Journal of Thoracic Oncology:
E-Cigarettes and Cancer Patients
Cummings, K. Michael PhD, MPH; Dresler, Carolyn M. MD, MPA; Field, John K. PhD, FRCPath; Fox, Jesme MB ChB, MBA; Gritz, Ellen R. PhD; Hanna, Nasser H. MD; Ikeda, Norihiko MD, PhD; Jassem, Jacek MD, PhD; Mulshine, James L. MD; Peters, Matthew J. MD, FRACP; Yamaguchi, Nise H. MD, PhD; Warren, Graham MD, PhD; Zhou, Caicun MD, PhD
Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC.
Disclosure: The authors declare no conflict of interest.
All of the authors are members of the IASLC Tobacco Control and Smoking Cessation Committee.
Address for correspondence: K. Michael Cummings, PhD, MPH, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 68 President Street, MSC861, BE 103-L9, Charleston, SC 29425. E-mail: email@example.com
The increasing popularity and availability of electronic cigarettes (i.e., e-cigarettes) in many countries have promoted debate among health professionals as to what to recommend to their patients who might be struggling to stop smoking or asking about e-cigarettes. In the absence of evidence-based guidelines for using e-cigarettes for smoking cessation, some health professionals have urged caution about recommending them due to the limited evidence of their safety and efficacy, while others have argued that e-cigarettes are obviously a better alternative to continued cigarette smoking and should be encouraged. The leadership of the International Association for the Study of Lung Cancer asked the Tobacco Control and Smoking Cessation Committee to formulate a statement on the use of e-cigarettes by cancer patients to help guide clinical practice. Below is this statement, which we will update periodically as new evidence becomes available.
Tobacco consumption is the second leading cause of death in the world today, currently responsible for more than 5 million deaths each year with many of these deaths occurring prematurely.1,2 Although there exists a wide diversity in the tobacco products available to consumers, ranging from cigars, pipes, and cigarettes to noncombustible forms of tobacco such a chewing tobacco and moist snuff, manufactured cigarettes are by far the most common type of tobacco product consumed and also the most dangerous.3 Both combustible and noncombustible tobacco products pose health risks to the user, but cigarettes and combustible tobacco products are particularly dangerous with more than 6000 known chemical constituents and 60 known carcinogens and inherent design features that allow for deep inhalation of smoke and nicotine into the lungs.4 As a result, most people develop a strong long-lasting addiction to cigarettes, which makes it hard to avoid the repeated exposures to harmful smoke toxins.5
The adverse effects of smoking continue after a cancer diagnosis. Continued smoking increases the risk for treatment-related complications, recurrence, the development of a second primary cancer, and mortality from both cancer-related and non–cancer-related causes.4,6–11 The adverse effects of smoking are noted across cancer disease sites and affect treatment outcomes for surgery, chemotherapy, radiotherapy, and targeted therapy such as biological therapies. Several studies have demonstrated that smoking cessation at or following a cancer diagnosis can reverse the adverse effects of tobacco on cancer treatment outcomes.12–15
Obviously, the best preventative measure to curb the adverse health effects associated with smoking is abstaining from smoking or tobacco cessation. Treatment-related guidelines are available to provide a foundation upon which to base smoking cessation intervention. However, the reality of helping patients overcome their nicotine dependence is not as simple as telling someone to quit and offering a prescription for a stop smoking medication.16
Most cancer patients who persist in smoking already recognize the adverse health effects and the importance of stopping smoking. The vast majority of patients will report that they want to quit and have tried to stop previously, with many having used a range of methods from cold turkey to various forms of pharmacotherapy and behavioral support.17–19 Because of the treatment-related consequences of continued smoking, there is urgency for most cancer patients to stop smoking immediately, yet tobacco cessation studies have often ignored cancer patients.20–22 Most cancer patients expect to be asked about their tobacco use when seen by their doctor and are generally receptive to the offer of cessation support.23 Some patients are embarrassed by their smoking and will sometimes misrepresent their tobacco use, so biochemical markers such as cotinine and/or carbon monoxide can be used to help ensure more accurate assessment of current tobacco use.24 Although most oncologists seem to ask about tobacco use and advise patients to stop smoking, most do not regularly provide cessation assistance.21,22 However, assessing and assisting patients who use tobacco should be standard of care for all cancer patients.16,25 That said, clinicians are now faced with a new dilemma—what do we tell our patients about e-cigarettes? What are e-cigarettes? Can e-cigarettes help someone stop smoking? Are e-cigarettes less harmful than cigarettes?
