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 Table of Contents  
Year : 2022  |  Volume : 34  |  Issue : 3  |  Page : 359-362

Electronic cigarettes use and pharmacological strategies as an intervention for tobacco cessation: Myth or reality?

1 Department of Oral Medicine and Radiology, Saveetha Dental College, Chennai, Tamil Nadu, India
2 Department of Oral Medicine and Radiology, Faculty of Dental Sciences, M.S. Ramaiah University of Applied Sciences, Bengaluru, Karnataka, India

Date of Submission30-Aug-2021
Date of Decision26-Oct-2021
Date of Acceptance26-Dec-2021
Date of Web Publication26-Sep-2022

Correspondence Address:
Ravleen Nagi
Department of Oral Medicine and Radiology, Saveetha Dental College, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaomr.jiaomr_246_21

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Tobacco use is a single leading preventable cause of death worldwide. It contains nicotine, which is one of the most addictive psychoactive drugs; thus, successful quitting becomes a challenging process. Occupation has a profound influence on tobacco use patterns, and in the majority of scenarios, users are unable to achieve abstinence to maintain the need for the psychoactive effect of nicotine to cope up with job stresses and to remain energetic. Various tobacco cessation aids are available with variable success rates. Electronic cigarettes (e-cigarettes) or vaping has become popular, particularly in Western Countries and among occupational workers as they contain less harmful chemicals than combustible cigarettes and can help heavy smokers to quit the habit. Reports of short- and long-term health effects of vaping have currently led to a ban on the production, manufacturing, and advertising of e-cigarettes. Pharmacological interventions such as bupropion and varenicline have been proven to provide long-term abstinence; however, neuropsychiatric side effects limit their use. This paper focusses on the hypothesis that whether the electronic nicotine delivery system (ENDS) or vaping and pharmacological interventions are an effective tobacco cessation interventions.

Keywords: Nicotine, occupation, pharmacotherapy, tobacco cessation, vaping

How to cite this article:
Nagi R, Muthukrishnan A, Reddy SS, Nagaraju R. Electronic cigarettes use and pharmacological strategies as an intervention for tobacco cessation: Myth or reality?. J Indian Acad Oral Med Radiol 2022;34:359-62

How to cite this URL:
Nagi R, Muthukrishnan A, Reddy SS, Nagaraju R. Electronic cigarettes use and pharmacological strategies as an intervention for tobacco cessation: Myth or reality?. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2022 Dec 10];34:359-62. Available from: http://www.jiaomr.in/text.asp?2022/34/3/359/356956

   Introduction Top

Tobacco consumption is the leading cause of mortality and morbidity worldwide and is a major public health problem in India.[1] Global Adult Tobacco Survey (GATS) II survey reports of 2016–17 have shown that the level of tobacco usage is high in India—around 250 million tobacco consumers in both smoke and smokeless forms, and 59% of adults consume it within 30 min of waking up.[2] Tobacco contains numerous toxic and noxious compounds, including nicotine, which is one of the most addictive psychoactive drugs.[1] Nicotine addiction is a complex process involving biobehavioral and psychological factors. In addition, it increases the release of the neurotransmitter, dopamine, in the brain, inducing a feeling of pleasure, happiness, and motivation, due to which addicts find difficult to quit. Many smokers report that smoking helps them in performing tasks efficiently; this can be due to the enhancement of cognitive abilities such as attention, working memory, and reasoning tasks by the nicotine.[3] However, chronic long-term tobacco usage can result in neurotoxicity; cerebrovascular, cardiovascular, and pulmonary diseases; and risk of developing cancer.[4] Studies have reported an association between smoking and job-related stress.[5],[6] In the majority of cases, an individual smokes to relieve stress to remain alert and to feel more energetic; thus, they continue to smoke in a need of psychoactive effects and find it difficult to quit the habit. In Western provinces, the use of e-cigarettes is popular as a smoking cessation aid with an assumption that they contain less harmful chemicals than combustible cigarettes. In addition, pharmacological therapy that includes bupropion and varenicline has been observed to provide effective cessation from tobacco use; however, neuropsychiatric side effects limit their use.[4],[5] This paper focuses on the hypothesis that whether e-cigarettes or vaping and pharmacological interventions are effective tobacco cessation.

