E-Cigarettes: Positive Smoking Substitute or a New Problem Replacing the Old?

Photo by Michael Dorausch, via Flickr

By Michael Fergenson, senior editorial coordinator

The dangers of smoking cigarettes are well documented, from the terrifying commercials about what smoking does to our bodies to the warnings right on the pack. Yet the Centers for Disease Control and Prevention estimates that 45.3 million people in the United States smoke.

Now, a new trend in tobacco products has become the center of much debate. I’m referring to the electronic cigarettes, or e-cigarettes, that are gaining popularity as a smoking alternative and, for many, as a tool to quit.

I personally know two people who are using this device in an attempt to stop smoking. An article published in the New York Times last November reports that the number of Americans trying e-cigarettes “quadrupled from 2009 to 2010.” The article also cites the results of a survey published in Tobacco Control last year, which found that 1.2% of adults, or close to 3 million people, had reported using these products in the previous month. But are e-cigarettes really a positive smoking substitute and aid to quitting?

How they work. Most e-cigarettes are shaped like a real cigarette, but some have a unique look. They work by heating up a liquid—purchased separately from the device—until it turns into an inhalable vapor. These liquids are available in a variety of flavors, scents, and levels of nicotine content. Some have no nicotine in them at all. Even though e-cigarettes don’t emit real smoke, they can’t be used everywhere—local governments can ban their use, as can private owners of buildings or transportation services. Because these products are fairly new, there’s no way to conclusively know whether or not they are healthier than cigarettes.

Proponents say that the vapor produced is as harmless as fog-machine smoke. The liquid usually contains five to 10 ingredients, all of which are licensed for human consumption and considered safe. This is compared to the more than 5,300 ingredients that have been identified in cigarette smoke, most of which are harmful. Most people use e-cigarettes as an aid to help quit cigarettes, but some just use them as an alternative nicotine delivery system.

What the critics say. One of the arguments against e-cigarettes is that it may lead to children smoking. Since the liquid packs come in many different flavors, this may appeal to a younger demographic. It would also be easier for teenagers to hide the fact that they are using e-cigarettes, since they don’t produce the tell-tale odor of tobacco smoke. There’s also a new “smart” cigarette pack, designed for use with e-cigarettes, that sets up a social network between smokers. Also seeming to target the younger demographic, this device connects wirelessly to social networking sites, and even flashes a blue light and vibrates when it detects another smart pack nearby.

The FDA’s Web site warns against the use of e-cigarettes, stating that they may contain ingredients that are known toxins (for example, diethylene glycol, an ingredient in antifreeze) or contain small amounts of nicotine or tobacco-specific byproducts even when listed as having no nicotine. The agency also says that there have been no clinical studies evaluating the product’s safety and efficacy. An analysis of the product carried out by the FDA’s Division of Pharmaceutical Analysis tested the liquid of two leading brands and found detectable levels of carcinogens and toxic chemicals that users could be exposed to. The report also notes that there are inconsistent or nonexistant quality control processes in the manufacturing of these products. (Read the full report here.)

Further questions were raised about the product this February, when an e-cigarette exploded in a man’s mouth. The man suffered severe burns, and lost his front teeth and a chunk of his tongue, E-cigarettes are also advertised as causing less discoloration and limiting the need for teeth whitening products. Fire officials found that this was caused by a faulty battery. (The full story can be seen here.)

Nurses can help. Only time will tell if e-cigarettes are safer than cigarettes and a viable option as an aid to quit smoking. In the meantime, nurses can help patients by being knowledgeable about these devices so they can provide accurate guidance regarding their use. By keeping up to date on e-cigarettes, nurses can offer informed advice when a smoker asks about using these devices as an aid for quitting smoking.

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2017-03-10T16:53:37+00:00 May 4th, 2012|Nursing|22 Comments
Managing editor, American Journal of Nursing


  1. Barry Freeman December 20, 2013 at 2:53 pm

    “The purpose of e-cigarettes is wholly to circumvent indoor smoking bans and ban on TV advertising of cigarettes.”

    You have GOT to be kidding me. You mean, for the last three years I’ve been part of an insidious conspiracy to circumvent anti-smoking laws? Well, blow me down, I never knew!

    And there I was, thinking that all the improvements to my own health and that of the people around me were something good.