WHAT ARE E-CIGARETTES?
Electronic cigarettes (i.e., e-cigarettes) are battery-powered devices that delivery nicotine in an aerosol to the user.26–39 The first electronic cigarette was created in 1963 when an American engineer named Herbert A. Gilbert filed a patent for a device that produced a nicotine-containing steam.40 However, this device was never commercialized. The modern electronic cigarette was invented in 2003 by a Chinese pharmacist named Hon Lik for his father who was a heavy smoker with lung cancer.41 E-cigarettes were sold first in China in 2004 and later exported by the Ruyan company and made available over the Internet and more recently in retail establishments in Europe and in the United States. E-cigarettes heat and vaporize a solution containing nicotine, and many are designed to look outwardly like traditional tobacco cigarettes (Figure 1). Thus, as a cigarette-like device that mimics both hand-to-mouth and oral-sensory experiences of a traditional cigarette, e-cigarettes have the potential to attract significant numbers of customers who might otherwise smoke cigarettes.
CAN E-CIGARETTES HELP SOMEONE STOP SMOKING?
There are no clinical guidelines that recommend the use of e-cigarettes for smoking cessation. Electronic cigarettes have not been approved as a stop smoking treatment by the U.S. Food and Drug Administration or any other government agency responsible for evaluating the safety and efficacy of drugs for smoking cessation. Australia and Canada have banned the retail sale of e-cigarettes. Other countries, such as the United Kingdom, are considering regulating e-cigarettes like medicinal nicotine products. Although many smokers report using e-cigarettes to reduce or help them stop smoking, there is a paucity of reliable data on their efficacy for smoking cessation.33–39 Although a recent study found that e-cigarettes with or without nicotine were about as effective as a nicotine patch in helping smokers abstain from using tobacco cigarettes,39 there are no published studies evaluating the safety and efficacy of e-cigarettes for smoking cessation in patients with chronic obstructive pulmonary disease (COPD) or cancer.
ARE E-CIGARETTES LESS HARMFUL THAN CIGARETTES?
E-cigarettes deliver heated nicotine aerosol with a few other chemicals, so compared with smoking cigarettes there is exposure to many fewer inhaled chemicals.31 For patients with a serious lung ailment, it is reasonable to be cautious about recommending the use of any treatment that involves inhaling foreign material into the airways. It is likely to be many years before the harms (if any) associated with the acute and long-term exposure to e-cigarettes can be more completely ascertained.
WHAT DO I TELL MY PATIENTS?
First, tell your patients to stop smoking cigarettes immediately. There needs to be an urgency to get cancer patients to stop smoking because the adverse effects of continued smoking can be immediate and severe.6–11 Second, tell your patients that you are willing to work with them to overcome their nicotine dependence. The treatment guidelines for tobacco dependence are a good starting point to identify evidence-based options for smoking cessation,16 although you can acknowledge that current treatment approaches for nicotine dependence are only minimally effective.42 Third, explain to your patient that the safety and effectiveness of e-cigarettes are not fully understood, nor is there any evidence to suggest that e-cigarettes are safer or more effective than existing government-approved stopping smoking medications. Table 1 provides some clinical scenarios and suggestions on when e-cigarettes might or might not be considered as an adjunct to established nicotine dependence treatments.
In summary, cancer patients deserve treatment guidance from their doctor. Those who smoke should be advised to stop smoking and informed of the evidence-based treatment methods that have been shown to increase cessation outcomes compared to unassisted quitting. Most smokers believe that they ought to be able to quit on their own without assistance and are skeptical about the value of current treatment approaches for nicotine dependence.43 However, given the importance of smoking cessation for cancer patients, oncologists should be insistent in their efforts to assist their patients to stop smoking including considering combination therapies.25,44
There are currently no evidence-based guidelines to support the recommendation of e-cigarettes. Whereas evidence-based cessation strategies should be used wherever possible, clinicians should consider the strong need for cancer patients to stop smoking as soon as possible to promote the most effective outcomes of cancer therapy. In the absence of sufficient evidence that e-cigarettes are effective and safe for treating nicotine dependence in cancer patients, the International Association for the Study of Lung Cancer advises against recommending their use at this time. However, this recommendation may change if new data become available. The International Association for the Study of Lung Cancer does recommend that research be done to evaluate the safety and efficacy of e-cigarettes as a cessation treatment in cancer patients to help guide clinical practice. For individual patients who are either using or planning to use e-cigarettes despite advice not to do so, they should be offered evidence-based stop smoking treatments while monitoring for any adverse effect of e-cigarette use.