Occupation and tobacco use

Occupation has been found to affect the tobacco-use patterns, and interactions between tobacco smoke and occupational toxins can increase the risk of cardiovascular and pulmonary complications through various mechanisms such as i) similarity of chemical compounds between tobacco smoke and work processes that include carbon monoxide, benzene, aromatic amines, and polycyclic aromatic hydrocarbons can result in cumulative exposure to a particular compound, ii) smoking and exposure to asbestos can result in a synergistic effect on the lung tissues with an increase in the incidence of lung cancer, iii) surface of cigarette can become contaminated with lead, with an increase of its inhalation, cutaneous absorption, and entry into the body. The literature has revealed that although tobacco use has declined among white-collar workers, its use is increasing day by day in blue-collar workers; this has become an issue of concern. Low-income people have been found to initiate smoking at an early age, are more exposed to secondhand smoke, and find it difficult to make quit attempts. In addition, they have reduced access to health care professionals and tobacco cessation centers and continue to use tobacco products despite being aware of its negative consequences on health.[5] According to reports, the smoking rate is high in the following occupational categories: 31.4% construction workers, 30% hospitality workers in food preparation and service, 28.7% workers in transportation, and 26.1% workers in production industry do not smoke but are exposed to second-hand smoke and have been found to have higher cotinine levels, an indicator of tobacco exposure in blood than other occupational workers.[5] It has been observed that in working places such as restaurants and bars with a high risk of environmental tobacco smoke, respirable particulate (<2.5 mm) concentrations can be as high as 242 μg/dL, which can pose a higher risk of lung cancer. In the majority of scenarios, people find it difficult to achieve abstinence from smoking due to withdrawal symptoms, cravings, and to alleviate the job-related stress and continue to smoke even beyond the working hours. White-collar workers have been found to smoke heavily as they face more work stress when compared to blue-collar workers, but this association needs to be further explored.[5],[6]

Cessation strategies

Although many National Tobacco Cessation Policies are being implemented, these may not directly help the chronic tobacco user as nicotine is quite addictive; thus, successful quitting becomes a challenging process because of nicotine dependence, withdrawal symptoms, and lack of adequate support.[6] Tobacco cessation programs include the cold turkey method, cognitive behavioral therapy, pharmacological interventions with nicotine replacement therapy (NRT) such as nicotine gums, lozenges, nasal sprays, and non-NRT bupropion, and varenicline.[7],[8] Varenicline, an anxiolytic drug has been found to be beneficial for long-term abstinence by reduction of craving and prevention of withdrawal symptoms. This drug can be started 1–2 weeks before the proposed tobacco cessation rate. However, neuropsychiatric adverse effects such as depression, mood changes, and agitation limit its use. An antidepressant drug, bupropion hydrochloride, is a better alternative for tobacco cessation in individuals with a history of depression. Bupropion in comparison to other antidepressants can lower seizure threshold and is a cost-effective option for smoking cessation.[7] [Table 1] illustrates the current pharmacotherapy available for tobacco cessation.
Table 1: Pharmacotherapy (nicotine and non-nicotine replacement therapy) for tobacco cessation with adverse effects

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Electronic nicotine delivery system (ENDS) or vaping, as a brand, has gained popularity in the United States as an alternative to conventional smoking as it contains less harmful chemicals than conventional cigarettes and can help heavy smokers to quit the habit. An e-cigarette is an electronic battery-powered device that uses aerosolized nicotine to produce vapor “e-liquid” that is inhaled by the user. In addition to nicotine, e-cigarettes contain propylene glycol and glycerol mixed with flavoring agents, and the toxicity of these compounds has been reported to be less than that of conventional cigarettes. [Table 2] shows different types of e-cigarettes and their components. Studies have suggested that smokers who vape daily can successfully achieve long-term abstinence up to 1 year than other smoking cessation aids.[9] Its daily use is becoming popular among occupational workers as a smoking cessation intervention to help them to cope up with job stresses. Although e-cigarettes do not burn tobacco leaves, the safety of e-cigarettes is questionable; heating of e-liquid leads to the release of harmful toxins that can cause DNA damage, mood disorders, seizures, high blood pressure, tachycardia, and pulmonary disease, referred to as “vaping lung disease” characterized by shortness of breath, coughing, wheezing, and chest pain [Table 3].[9]
Table 2: Different types of e-cigarettes and their components

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Reports have indicated that vitamin E acetate, a chemical present in e-cigarettes, is responsible for the psychological or cannabis-like effects; inhalation of vitamin E acetate interferes with lung functioning. Due to the increased addiction of youths toward e-cigarettes, the Food and Drug Administration (FDA) in the US has officially stated that “e-cigarette use is becoming an epidemic among youth.” Thus, the production, manufacturing, and surrogate advertising of e-cigarettes were banned across 25 countries, and its sale now requires market authorization.[9],[10] [Figure 1] illustrates the World Health Organization MPOWER policies for tobacco cessation.[11]
Figure 1: World Health Organization MPOWER policies for tobacco cessation[5]

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The use of tobacco in both smoke and smokeless form is more prevalent in low-income countries; therefore, education in low-income communities by means of mass media such as radio or television, newspapers, educational brochures or leaflets, and verbal lectures about the harmful effects of tobacco on overall health is the cornerstone to achieve better outcomes from tobacco cessation strategies.