    Just goes to show. Maybe YOU ought to take a closer look at the PEER REVIEWED studies done by Johns Hopkins, Walter Reed, Boston School and many others around the world that scientifically state, with actual honest to god evidence, that there is ZERO danger from “passive vaping”

    Of course, actually doing that might invalidate your obviously concrete opinion.

    I don’t vape just to annoy people. I vape because it’s a damn sight healthier and more effective than the patent nostrums peddled by the pharmaceutical industry who only seem concerned with lining their own pockets at the expense of people’s health.

    The very fact that you specify anti-freeze proves your total ignorance of the subject.

    Ignorance is forgiveable. Wilful ignorance is utterly inexcusable.

  2. Betsy Marville RN December 20, 2013 at 1:16 pm

    The purpose of e-cigarettes is wholly to circumvent indoor smoking bans and ban on TV advertising of cigarettes. The TV ad states something like “take back your rights.” As a passive involuntary inhaler of 3 office mates’ e-cigs that immediately made me sick, I dread this end run around the laws that took so long to pass and enforce. I don’t wish to inhale propylene glycol or antifreeze or nicotine for that matter (My sweet office mates immediately stopped when I reacted). No one is forcing you to give e-cigs up. The scary part is the lack of laws to prevent you from making me participate, and the obvious appeal to kids with the return of TV ads with the marketing of a cool electronic gadget for smoking (Think marketing doesn’t work? I am 55 years old and I can still sing you the theme songs for Virginia Slims, Benson & Hedges 101, and recite the pitches–I’d walk a mile for a Camel, Winston taste good, like a cigarette should, show us your Lark pack, and on). Remember the tobacco execs and the doctors that they hired to testify that smoking did not cause cancer? At the same time they were spiking cigarettes with nicotine to keep levels high in order to keep users addicted. The staunch support of a new tobacco product here is troublesome. Let’s not go backward.

  3. […] May 4, 2012, the American Journal of Nursing weighed in on the controversy of  E cigarette reviews. Their views and findings were equivocating, […]

  4. BAzz July 11, 2012 at 9:15 am

    How do you know?
    You say ‘clearly the manufacturers of these items have not met these standards.’

    Where’s your evidence? I’d say that was a ‘personal belief’ just as much as me saying ‘E-Cigs are safer than cigarettes’

    The fact is, that there are NO independent studies that prove one way or the other that E-cigs are harmful or not.

    All I can point to are these articles:


    Most investigatory bodies have concluded that E-Cigs are safer than cigarettes, but are not prepared to state whether they are harmful in and of themselves.

    The constituents of E-cig juice are generally:
    Propylene Glycol
    A substance Generally Recognised as Safe
    Vegetable Glycerin
    A substance Generally Recognised as Safe
    Nicotine in amounts from 0 to 3.6mg/ml
    A substance with known addictive properties, toxic by absorption in high concentrations
    Usually food-safe flavouring are used though not those based on oils.

    My own personal experience over the last 18 months has been positive. That’s a FACT, not an opinion.

    The Nicotine inhalers that are sold are very expensive and provide 10Mg/ml (YES! TEN rather than my 1.6) and still have a high failure rate.

    I suggest you read this. It’s not independent, but infomative none the less:


    Go to section 5.

  5. Jenn July 10, 2012 at 5:31 pm

    It seems to me that there are many people confusing the debate about overall safety and efficacy of e-cigarettes with their own personal beliefs and actions. Just because you believe what you are doing is ok, does not mean that it is safe. There are certain rules and guidelines in place to keep users safe and clearly the manufacturers of these items have not met these standards.

  6. Bazz July 10, 2012 at 4:24 pm

    Isn’t Caffeine also a vasoconstrictor? I suppose coffee will be next on the list of banned products.

    I know exactly how much nicotine is in my PV (Personal Vapouriser) because I mix my own juice. In the morning I use 1.8mg/ml and in the evening I use 1.2Mg/ml.

    I go through maybe 3ml of juice per day. I’ll leave the math up to you.