1. Ezzati M, Lopez AD. Estimates of global mortality attributable to smoking in 2000. Lancet. 2003;362:847–852
3. Cummings KM, O’Connor RJHeggenhougen K, Quah S. Tobacco harm minimization. International Encyclopedia of Public Health, Vol b. 2008 San Diego Academic Press:322–331
4. Warren GW, Cummings KM. Tobacco and lung cancer: risks, trends, and outcomes in patients with cancer. Am Soc Clin Oncol Educ Book. 2013;33:359–364
5. US Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. 2010 Atlanta, GA US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease prevention and Health Promotion, Office on Smoking and Health
6. Warren GW, Kasza KA, Reid ME, Cummings KM, Marshall JR. Smoking at diagnosis and survival in cancer patients. Int J Cancer. 2013;132:401–410
7. Gajdos C, Hawn MT, Campagna EJ, Henderson WG, Singh JA, Houston T. Adverse effects of smoking on postoperative outcomes in cancer patients. Ann Surg Oncol. 2012;19:1430–1438
8. Gillison ML, Zhang Q, Jordan R, et al. Tobacco smoking and increased risk of death and progression for patients with p16-positive and p16-negative oropharyngeal cancer. J Clin Oncol. 2012;30:2102–2111
9. Kenfield SA, Stampfer MJ, Chan JM, Giovannucci E. Smoking and prostate cancer survival and recurrence. JAMA. 2011;305:2548–2555
10. Bittner N, Merrick GS, Galbreath RW, et al. Primary causes of death after permanent prostate brachytherapy. Int J Radiat Oncol Biol Phys. 2008;72:433–440
11. Hooning MJ, Botma A, Aleman BM, et al. Long-term risk of cardiovascular disease in 10-year survivors of breast cancer. J Natl Cancer Inst. 2007;99:365–375
12. Jerjes W, Upile T, Radhi H, et al. The effect of tobacco and alcohol and their reduction/cessation on mortality in oral cancer patients: short communication. Head Neck Oncol. 2012;4:6
13. Chen CH, Shun CT, Huang KH, et al. Stopping smoking might reduce tumour recurrence in nonmuscle-invasive bladder cancer. BJU Int. 2007;100:281–286; discussion 286
14. Alsadius D, Hedelin M, Johansson KA, et al. Tobacco smoking and long-lasting symptoms from the bowel and the anal-sphincter region after radiotherapy for prostate cancer. Radiother Oncol. 2011;101:495–501
15. Joshu CE, Mondul AM, Meinhold CL, et al. Cigarette smoking and prostate cancer recurrence after prostatectomy. J Natl Cancer Inst. 2011;103:835–838
16. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. 2008 Rockville US Public Health Service
17. Park ER, Japuntich SJ, Rigotti NA, et al. A snapshot of smokers after lung and colorectal cancer diagnosis. Cancer. 2012;118:3153–3164
18. Duffy SA, Louzon SA, Gritz ER. Why do cancer patients smoke and what can providers do about it? Community Oncol. 2012;9:344–352
19. Simmons VN, Litvin EB, Patel RD, et al. Patient-provider communication and perspectives on smoking cessation and relapse in the oncology setting. Patient Educ Couns. 2009;77:398–403
20. Gritz ER, Dresler C, Sarna L. Smoking, the missing drug interaction in clinical trials: ignoring the obvious. Cancer Epidemiol Biomarkers Prev. 2005;14:2287–2293
21. Warren GW, Marshall JR, Cummings KM, et al.IASLC Tobacco Control and Smoking Cessation Committee. Practice patterns and perceptions of thoracic oncology providers on tobacco use and cessation in cancer patients. J Thorac Oncol. 2013;8:543–548
22. Warren GW, Marshall JR, Cummings KM, et al. Addressing tobacco use in patients with cancer: a survey of American Society of Clinical Oncology members. J Oncol Pract. 2013;9:258–262
