Assuming e-cigarettes are equal to cigarettes could distort research – and policy

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e-cigarettes‘Cigarette’ might appear in the term ‘e-cigarette’ but that is as far as their similarities extend, reports a new Northwestern Medicine study. Assuming e-cigarettes are equal to cigarettes could lead to misguided research and policy initiatives.

“Comparing cigarettes to e-cigarettes can give us a false sense of what dangers exist because it misses the gap in understanding how people use them and how they can make people dependent,” said first author Dr Matthew Olonoff, a postgraduate student at Northwestern University Feinberg School of Medicine.

“Before we start making policy changes, such as controlling nicotine or flavour options in e-cigarettes, we need to better understand what role these unique characteristics have.”

The commentary distills articles and published studies that compare e-cigarettes to cigarettes and supports the importance of investigating e-cigarettes as a unique nicotine delivery system. It was published less than a month after the US Food and Drug Administration declared youth vaping an epidemic.

“There are enough key differences between cigarettes and these products, especially newer-generation devices, to show that they are not interchangeable nicotine delivery systems,” Olonoff said.

Key differences between the products include: the amount of nicotine in e-cigarettes can vary widely, which doesn’t provide enough consistency for researchers who study the device and smokers’ behaviour; e-cigarette nicotine is ingested by vaping a liquid; the ability to stop and restart e-cigarettes allows far more variability in intermittent use and nicotine dosing compared to a traditional cigarette; the teen-friendly marketing and technology offered in e-cigarettes makes them more attractive than traditional cigarettes.; e-cigarettes are allowed in areas where cigarettes are prohibited; and teens are at greatest risk because e-cigarette use and marketing is on the rise.

“Teens could potentially be getting addicted to something dangerous and harmful to their health,” Olonoff said. “The only way we’ll know if this is true is to study e-cigarettes as if they’re their own unique device.”

“From a research perspective, when we call it a ‘cigarette’, we know how many puffs are typically in a cigarette, how people use it, the amount of nicotine in it,” Olonoff said. “Even though it has the word ‘cigarette’ in it, e-cigarettes are not the same thing.”

To help alleviate this inconsistency, the National Institute on Drug Abuse in March 2018 introduced a standardised research-specific e-cigarette for researchers to purchase. The device allows every researcher to study the same e-cigarette so that the chemical components (nicotine, formaldehyde) are consistent, as is the number of puffs it takes to finish the e-cigarette. Olonoff’s commentary encourages researchers to use these for consistency across all research.

E-cigarettes have been commercially available since the mid-2000s, Olonoff said. The technology has been advancing rapidly, which makes it nearly impossible to set up-to-date policy initiatives.

When e-cigarettes were introduced, marketing campaigns suggested they could be used to curb cigarette use. But years later, this claim is still unsubstantiated, Olonoff said.

The relative ease with which teens can use e-cigarettes – such as Juul selling a USB drive-like e-cigarette – might be enticing youths to think the devices are safe, Olonoff said.

“We’ve done so much to convince our youth that cigarettes and smoking are bad, and overall, it’s been a relatively successful campaign when you look at how much smoking has decreased and continued to decrease,” Olonoff said. “If teens use the device and they see it differently than the rest of the nicotine products, the researchers should adopt a different philosophical belief, too.”

Abstract
As the prevalence rates of cigarette use have declined over the past decade, use of electronic cigarettes (e-cigarettes) continues to increase and companies are heavily invested in manufacturing new e-cigarettes products. Scientists are therefore studying e-cigarette use at a rapid rate, generally by conceptualizing e-cigarettes as similar to traditional cigarettes in their use and effects. Thinking of e-cigarettes as largely comparable to cigarettes, however, fails to capture the unique e-cigarette capabilities, user experiences, and effects on nicotine dependence and even health. Assuming that e-cigarette users puff on their devices as they do cigarettes to attain doses of nicotine comparable in magnitude, and asking questions about e-cigarette use modeled after how smoking behavior has been usually assessed (e.g., puff number, duration, number of cigarettes per day) may miss important differences. A greater appreciation of the distinct uniqueness of e-cigarettes, as compared with cigarettes, will help to accelerate innovative research on e-cigarettes and other electronic devices, leading to new theoretical models and behavioral measures.

Authors
Matthew Olonoff, Raymond Niaura, Brian Hitsman

Northwestern University material
Nicotine & Tobacco Research abstract


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