  7. fred July 10, 2012 at 3:50 pm

    Ecigs gives users a lot of control over how much nicotine they use and when they use it. This isn’t the same for NRTs, though pretty close. In the end you’re still using nicotine, so the addiction survives. Safer with ecigs, is still unknown, but it does make sense they would be safer. The concern with nicotine is constriction of blood vessels … which of course would be an issue over time. This does occur with smoking as well, but ecig users tend to vape more often which leads to a consistent daily constriction of blood vessels. — Calling these things ecigs doesn’t make sense. They simply vaporize nicotine and anywhere it contacts if gets absorbed into the body. There is no real comparison between ecigs and smoking. — As a smoking cessation aid, they would likely not prove anymore effective than any NRT … except group social behavior may encourage using ecigs more than smoking. — Regardless, bottom line is, as long as your using nicotine, you will still crave it and fail to learn different live style for managing stress etc. — Though, ecigs may be easier to quit then smoking. === In my view, ecigs are more a farce than anything else …HOWEVER… they are the only nicotine replacement available that allows users control over nicotine use, as they try to limit or remove smoking. — I use ecigs myself, and they do help reduce smoking, if you choose, somewhere between 50-80% … quite significant. BUT the only way to break from nicotine and smoking is to stop both. Harm reduction is a good in between that ecigs provide. Though nicotine replacement in any form is NOT the way to quit nicotine/smoking for long term success … to do that you need to put in the effort to transition to a non-smoking life style. — Again, the potential harm reduction of ecigs, should be the focus and the goal. Quitting nicotine is a separate issue.

  8. J July 10, 2012 at 9:32 am

    There is no healthier alternative to smoking other than becoming tobbacco free. One of the problmes with e-cig companies is that they do not use an approved quality control. That means that you may get x amount of nicotine this time and y amount next time. It also does not ensure that you are reciving a safe product 100% of the time. By your logic chewing tobacco or snus would be good “safe” alternative too. Bottom line is we should be encouraging and helping out patients quit tobacco in all forms, not swich them to a supposed “safer” method of ingesting it. While e-cigs may not have the tar and other by products of a cigarrette they still contain nicotine which is a vasoconstrictor and can in itself cause health problems in patients.

  9. Dan July 8, 2012 at 2:53 am

    Analog cigs kill end of story. If e-cigs will help you stop using analog cigs then it is worth the risks if any to switch. There alot of independant studies that do say e-cigs are a healthier alternative to smoking and that any harmful levels are equal to that in FDA approved medications i.e. patches, gum and inhalers (just google it there is alot of info out there). The FDA only tested 2 companies and both of them from China and the amounts of harmful chemicals were below the amounts considered dangerous by FDA standards. FDA didn’t want to include USA made e-liquids in there study because they knew they wouldn’t have found any harmful chemicals in them. E-cigs have come along way in 8 years since China first marketed them and other countries have made much better products since e-cigs have become availible. I would rather have children not vape or smoke but if they did I would rather have them vape. I don’t condon the use for minors, but to ban e-cigs because a minor might use them? Tell that to someone who just got cancer because he had to go back to analog cigs because the prunes in the USA made his e-cig illegal. Anyway it’s just stupid to try and stop something that is better for you. Why not ban analogs? Oh wait those are already known to kill. Lets go after healthier alternatives that we can’t tax.

  10. J June 28, 2012 at 4:10 pm

    It is a temptation. Many children first get cigarettes from their parents, either willingly or sneaking them. By flavoring the cigarettes with candy or fruit flavors you help to mask the tobacco flavor that may detour the child from smoking.

  11. Ecig Fan June 28, 2012 at 12:53 pm

    I don’t really see how e-cigarettes could be responsible for getting children to smoke. Just like analogs, it’s ILLEGAL to sell them to minors, so if someone is to blame it’s shops who break the law and sell them to kids. Otherwise they can be a much healthier alternative for smokers wanting to quit.

  12. Sugel May 19, 2012 at 2:49 am

    Current smoking rates among 8th- and 12th-grade students reached an all-time low in 2009. According to the Monitoring the Future survey, 6.5 percent of 8th-graders and 20.1 percent of 12th-graders reported they had used cigarettes in the past month. Current smoking also decreased among 10th-graders, to about 13 percent in 2009. Although unacceptably high numbers of youth continue to smoke, these numbers represent a significant decrease from peak smoking rates (21 percent in 8th-graders, 30 percent in 10th-graders and 36 percent in 12th-graders) that were reached in the late 1990s.

