This study, called Effect of Smoking Abstinence and Reduction in Asthmatic Smokers Switching to Electronic Cigarettes: Evidence for Harm Reversal, was conducted by Riccardo Polosa, Jaymin Morjaria, Pasquale Caponnetto, Massimo Caruso, Simona Strano, Eliana Battaglia, and Cristina Russo, and published on May 8, 2014 in the International Journal of Environmental Research and Public Health.

You can see the full study here. Below is our review of the study and its findings.

Summary & Review

This study compared the effects that e-cigarettes have on asthmatic smokers to the effects that traditional cigarettes have on asthmatic smokers. E-cigarettes have been marketed as safer alternatives to traditional cigarettes and have been shown to reduce consumption of cigarettes in regular smokers.

In the study, multiple asthmatic parameters were measured, including spirometry data and subjective asthma control in 18 asthma patients who were smokers and switched to e-cigarettes.

At the end of the study, there were significant improvements in spirometry, and asthma control (how the patient felt); these significant improvements were found in both dual (e-cigarette and reduced cigarette) and single users (just e-cigarettes). Decrease in exacerbations was reported as well, but was not significant.

The study indicates both subjective and objective improvements in asthma-related symptoms in users who have substituted e-cigarette use for cigarette smoking. Because e-cigarettes are reportedly less harmful than traditional cigarettes and can curb cravings for traditional cigarettes in addition to improving certain asthma-related symptoms, this study shows that e-cigarettes are a viable option for asthma patients who have not been able to quit smoking traditional cigarettes by any other means.

The percentage of asthma patients who smoke is comparable to the percentage of all smokers in the general (non-asthmatic) population. Asthma patients who smoke seem to have a lower response to inhaled corticosteroids (ICS) and other oral corticosteroids (inhalers) compared to asthma patients who do not smoke. It has been found that smoking cessation can reverse worsening asthma symptoms and lung function changes. However, reported levels of smoking cessation in asthma patients are low due to the lack of awareness of the direct correlation between smoking and their poor respiratory symptoms.

Materials & Methods

An electronic cigarette is a battery-operated device designed to deliver nicotine without burning tobacco. Instead, it heats e-juice, a mixture of propylene glycol and/or vegetable glycerine, flavorings, and nicotine. These devices can be attractive to smokers who see their smoking as a recreational habit and want to continue it in a less harmful manner, and also attractive to smokers who have had trouble quitting using available medications.

Data was collected during four visits, using multiple data points. The four visits included a pre-baseline visit (the subjects of the study were existing patients at a clinic), a baseline visit just before switching to e-cigs, and two follow-up visits, one at about 6 months and the next at about 12 months from the baseline visit.

At each visit, spirometry data, exacerbation values, and a Juniper’s Asthma Control Questionnaire (ACQ) score (subjective test of how the patient feels) were collected.

• Spirometry measures how much air you can inhale and exhale, and how fast you can exhale. Data was collected using a spirometer, a tube through which a subject inhales and exhales for an allotted amount of time. The data produced may be fed into a computer that converts the readings into numerical data values to allow for easy analysis. Spirometry data is used to evaluate the severity of asthma in a patient and sometimes to diagnose Chronic Obstructive Pulmonary Disease (COPD).
• An asthma exacerbation is an episode of progressive worsening of asthma symptoms, including shortness of breath, wheezing, coughing, and chest tightness.
• Juniper’s Asthma Control Questionnaire (ACQ) is a simple questionnaire completed by asthma patients to determine the effectiveness of treatment or medication. The patient simply answers questions about the way he or she feels and these answers are compared with the patient’s earlier ACQs.

Study Results

As to be expected, there was no significant difference in data collected at the pre-baseline and baseline visits. At the six-month, or first follow-up visit, there were significant improvements in both ACQ scores and some spirometry data points. At the 12-month, or second follow-up visit, there were significant improvements in ACQ scores, as well as several spirometry data points.

During the observation period (time during which the e-cig was used), there were no reported severe adverse effects or acute exacerbations of asthma symptoms (coughing, wheezing).