   Future Recommendations Top

For effective tobacco control, taxation should be raised on tobacco products; in addition, various health policies, state-wise workplace smoking ban, and strict laws should be reinforced by state legislation for a ban on the sale and purchase of tobacco products and their availability to minors under 18 years. The Center for Disease Control (CDC) has formulated recommendations for tobacco users who are willing to quit: i) To take help and support of health care provider for successful quit attempts; ii) To call the nearby “Quit Helpline” number; and iii) To use evidence-based cessation strategies, which include behavioral counseling and NRTs as approved by FDA.[3] [Table 4] illustrates tobacco cessation interventions based on the level of nicotine dependence assessed by Fagerstrom.[12]
Table 3: Harmful effects on oral and systemic health of an individual with use of electronic nicotine delivery system (ENDS)

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Table 4: Tobacco cessation interventions based on level of dependence (Fagerstrom test score)

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   Conclusion Top

To conclude, tobacco cessation requires a comprehensive approach involving multiple stakeholders. Evidence has shown that a combination of behavioral counseling, brief intervention strategies based on 5As (Ask, Assess, Advise, Assist, and Arrange), and pharmacological interventions can result in positive outcomes toward successful quitting.

Role and safety of advocating the use of e-cigarettes to quit tobacco use needs to be further validated by randomized controlled trials. Self-restraint, strong will to quit tobacco, and a positive attitude to life are the most essential prerequisites which can be used in conjunction with the right pharmacotherapeutic agents is the solution to get over tobacco addiction. Smoking and other tobacco use is an occupational hazard, and its elimination is necessary for the optimal health of occupational workers.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

West R. Tobacco smoking: Health impact, prevalence, correlates and interventions. Psychol Health 2017;32:1018-36.  Back to cited text no. 1
Wal A. Half of India's tobacco users try to quit but give up in a month, Now Gov Centres will help them. Available from: https://www.news18.com/.  Back to cited text no. 2
Swan GE, Lessov-Schlaggar CN. The effects of tobacco smoke and nicotine on cognition and the brain. Neuropsychol Rev 2007;17:259-73.  Back to cited text no. 3
Mishra A, Chaturvedi P, Datta S, Sinukumar S, Joshi P, Garg A. Harmful effects of nicotine. Indian J Med Paediatr Oncol 2015;36:24-31.  Back to cited text no. 4
[PUBMED]  [Full text]  
Jones MR, Wipfli H, Shahrir S, Avila-Tang E, Samet JM, Breysse PN, et al. Secondhand tobacco smoke: An occupational hazard for smoking and non-smoking bar and nightclub employees. Tob Control 2013;22:308-14.  Back to cited text no. 5
Stitzer ML, Gross J. Smoking relapse: The role of pharmacological and behavioral factors. Prog Clin Biol Res 1988;261:163-84.  Back to cited text no. 6
Antoniu SA, Buculei I, Mihaltan F, Crisan Dabija R, Trofor AC. Pharmacological strategies for smoking cessation in patients with chronic obstructive pulmonary disease: A pragmatic review. Expert Opin Pharmacother 2021;22:835-47.  Back to cited text no. 7
Brandon KO, Simmons VN, Meltzer LR, Drobes DJ, Martínez Ú, Sutton SK, et al. Vaping characteristics and expectancies are associated with smoking cessation propensity among dual users of combustible and electronic cigarettes. Addiction 2019;114:896-906.  Back to cited text no. 8
Kosecki F. Vaping: FDA to ban sale of flavored cartridge-based products, 2020. Available from: https://www.cnet.com.  Back to cited text no. 9
Singh AG, Chaturvedi P. Tobacco use and vaping in the COVID-19 era. Head Neck 2020;42:1240-2.  Back to cited text no. 10
Chauhan G, Thakur JS. Innovative approaches to implement MPOWER policies in low-resource settings: A significant reduction in tobacco use (21.2%–16.1%) since Global Adult Tobacco Survey-1 in Himachal Pradesh, India. Int J Non-Commun Dis 2019;4:10-4.  Back to cited text no. 11
Etter JF, Duc TV, Perneger TV. Validity of the Fagerström test for nicotine dependence and of the Heaviness of Smoking Index among relatively light smokers. Addiction 1999;94:269-81.  Back to cited text no. 12


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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