  13. BAzz May 17, 2012 at 3:50 pm

    Same here. Every vendor I have used in the UK is compliant with the ChP packaging – they have to be or they cannot sell nicotine fluids. I stand by my opinion that most of the opposition comes from those most likely to lose when E-Cigarettes become much more mainstream – the Pharma and tobacco companies.

  14. Marsha May 17, 2012 at 3:25 pm

    Re: Child Proof Caps in the US

    As I was reading the discussion about the child proof caps. I picked up the E-Liquid on my desk which has a child proof cap and on the label is says:
    “This product contains Nicotine and is not suitable for people under 18. Keep away from Pets and Children!”

    Some of my liquids not only have child proof caps but are also shrink wrapped. I have never received E-liquid without a safety cap and properly labeled.

  15. BAzz May 16, 2012 at 4:38 pm

    OK, we’ll have to disagree, but I’d like to point out that there is no constituent of anti-freeze in E-Liquid. I mix my own e-juice and it contains Propylene Glycol (NOT Ethylene Glycol, which is what is in Anti-freeze) Glycerin, water and food flavoring.
    As to packaging, maybe it’s more lax in the US, but in the UK ANY potentially harmful liquid must be sold in child-proof containers. Our trading standards would come down very hard , and rightly so, if a vendor is found to be non-compliant.

    The person who had his e-gig explode, was using incorrect batteries in a non-supported configuration. Contrary to the vendor’s stated requirements, he thought he could save a few bucks and bought cheap batteries from Radio Shack. he saved about $10 and lost his face. This is not the E-cig’s fault.

    As to the lack of studies I really wish there were some. All I can say is that after 30 years of smoking I haven’t had a cigarette for 16 months. My nicotine intact has dropped from 18mg/ml at first to 12 mg/ml now. Over that last year observed changes have been:
    No cravings
    My taste buds have come back
    I don’t get out of breath when taking even mild exercise
    I sleep better
    No morning cough
    No smelly clothes

    I talked with my doctor when I first started and I do get regular checkups.

    Recently Lorilard, a major Cigarette company has bought out an e-Cig company (Blu). I suspect that we’ll see more of this in the future as the use of e-cigs becomes more popular.

    The issue of sales to minors is no more problematic than selling cigarettes to minors. Or vodka shots disguised with bright colours and sexy names.

    If the governments and regulatory agencies were serious about stopping people smoking, then there would be studies, committees and all sorts of regulation. The fact that there isn’t says to me that such things are being blocked.

  16. Jenn May 16, 2012 at 4:17 pm

    I respectfully disagree with you BAzz. E-liquid is not always, and very often not, in childproof containers. In my area, it is sold in small bottles that are not childproof. It is also unregulated and there are no laws preventing the sale of this product to minors. The liquid is offered in many different flavors which entice youth to try. This is why flavored cigarettes are not longer allowed in the U.S.
    Because it is unregulated the nicotine content is not standardized. In a study performed by the FDA it was found that the nicotine content in different bottles of the solution had different amounts of nicotine. In addition, it was also found that the bottles of non-nicotine liquid did, in fact, contain nicotine.
    The advertisement of e-cigarettes as a safe or safer alternative to tobacco is misleading. There has been no research done to show that these products are 1. useful in the cessation on tobacco products or 2. that they are safe to use. E-cigs are known to contain chemicals present in antifreeze, can contain other carcinogens and recently in the news was a man who lost teeth and part of his tongue as a result of a malfunction of the cigarette. The FDA has put out a statement prohibiting the advertisement of these products and smoking cessation aids.
    These products are meant to entice and prey a population who is addicted to a harmful substance.
    Current tobacco cessation aids on the market are more expensive than the e-cig. This is because it has taken companies time and money to develop a safe product where the side effects, both short and long term, are known. (They do want to earn a profit as well) These products also have appropriate warning labels and usage instructions to prevent misuse. While not 1 drug will prevent all cravings, nor is 1 drug appropriate for all individuals, nicotine lozenges, gum, inhalers, patches and medications are helpful and appropriate in quitting tobacco. It is important for individuals to seek assistance from a health care provider when trying to quit. The use of medication and/or counseling has been proven successful. The correct combination of cessation aids is helpful to those who are ready to quit. In addition to medications, it does take a lot of strength and will power by those who are addicted.
    Many health care facilities do have programs that offer smoking cessation medications for no cost or at a reduced rate. If you are interested in quitting contact your local department of health or hospital for a list of cessation resources.