This study shows, for the first time, improvements in asthma control, airway hyperresponsiveness, and pulmonary function in asthmatic smokers as a result of lowering or ceasing cigarette consumption by switching to e-cigs.

The high success rate of quitting or reducing smoking may be because of how easily the e-cig can replace the physical and behavioral habits that are formed through cigarette smoking (such as the hand-to-mouth action). The results of this experiment suggest that the harmful effects of smoking on asthmatic airways may be reversed.

The improvement in lung function could be due to the lack of pro-inflammatory effects in the airways caused by cigarettes. This improvement in lung function could also be associated with the asthmatics’ increase in beneficial effects from inhaled corticosteroids (inhaled acetylcholine or inhaler), which are diminished by cigarette smoking (most smoking asthmatics experience little to no relief from corticosteroids).

Although it is impossible to know if the patients’ use of e-cigs caused the positive improvements seen in these mild-to-moderate asthmatic smokers in this study or not, evidence clearly suggested that e-cig use was not harmful to asthmatic smokers.

Conclusion

This study shows that e-cigarettes help reduce or cease cigarette consumption in asthmatic smokers and therefore reduce the affliction of smoking-related asthma symptoms.

Due to the positive findings of this experiment, we can confidently support the idea that smoking cessation or tobacco harm reversal using e-cigs is a valuable alternative to smoking not only in habit replacement but in improved pulmonary function as well.

The following is a summary of a public lecture given by Dr. Lynne Dawkins at the University of East London on July 3, 2013, called “Electronic Cigarettes: What We Know So Far.”

Dr. Lynne Dawkins is an Experimental Psychologist at the University of East London, and has more than 15 years of experience researching tobacco, nicotine delivery, and electronic cigarette use by new and experienced vapers. Dr. Dawkins is the leader of the Drugs and Addictive Behaviours Research Group at UEL, and is considered on of the UK’s leading authorities on e-cigarettes. She has published many papers on e-cigarette use, effects, and nicotine delivery, and has shared her research at academic conferences and in public lectures. The full video of this lecture can be viewed here. The presentation slides can be viewed here.

History of Electronic Cigarettes:

• Electronic cigarettes were introduced in China in 2004 and in Europe in 2006. Since then, the number of e-cigarette users (also known as vapers) has skyrocketed.
• Between 2012 and 2013, the number of e-cigarette users in the UK rose from 2% to 12% of the population. There are an estimated 1.3 million e-cigarette users in the UK as of 2013.
• Production of E-cigarettes is rooted mostly in China with some production in both the UK and the USA.
• Due to the rapid growth of e-cigarettes, tobacco companies are now investing in the e-cigarette market.

Current Use of E-Cigarettes:                

• ~72% of vapers in the UK use 2^nd generation e-cigarettes, meaning the non-disposable kind.
• ~18% use disposable e-cigarettes, also known as “ciga-likes.”
• ~9% use customized devices.
• Regarding nicotine concentrations, ~49% of vapers use e-juice with 18mg/ml of nicotine; ~33% use 11mg/ml; ~21% use combined strengths (for a custom nicotine levels); and ~1% use 0mg/ml.

Why Do People Use E-Cigarettes?

• People use electronic cigarettes for several important reasons. The most common of which is as an alternative to smoking.
• Why are e-cigarettes an appealing alternative to smoking tobacco cigarettes? Because they make it easier to quit by curbing withdrawal symptoms and cravings; they are much less toxic than cigarettes; they are also significantly cheaper than cigarettes.
• Tobacco contains more than 5000 known chemicals, 40 of which are known carcinogens (cancer-causing substances). The adverse effects of cigarettes result from the combustion of tobacco. Nicotine by itself is relatively safe, other than its addictive nature.

Smoking Cessation Stats:

• 67% of smokers want to quit, and 75% of smokers try to quit. However, only about 8% are successful at quitting after two years (Omnibus Survey, 2009).
• Common reasons for relapse include: liked smoking (20%), and missed the habit (12%).
• 95-97% of unaided quit attempts end in failure.
• Nicotine Replacement Therapy (NRT) — such as gum, patches, and inhalers — double a smoker’s chance of quitting. Even doubled, that still leaves a success rate of only 6-10%.

