstein JS (2011), Tracking the rise in popularity of electronic nicotine delivery systems (“electronic cigarettes”) using search query surveillance. Am J Prev Med 2011;40(4):XXX–XXX. Authors monitored keywords for internet searches on google search engine for several keywords which were names of most popular nicotine replacement therapies (NRT), including ecigarettes. Authors found that electronic cigarette searches (ENDS) were significantly higher compared to other NRT tools and this tendency seemed to increase over time. Authors conclude that even though ENDS are newer products compared to other NRT tools there is significantly greater internet interest for ENDS compared to other NRT tools. FDA (2010), FDAacts against 5 electronic cigarette distributors, FDA PRESS RELEASE, Consumer Inquiries: 888-INFO-FDA, For Immediate Release: Sept. 9, 2010, available online at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2010/ucm225224.htm Official news release from the FDA department of the government of US about the actions taken against distributors and importers of ecigarettes. FDA reports that distributors of ecigarettes were accused for violation of various violations of the Federal Food, Drug, and Cosmetic Act (FDCA) including unsubstantiated claims and poor manufacturing practices. This text doesn’t show hat ecigarettes were banned but simply that some actions have been taken against companies involved in import and distribution of ecigarettes. Anna Trtchounian, Monique Williams and Prue Talbot (2010), Conventional and electronic cigarettes (e-cigarettes) have different smoking characteristics, Nicotine & Tobacco Research, Volume 12, Number 9 (September 2010) 905–912, doi: 10.1093/ntr/ntq114 Authors conducted well designed study to monitor physical characteristics of conventional and ecigarettes. They conclude that generally, e-cigarettes required stronger vacuums (suction) to smoke than conventional brands, and the effects of this on human health could be adverse. The amount of aerosol produced by e-cigarettes decreased during smoking, which necessitated increasing puff strength to produce aerosol. The decreased efficiency of aerosol production during e-cigarette smoking makes dosing non-uniform over time and calls into question their usefulness as nicotine delivery devices. Bridget M. Kuehn (2009), FDA: Electronic Cigarettes May Be Risky, JAMA, September 2, 2009—Vol 302, No. 9 This is outline of the conducted analysis of 2 widely marketed and used electronic cigarettes conducted by FDA. FDA states that tested ecigarettes showed inconsistency of the level of nicotine they release and nicotine was found even in ecigrettes that were marketed as nicotine free. FDA report’s findings of cancerogenous materials in the tested ecigarettes and also found toxic materials in the refill bottle that were intended to refill the cartridges used by ecigaretes. Zachary Cahna and Michael Siegelb (2010), Electronic cigarettes as a harm reduction strategy for tobacco control: A step forward or a repeat of past mistakes?, Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy 1–16 available online at: www.palgrave-journals.com/jphp/ Authors state that ecigarettes can be accepted as a harm reduction tool. They state that until the appearance of ecigarettes harm reduction was inapplicable on the tobacco industry because of several reasons, including that tobacco industry cannot be trusted that will produce risk free or low risk substitute for cigarettes. This is confirmed by the previous history of tobacco industry. However ecigaretted are not produced by the tobacco industry and are in fact competition to the conventional cigarettes. This is the reason why authors state that ecigaretes can be marketed as harm reduction tool. Jean-François Etter (2010), Electronic cigarettes cigarettes: a survey of users, Etter BMC Public Health 2010, 10:231, available online at: http://www.biomedcentral.com/1471-2458/10/231 Authors used internet as a tool to recruit ecigarettes users and obtain their opiniot on several important topics regarding subjective feelings and opinions of the ecigarette users. Authors found that ecigarette users were satisfied with the product and stated that ecigaretes helped them to reduce or quit smoking in relatively large percentages. However participants stated that they are concerned about the safety of ecigaretes and their quality of production. Laugesen M (2009), Ruyan e-cigarette bench-top tests. Poster presented at the Conference of the Society for Research on Nicotine and Tobacco Dublin, April 27-30, 2009 2009. This