  17. Marsha May 16, 2012 at 3:22 pm

    Btw, did you know PG is used in asthma inhalers and nebulizers.

  18. redhotlucy May 16, 2012 at 2:09 pm

    I will have to respectfully disagree with you BAzz. Not all refill are available in childproof containers. In fact my local retailer of them does not have refills in childproof containers. The refills are in small bottles and have as much childproofing as a bottle of eye drops. They are also not regulated like tobacco products making it much easier for minors to access them and are made more appealing due to thier flavorings. This is the reason that flavored cigarettes are not long allowed in the U.S.
    Nicotine patches, gum, lozenges, inhalers, and prescription medications are benefical and do work for many people. If used correctly and in conjuction with counseling they are proven to be effective. There is currently no treatment that will stop 100% of the cravings and quitting requires a lot of work and will power from the individual. Additionally, there is not 1 medication that works for for everyone either. A health care professional is a great resource to use in help with combining treatments for the best outcomes.
    There have been studies done, one specific study was done by the FDA, where the nicotine content of the refill liquid was measured. It was found that even the non-nicotine liquid did, in fact, contain nicotine. It was also found that there was no regulation between the amount of nicotine in the regular liqiud. There was a wide range of variation in nicotine levels between the bottles tested.
    It has also not been proven that e-cigarettes are safe. The chemical in them that makes them “Vape” is found in antifreeze and there was a recent news story where a man lost part of his teeth and tounge when an e-cigarette exploded while being used. The advertisement that these products are safe or safer are misleading as there have not been any studies to prove this and are giving the consumer a false sense of security in the product. They are also preying the in individuals desire to quit smoking by offering a relatively inexpensive (prices vary from e-cig to e-cig) cure all. While tobacco cessation products on the market are more expensive, they are also researched and the longterm and short term side effects are known and documented. In many areas there are opportunities through health care facilities to recieve tobacco cessatin products at a reduced rate or even at no cost to the individual.
    For those who are wanting to quit, please contact a health care professional who is familiar with current smoking cessation methods. With proper medication and/or counseling it is possible to quit this addiction.

  19. BAzz May 16, 2012 at 10:53 am

    That’s why e-liquid refills are sold in Child-Proof containers, just like any other dangerous substance. Honestly, it seems some people are determined to support the bloated, greedy, inconsiderate, selfish pharmacy conglomerates who stand to lose billions when people realise that heir useless patches, gum and dangerous drugs are just that: Useless and dangerous.
    E-Liquid does not HAVE to contain any Nicotine AT ALL which you would know if you’d done even a little bit of basic research.

    Once again, the nannies are out in force lining their own and the corporate pocket.

  20. Jenn May 16, 2012 at 9:23 am

    The FDA prohibits e-cigarettes from being marketed as a smoking cessation device. This is NOT a tool to help smokers quit! The liquid refills, often candy or fruit flavored, contain enough nicotine to kill if consumed. This means that if your child or pet gets ahold of this small bottle it can kill them. Consumers need to be aware of what they are purchasing and need to be educated that this in another ploy of a “safe” way to smoke. Those who would like to quit smoking should seek assisntace from thier health care providers or a smoking cessation counselor.

  21. Marsha May 10, 2012 at 4:39 pm

    Not all e-cigarettes brands or the liquids used in them are the same, some are better/worse than others. I would suggest trying a different brand and maybe a lower nic level. Some flavors will cause me to cough while others do not.

    The first time I tried an e-cig was in 2009, the taste was terrible and the battery life was very short. I tried a different brand in 2011 and was able to get off of tobacco cigarettes within one week. However, it did take some searching to find liquids that I liked.

  22. Rose Lindenmayer May 6, 2012 at 12:25 pm

    I am a smoker who has tried everything (from hypnosis to patches, gum, inhalers, etc.) and have tried the new e-cigarette. The e-cigarette that I bought had nicotine and I believed it could help me stop smoking. However, the chemicals in it were so strong and irritating that it made me have coughing spells for so long that I would end up gagging. When I smoke my regular cigarettes (American Spirit “all-natural, no additives”) I do not cough. Consequently, I gave up the e-cigarette. I am looking for another alternative. I wonder if others who have tried the e-cigarette have experienced the same symptoms I did? Thank you for your article! I agree that more research into the e-cigarette is needed.

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