Why do most attempts to quit end in failure?

Some of the most common reasons include:

• Reluctance to use nicotine while quitting.
• Ineffective nicotine delivery from NRT.
• Lack of control over nicotine delivery.
• Inability to replace the “habit” of smoking. i.e. the oral fixation.
• For many people, e-cigarettes can help overcome these issues when trying to quit smoking cigarettes.

Studies on Quitting Tobacco Cigatettes Using Electronic Cigarettes:

• Study One Results: 74% of respondents had not smoked at all for at least a few weeks since starting to use e-cigarettes, and 14% dramatically reduced their cigarette consumption.
• Study Two Results: 92% of respondents claimed that e-cigarettes helped them to reduce their smoking. 96% of ex-smokers claimed that using an e-cigarette helped them to quit smoking.

Survey of Smokers Who Purchased an E-Cigarette:

• 31% of the participants were abstinent from smoking at 6 months.
• For those participants who were using the e-cigarette more than 20 times a day, the quit rate was 70%.

Study of 40 Smokers Not Willing to Quit:

• In this study, 40 smokers who were unwilling to quit smoking were given e-cigarettes. At 6 months, 55% of participants were either abstinent of smoking or had a reduction of at least 50% of their prior consumption of cigarettes.
• In another study performed in Italy, 300 smokers who did not want to quit were surveyed after being given e-cigarettes 3 different nicotine levels. The abstinence rates at one year were as follows: 7.2mg = 13% abstinent; 4.8mg = 9%; 0mg = 4%.

Are Electronic Cigarettes Safe?

• The safety of electronic cigarettes is perhaps the biggest source of contraversy. Are e-cigarettes safe? The answer is no, they are not ABSOLUTELY safe. But what is? How many products do we come into contact with on a regular basis that are not 100% safe?
• When discussing the saftey of electronic cigarettes, the questions needs to be, are they safer when compared to traditional cigarettes?

E-Juice Ingredients, Vapor, & Safety Concerns

• Components of e-juice include nicotine, flavorings, propylene glycol and/or vegetable glycerin.
• Propylene glycol (PG) is found in foods, medicines, cosmetics, and artificial fog, and is generally regarded as safe for oral consumption by the FDA. Long term effects of inhalation of PG are unknown.
• A 20 ml bottle of e-juice that is 18 mg/ml nicotine contains 360 mg of nicotine.
• A lethal dosage of nicotine is 30 mg of nicotine (higher for a smoker). A person cannot realistically overdose from vaping e-ciagetettes due to controlled intake, and the physical effects that would be felt before reaching that amount. The only way to overdose would be to drink the liquid straight.
• A study on E-cigarette vapor and air quality showed that over a 3-minute period, e-cigarettes contaminated the air at an amount of 43 parts per million, whereas traditional cigarettes contaminated the air at an amount of 901 parts per million.

E-Cigarettes & Minors

• It is argued that e-cigarettes are geared towards young people, however there is no real evidence proving this.
• In a study of Polish youth, of those who had smoked a cigarette before, only 1/5 of those youths had tried and e-cigarette. In that same study, of those who had never smoked, only 3.2% had tried an e-cigarette.

Conclusions About Safety & Regulation

• Although e-cigarettes cannot be considered safe necessarily, they can be considered far less harmful than cigarettes. It is up to users to decide whether a safer addiction to nicotine is the right choice for them.
• With e-cigarettes, the addiction to nicotine can be more closely monitored, and the amount of nicotine received can be better controlled.
• The National Institute of Clinical Excellence has endorsed NRT to curb and quit smoking.
• We now know more about e-cigarettes than tobacco cigarettes. This is due to the fact that the number of chemicals found in cigarette smoke vastly outnumbers those found in e-cigarette vapor.
• Because of the risks associated with e-cigarette use, we must strive for safety and regulation on e-cigarettes without over doing it, and without making it a less viable option for helping those who want to quit smoking cigarettes.
• E-cigarettes are less harmful than cigarettes, and thus have a huge potential for lowering death and disease rates associated with smoking cigarettes.
• Electronic cigarettes must be fought for, and overregulation of electronic cigarettes is not in the best interest of public health which is a really serious matter for any people that doesn’t like cigarettes of any sort since they can even produce heart diseases, and they actually want to prevent a heart attack using the right supplements for it.