23. Warren GW, Marshall JR, Cummings KM, et al. Automated tobacco assessment and cessation support for cancer patients. Cancer. 2013;120:562–569
24. Morales NA, Romano MA, Michael Cummings K, et al. Accuracy of self-reported tobacco use in newly diagnosed cancer patients. Cancer Causes Control. 2013;24:1223–1230
25. Toll BA, Brandon TH, Gritz ER, Warren GW, Herbst RSAACR Subcommittee on Tobacco and Cancer. . Assessing tobacco use by cancer patients and facilitating cessation: an American Association for Cancer Research policy statement. Clin Cancer Res. 2013;19:1941–1948
26. Cahn Z, Siegel M. Electronic cigarettes as a harm reduction strategy for tobacco control: a step forward or a repeat of past mistakes? J Public Health Policy. 2011;32:16–31
27. Vansickel AR, Eissenberg T. Electronic cigarettes: effective nicotine delivery after acute administration. Nicotine Tob Res. 2013;15:267–270
28. Siegel MB, Tanwar KL, Wood KS. Electronic cigarettes as a smoking-cessation: tool results from an online survey. Am J Prev Med. 2011;40:472–475
29. Cobb NK, Abrams DB. E-cigarette or drug-delivery device? Regulating novel nicotine products. N Engl J Med. 2011;365:193–195
30. McCauley L, Markin C, Hosmer D. An unexpected consequence of electronic cigarette use. Chest. 2012;141:1110–1113
31. Goniewicz ML, Knysak J, Gawron M, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control. 2012 Published Online First: March 6, 2013
32. Etter JF. Electronic cigarettes: a survey of users. BMC Public Health. 2010;10:231
33. Dawkins L, Turner J, Roberts A, Soar K. ‘Vaping’ profiles and preferences: an online survey of electronic cigarette users. Addiction. 2013;108:1115–1125
34. Bullen C, McRobbie H, Thornley S, Glover M, Lin R, Laugesen M. Effect of an electronic nicotine delivery device (e cigarette) on desire to smoke and withdrawal, user preferences and nicotine delivery: randomised cross-over trial. Tob Control. 2010;19:98–103
35. Vansickel AR, Eissenberg T. Electronic cigarettes: effective nicotine delivery after acute administration. Nicotine Tob Res. 2013;15:267–270
36. Barbeau AM, Burda J, Siegel M. Perceived efficacy of e-cigarettes versus nicotine replacement therapy among successful e-cigarette users: a qualitative approach. Addict Sci Clin Pract. 2013;8:5
37. Adkison SE, O’Connor RJ, Bansal-Travers M, et al. Electronic nicotine delivery systems: international tobacco control four-country survey. Am J Prev Med. 2013;44:207–215
38. Caponnetto P, Campagna D, Cibella F, et al. EffiCiency and Safety of an eLectronic cigAreTte (ECLAT) as tobacco cigarettes substitute: a prospective 12-month randomized control design study. PLoS One. 2013;8:e66317
39. Bullen C, Howe C, Laugesen M, et al. Electronic cigarettes for smoking cessation: a randomized controlled trial. Lancet. 2013;382:1629–1637
40. Gilbert HA. Smokeless non-tobacco cigarette. 3,200,819 United States Patent Office 1965; Filed April 17, 1963.
42. Carpenter MJ, Jardin BF, Burris JL, et al. Clinical strategies to enhance the efficacy of nicotine replacement therapy for smoking cessation: a review of the literature. Drugs. 2013;73:407–426
43. Bansal MA, Cummings KM, Hyland A, Giovino GA. Stop-smoking medications: who uses them, who misuses them, and who is misinformed about them? Nicotine Tob Res. 2004;6(Suppl 3):S303–S310
Electronic cigarette; Smoking cessation; Lung cancer
Copyright © 2014 by the International Association for the Study of Lung Cancer
Highlight selected keywords in the article text.