is poster presentation of the results of chemical analysis of the ingredients found in the ecigarettes. Authors also tested the mechanism and concistency of ecigarettes regarding smoke release, intensity of effort needed to smoke the ecigarette and other parameters. Authors also conducted chemical analysis of the content of ecigarettes and found traces of mercury and other substances. Michael B. Siegel, Kerry L. Tanwar, Kathleen S. Wood (2011), Electronic Cigarettes As a Smoking-Cessation Tool Results from an Online Survey, American Journal of Preventive Medicine, Published by Elsevier Inc. Am J Prev Med 2011;xx(x)xxx, doi: 10.1016/j.amepre.2010.12.006 Authors used the email database of one of the largest distributors of ecigarettes in order to contact the first time users of ecigarettes. They contacted them by email 6 months after the purchase in order to complete a survey of question. Authors found that ecigarettes helped the users to significantly reduce number of cigarettes a day and in 31% of the cases to completely quit smoking. Authors also note that large percentage of users was still using ecigarettes after 6 months of purchase. Stead L, Perera R, Bullen C, Mant D, Lancaster T (2008), Nicotine replacement therapy for smoking cessation (review). The Cochrane Collaboration 2008;3:1–160. Authors tested the effectiveness of different nicotine replacement therapies and found. They state that NRT tools aim to reduce withdrawal symptoms associated with stopping smoking by replacing the nicotine from cigarettes. They are available as skin patches that deliver nicotine slowly, and chewing gum, nasal spray, inhalers, and lozenges/tablets, all of which deliver nicotine to the brain more quickly than from skin patches, but less rapidly than from smoking cigarettes. Effectiveness of these tools s a smoking cessation tool are relatively small and future research is needed in order to design more effective NRT Andrea R. Vansickel, Caroline O. Cobb, Michael F. Weaver, and Thomas E. Eissenberg (2010), A Clinical Laboratory Model for Evaluating the Acute Effects of Electronic “Cigarettes”: Nicotine Delivery Profile and Cardiovascular and Subjective Effects, American Association for Cancer Research, Cancer Epidemiology, Biomarkers & Prevention, Published OnlineFirst on July 20, 2010 as 10.1158/1055-9965.EPI-10-0288 Authors tested several brands of ecigarettes and conventional cigarettes in order to test their ability to deliver nicotine and in the same time release of carbon monoxide. Authors did not detect that any of the tested ecigarettes brands elevated the blood levels of nicotine and in the same time, compared to conventional cigarettes, ecigarettes did not release carbon monoxide. Regardless of this fact ecigarettes acted as an effective cessation tool because they reduced the carving and urge to smoke by the participants. Carl V Phillips (2009), Debunking the claim that abstinence is usually healthier for smokers than switching to a low-risk alternative, and other observations about anti-tobacco-harm-reduction arguments, Harm Reduction Journal 2009, 6:29 doi:10.1186/1477-7517-6-29 Authors systematically present his professional view about the choices and methods for smoking cessation. He concludes that available NRT tools are not es effective as they should be and new methods should be developed. He states that ecigarettes show promise that may be an effective smoking cessation tool, however is yet untested and unstandardized. Regardless of this fact authors states that banning of ecigarettes will result in more death because regardless of the fact that ecigarettes are not entirely tested continous use of cigarettes will result in more death compared to ecigarette use. Ware G Kuschner, Sunayana Reddy, Nidhi Mehrotra, and Harman S Paintal (2011), Electronic cigarettes and thirdhand tobacco smoke: two emerging health care challenges for the primary care provider, Int J Gen Med. 2011; 4: 115–120. Published online 2011 February 1. doi: 10.2147/IJGM.S16908, PMCID: PMC3068875 Authors state that primary care providers should be aware that there is a new threat that they must consider when searching for the etiology of the respiratory or other problems. Ecigarettes are emerging as a factor for health regardless of the fact that they are found to have small concentrations of harmful materials. The appearance of ecigarettes on the marked should te a subject of attention similar to the third hand tobacco smoking because there is a increasing number of users and the characteristics of these devices is not fully tested. Read More