Characterization of chemicals released to the environment by electronic cigarette use (ClearStream-AIR project): Is passive vaping a reality? See the full study here.

Researchers

The study was conducted by G. Romagna MD, L. Zabarini, L. Barbiero, E. Bocchietto, S. Todeschi, E. Caravati, D. Voster from ABICH S.r.l., biological and chemical toxicology research laboratory in Verbania, Italy; and K. Farsalinos MD at the Onassis Cardiac Surgery Center in Athens, Greece.

Summary & Methods

The following study was conducted to learn more about the effects of side stream (secondhand) smoke/vapor and air pollution caused by both traditional cigarettes and electronic cigarettes. To test traditional cigarettes versus electronic cigarettes and determine the amount of matter released into the air by each, the experimenters used a 60 mᶾ closed room without renewal of indoor air to ensure accurate readings.

The room contained several different air sampling systems, each of which sampled for a different form of matter. In the experiment, two sessions were recorded. The first session was for traditional cigarettes; and the second was for electronic cigarettes.

In this first session, five smokers were allowed to smoke however many cigarettes they had the urge to smoke for a total of five hours. The room was ventilated for 65 hours before the second session started. In the second session, 5 vapers were allowed to vape however often they pleased for a total of five hours in the same room.

Definitions

• Total Organic Carbons (TOC) – Can be classified as neither toxic nor non-toxic, these are just a measure of the amount of carbonic matter found in air.
• Carbon Monoxide (CO) – Colorless, odorless, tasteless gas which is toxic to humans and animals in large amounts.
• Glycerine – non-toxic, colorless, odorless liquid used in foods and beverages as a humectant (moistener), solvent, or sweetener.
• Acrolein – toxic, and a strong irritant for skin, eyes, and nasal passages. Glycerine is converted into Acrolein when combusted.

Secondhand Smoke vs. Secondhand Vapor: The Results

Here are the results recorded at the end of each 5 hour session.

Traditional Cigarettes: Over the course of the five-hour session, 19 cigarettes were smoked by the five participants, delivering a total of 11.4 mg of nicotine. Here’s what was found in the air after the session:

• TOC: 6.66 mg/ mᶾ
• CO: 11 mg/ mᶾ
• Glycerine: None
• Acrolein: 20 µg/ml

Electronic Cigarettes: Over the course of the five-hour session, 1.6ml of e-juice was vaped by the five  different participants, delivering a total of 17.6 mg of nicotine. Here’s what was found in the air after the session:

• TOC: 0.73 mg/ mᶾ
• CO: None
• Glycerine: 72µg/ mᶾ
• Acrolein: None

 

These results not only show the effects on air of a closed space caused by each of the two choices, but also the toxicity of the respective cigarettes. As clearly displayed in the graph above, carbon monoxide production is literally infinitely greater from tobacco cigarettes (11 mg/mᶾ) than electronic cigarettes (0 mg/ mᶾ).

Additionally, traditional tobacco cigarettes do not produce glycerine, whereas electronic cigarettes do. Glycerine is used to keep tobacco moist in an un-burnt cigarette. It’s also a common ingredient in the nicotine e-juice for electronic cigarettes. However, glycerine actually is a non-toxic chemical used in a wide range of foods and beverages.

Glycerine, when combusted (burned), is converted into acrolein, a toxic irritant to the skin, eyes, and nasal passages. This accounts for the lack of glycerine found in the air after the smoking of traditional cigarettes. Because combustion never happens in e-cigarettes, the glycerine contained in the e-liquids is never converted to acrolein, which accounts for the lack of acrolein found after the vape session.

Overall this study demonstrates the vast differences in air quality resulting from cigarette smoke compared to electronic cigarette vapor.

Further Examination: Electronic Cigarette Vapor vs. Urban Air Pollution

The researchers of this study compared these results to an array of studies that tested urban air pollution. They drew the conclusion that it is unhealthier to breathe air in big cities than it is to breath air in a room in which someone is vaping.